Routine Vaginal Examination in Labour - Essay Example

? Routine Vaginal Examination in Labour Introduction The essay will be presenting a situational analysis of the routine vaginal examinations in labour in context to change. The conclusion will cater to the results of the findings through different researches and the importance and ways of implementing change in the role of midwives and vaginal examination. For this purpose, the paper sheds some lights on the vaginal examination in labour, the information that healthcare professionals gather from it, the role of midwives and patients, and the current situation of vaginal examination; whether vaginal examination is a clinical intervention or an essential assessment tool; whether vaginal examination is necessary or it is just a practice by midwives. Furthermore, the benefits and harms of the examination will also be elucidated. These will make it easier for us to point out the changes that can be made; changes that are necessary in the assessment of this practice and how those changes can be employed, as well as the role of supervisors when implementing or planning a change. Change is an important issue in all the fields of life; it is always needed. But change requires proper planning, devoted leaders, and supervision. Without these factors, making change an acceptable element is difficult. All these issues will be discussed in this paper, along with the findings and analysis of different researchers. Authentic sources are used in order to analyze the situation of vaginal examination in different countries. The role of midwives and patients will be determined through their experiences, the transfer of information from doctors and/or midwives to the patient, and the importance of routine vaginal examinations in labour. Moreover, the changes that can be introduced in order to make routine vaginal examination acceptable will be our focus of discussion through the course of this paper. Vaginal Examination The act of examining the vagina for a disease or labour progress is called the vaginal examination. A vaginal examination is performed for three health care issues: firstly for the diagnosis of any infections, vagina, external genitals, pregnancy, and investigation in case of sexual abuse; secondly for screening of vaginal swabs, cervical cytology etc; and thirdly for the treatment of vaginal dilatation, and removal of polyps etc. Vaginal exams have become routine during pregnancy in most parts of the United States. Interpreting labour progress is complex and requires experience, knowledge, and judgment, which are aided by continuity of care from a midwife to the pregnant woman (Dixon & Foureur, 2010). In this essay we will be focusing on the vaginal examination in labour. It has been observed that vaginal examinations in labour are used as a procedure through which the healthcare professionals demonstrate the progress of labour and the condition of labouring women. Vaginal examination helps and guides the doctors and midwives to estimate the time left in labour. The care and importance that a woman experiences during her pregnancy always has a great influence on her (Beech & Phipps, 2004). The regular examination of vagina to evaluate the progress of labour is one such care. The woman through this examination can assess the length, strength, position, and intensity required to take it to the end. Vaginal examination is not just a routine practice; rather it is undertaken to get variety of information for the well being of a mother and her child. The information that the healthcare professionals get from it are the fetal presentation, information on cervical effacement, consistency and dilatation of cervix, head movement of the fetal, and position of the nuchal cord. The doctors and midwives get to know what is happening to the patient and her labour with regard to the intensity of contraction (Thorpe & Anderson, 2006). They can identify the length of cervix dilatation and the time remaining for the labour. Vaginal examinations remain the most traditional and acknowledged method of measuring progress in labour (Enkin et al. 2000). However, these examinations should be carried out once it is discussed with the patient, and when the midwives can justify its necessity and importance in order to make a decision (NICE, 2007). Friedman (1954) identified that the most appropriate measure with which a vagina is examined is the cervical effacement and dilation. It helps is defining the time parameters so that in case of any abnormalities, an action could be taken. This protects the mother and her baby from incidents with adverse outcomes. With such advantage of a single examination, patients ask as to how often this examination is necessary in order to avoid any adverse event (Enkin et al., 2000). There is no decided consensus for the timings of vaginal examination. It depends on the doctors, nurses and midwives as to when they suggest a vaginal examination to the patient. Here the role of midwives and doctors matters. The position of midwives has shifted since the occupation began. Since 1904 to 2004, the position has shifted from the autonomy of normal childbirths and care to practice under the supervision of professional autonomy that includes handling cases of all types. The reason behind this shift is the change in women’s worth in the society, changes in relationship between midwives and nursing, as well as the change in the complications in childbirth. The role of midwives evolves around their practice and society. The trained midwives suggest a vaginal examination to women who are giving birth for the first time, or those who have any type of complications. However, the women who have given birth more than once are aware of their condition, and can discuss with their midwives in case they do not want an examination. The role and comfort provided by the midwives affect the situation in a scenario like this. In 1995, the RCN published a report regarding its Bimanual Vaginal examination guidance for nurses and midwives. The Steering Committee of the RCN, Gynecological nursing forum felt to update the nurses on their role through a publication with knowledge and guidance from the best evidence and expert views. The publication covered all the topics related to vaginal examination. The continuing development in this field required the nurses to play their role effectively, and extend their practical roles. The major emphasis of the publication was on having more midwives with proper experience to perform the examination (Vaginal and Pelvic examination, 2006). Vaginal examination is considered to be the routine assessment of a woman during labour. The examination was emphasized by RCN because it was a procedure through which diagnosis and treatment could be evaluated (Vaginal and Pelvic examination, 2006). In the publication, it was mentioned that most of the women hinder to go for routine examinations due to the previous experience or any other disturbing events that make them unwilling to go for it. For coping up with such situations, the experience of nurses should be of the extent that they are able to convince or make the patient comfortable for routine vaginal examinations. Nurses and midwives need to be sensitive enough to counsel the women and make them feel less traumatic before and during the examination. They need to maintain sensitivity and respect for the women’s dignity. The role of the nurses was emphasized because a nurse can mould a patient the way she wants, only if she has the right attitude and experience. According to NMC code of Conduct (2004), nurses and midwives are solely responsible for their practice and are answerable to their actions and notions (Vaginal and Pelvic examination, 2006). It is the duty of midwives to provide safe care to the patients; they are entitled to provide respect, comfort, and care to patients. This is acquired by the practice and experience, and not by training. There is no single training centre for such practices where a nurse is trained to be respectful towards the patient. “Sexual health competencies (RCN, 2004) provide a framework for lawful, safe and effective professional practice without direct supervision (Vaginal and Pelvic examination, 2006)”. Vaginal examination demands the exposure of a woman’s genitals to a stranger. In such a situation of distress and trauma, the nurses and midwives are liable to provide the emotional and psychosexual considerations that are needed by the patients at that time (Devane 1996). Normally women agree for the examination but need the trust of nurses and midwives that they would respect their dignity. Women want to be supported during the examination by someone they trusted; they appreciate examiners who try to minimize their physical and psychological discomfort. The midwives or examiner has to perform examination skillfully and communicate with the patient. All the findings and information should be conveyed to the patient. Pain and embarrassment are frequently experienced during vaginal examination; and then there is discomfort that the women go through when examined by a male doctor; the midwives should take this into account. In such cases, the hospitals or the healthcare centers should always have an alternative. “Each woman should be treated with courtesy and respect, and her modesty protected by minimal exposure to examiners/examinations (Ying Lai & Levy, 2002)”. From the findings of the research conducted by Lewin, Fearon, Hemmings and Johnson (2005) on the role of midwives in examining the vagina, it was concluded that the midwives provided care and handled women sensitively. It has become a routine and the midwives are experienced enough to maintain the pain, distress and preferred options. According to the research, the midwives were observed to be providing patients with care during the examinations and frequently communicating with them during the entire procedure. The result concluded this to have increased the comfort level of women undergoing the exam. Another research was conducted that involved interviews of midwives who responded that the nature of examination depends on the women undergoing the exam. According to the survey, midwives and nurses had a viewpoint that vaginal examination is not a routine procedure and not everyone needs one. They performed the examination only when some information was needed or the patient requested for it. The practice of this examination was kept minimal and they used other mediums to deduce the time parameter and labour progress. The midwives also suggested that everything depends on the care and respect. If midwives give the respect and care to the patient, they will be able to utilize their experience and knowledge (Kirkham, 2004). A vaginal examination is viewed in two ways. The first regards vaginal examination as a “physically invasive intervention which can have adverse psychological consequences (Kitzinger, 2005)”. The second regards it as an “essential clinical assessment tool (Enkin et al., 2000)” that can enable the doctor gain information about the labour progress. As discussed earlier, midwives have a variety of ways through which they can determine the labour progress, but the vaginal examination gives accuracy. “Normally when we refer to clinical interventions, we discuss practices such as artificial rupture of the membranes (ARM), intravenous syntocinon to accelerate labour, epidural anesthesia, instrumental and caesarean births” (Tracy, 2006). Many of the actions that are taken by doctors or midwives can be considered as intervention. One of them is the vaginal examination which can be carried out frequently and routinely during labour (Cheyne, Dowding, & Hundley, 2006). It is considered to be an intervention because midwives intervene personally with a patient. When the examination is undertaken, the patient is asked to take a specific position and an intimae examination is performed. This procedure is traumatic, both physically and psychologically. But the doctors and midwives consider it to be a clinical assessment tool, because it provides with the information regarding the progress made by the labour and assures midwife and mother about the on going progress. Generally, a mother may ask her midwife about the vaginal examination as it assures her about the progress and time parameter. “The vaginal examination and cervical assessment give information that can be employed to validate normality or identify pathology (NICE, 2007)”. Most of the doctors admit that vaginal examination is an effective procedure through which significant information can be evaluated. The vaginal examination has some benefits and harms as well. The benefits of having vaginal examined, as described earlier, are that the midwives and patient gets an assurance of the progress being made by the labour. It shows the cervical dilatation and position of the fetal head and chord as well. The advantage of avoiding vaginal examination is only for the woman who fear or go through distress, trauma and pain. Vaginal examination is necessary in the first labour because at that time the woman herself is inexperienced and wants to know about the details (Hanson, 2003). It is an important clinical assessment tool which helps the midwives in understanding labour (Cheyne et al., 2006). The greatest harm of vaginal examination is the emotional distress that is suffered by the patient when she is in a position that is awkward. It is distressful due to the intimate nature (NICE, 2007). According to the researcher Devane (1996), women regard vagina as associated with sexual functions, before the childbirth. With the first vaginal examination, the vagina changes its association and establishes links to other functions, apart from the sexual functions. The other harms include that vaginal examination can cause embarrassment for both the participants i.e. the woman and the midwife (Stewart, 2005). “The use of vaginal examination can also be seen as disempowering for women with the perception that the childbirth professional will trust the ‘science’ rather than woman’s knowledge of their body or their labour (Beech & Phipps, 2004)”. This happens when the vaginal examination’s result causes the woman to focus on the cervical dilatation than on pushing. This lessens her confidence and makes her feel that she is unable to labour the child. In other events, the woman labours well but is asked to wait for full dilatation. “In such situations midwives explain the use of distraction techniques that is used as a means of waiting longer before undertaking a vaginal exam” (Dixon, 2005). Other harms include the psychological consequences associated with vaginal examination. It causes disruption to the emotions and pain physically (Edwards, 2005). Vaginal examination causes “membranes to rupture (Dixon, 2005)” this may lead a normal case to cesarean section. There is a risk of being infected which can be harmful for both the mother and the child. An individual responds to a positive, unwelcome or unnecessary change in a similar way. The change is responded to a denial at first, while sometimes people become uncertain and frustrated towards the change. With the passage of time they start exploring the change and accept it. Finally when they have no other option they become committed with the change. This cycle is evident in all cases whether the change is for positivity or it is unnecessary. People always react in a similar way; during the denial stage, individuals typically do not acknowledge the change because new paths of behaving are not established by them. They are not familiar with the change so they deny it. After denial stage has passed, the individual gets emotional and uncertain regarding the change, grieves due to the loss of old ways, which makes the individual emotional and frustrated. Before the next stage of adapting to the new situation begins, resistance and unwillingness to engage can reduce the morale, and therefore performance reduces significantly. By engaging and exploring the new ways, the individual develops their confidence and their performance begins to rise. In the final stage, individual becomes fully committed and become responsible for themselves in the change (Change management Toolkit, 2005). Only introducing the change is not enough. It has to be employed with proper planning and appropriate approach. In such cases the fusion of structural approach and people-oriented approach is quite effective. If both are used separately, either it will fail due to poor planning and project control or due to people’s issues. It is necessary to deal with both of them at the time of implementation. The people who want to bring change need to set a direction but have to be flexible at the same time. Support is needed from top to bottom in order to process the change from down to top. The change must have objectives that can be improved by the people who accept it. Planning the change is important but gaining the confidence and acceptance of people is essential. Changes cannot take place randomly without any implementation plan; vital steps are required to implement a change. The change needs to be supported by he key people; their involvement is fundamental in making a good plan. The key people need to support the plan with a consistent behavior, training workshop, and communication sessions etc that should be aligned and milestones set. This gives an impressive outlook to the people and they adapt the change easily (Change management Toolkit, 2005). Defining the procedure of making the change effective and the stages that the individual goes through before accepting a change was necessary so that the essay audience may get to know how a particular change needs to be accepted and planned. There is always some room for new ideas, changes and innovations in any field or work. Similarly, there can be some changes made in the role of midwives and the procedure of vaginal examination in labour. It is always helpful in making future strategies to have a review of the on going process. The way midwives are performing will help in identifying the improvements that can be made with the outcomes for women for whom midwives care. Change is always introduced for betterment and improvement. The change in quality program will help the midwives in performing well and providing high quality care to women. Another change that can be made to improve the practice is to undertake research and then reflect with respect to the practice that the midwives are performing The vaginal examination is an important skill that midwives should develop and that can help them to interpret labour timings and dilatation from the physiological process. Indeed for many midwives it has been the use of vaginal examinations that has helped them to develop their skills in observation of labour by improving their abilities to understand the signs of labour progress that may vary with each woman. Taking in view the change in this scenario, old fashion midwives do not accept a change unless they are convinced. As discussed earlier, the roles of midwives have changed from 1904 till now. They have become more involved in other activities as well, like the routine checkups, vaginal examination, pelvic examination etc. The change in the role of midwives is due to a proper supervision and leadership. Only the change for plan is not worthy, the leaders and supervisors have to play an appropriate role in order to make change acceptable (Change management Toolkit, 2005). NICE (2007), suggested that vaginal examination should not be made a recurrent routine. It should be conducted after 4 hours or when needed. Earlier midwives made it a routine to check and examine vagina every hour, this was not only physically painful, but was an emotional distress for the pregnant woman. The patient was not able to concentrate on her labour when the midwives kept on examining cervical dilatation. The supervisors helped midwives in changing this attitude and to give the patient her space so that she can fully concentrate on the labour. The head midwife is responsible for changing the role of midwives and the type of actions they practice. The guidelines need to be modified. They should cater to the conditions in which vaginal examination is necessary. There are other ways as well through which the progress of labour can be evaluated. For that a midwife has to be on duty for checking the condition of the patient. And after her shift ends, she has to hand over the duty to the next supervisor. The supervisors must personally adopt the changes before asking others to adopt it. This is the primary function that affects the whole scenario and planning of change. The supervisor needs to evaluate the forces that are required to employ a change; these could be introduction of a new technology for instance. In case of midwives, these technologies could be, for example, invention of a new way to examine the cervical dilation. Other forces that can help in employing a change could refer to the supervisor’s role, for instance the supervisor could change the work values, and provide the junior midwives with more knowledge and practice. Globalization can also be effective in implementing the change. The resistance from the leaders and the key people is logical while implementing the change. Resistance is also made from the individuals and groups in terms of emotions, and social ties, etc. The resistance that is valuable for leadership and organization in terms of rules, and structure of change is fairly reasonable. The building relationship of trust between supervisor and those who are working with them is also necessary. The midwives cannot adopt a change until they have seen the supervisor practicing it. For this purpose, the supervisors and leaders have to provide them with support and guidance. Conclusion Through this situational analysis, we come to know the whole procedure of vaginal examination. The midwives’ practice and role is accounted as the most major during this process, even more vital than a doctor. It all depends on midwives whether they feel the need for a vaginal examination or not. Mostly, they are so experienced that they can anticipate about the progress of labour through the breathing and condition of a patient. Vaginal examination is considered to be an essential clinical assessment tool through which the progress of labour is determined. Before introducing a change, the supervisors and the key people have to make plans for its implementation and a strategy through which the midwives can easily adopt the change. For this the supervisors have to prepare themselves for the meetings, research the ways through which they can convince the midwives, and prioritize the actions. Bringing a change is not easy, and to implement a change, the change has to be valid and have proper consents. References Beech, B., & Phipps, B. (2004) Normal birth: women's stories. In S. Downe (Ed.), Normal Childbirth: Evidence and debate. London: Churchill Livingstone. Change management Toolkit, (2005) http://www.fsdnetwork.com/documents/change%20management%20toolkit.pdf Cheyne, H., Dowding, D., & Hundley, V. (2006) Making the diagnosis of labour: midwives diagnostic judgment and management decisions. Journal of Advanced Nursing, 53(6), 625-635. Devane, D. (1996). Sexuality and midwifery. British Journal of Midwifery, 4(8), 413 - 419. Dixon, L. (2005). Building a picture of labour: How midwives use vaginal examination during labour. New Zealand College of Midwives Journal, 33, 24-28. Dixon, L., & Foureur, M. (2010).The vaginal examination during labour: Is it of benefit or harm? New Zealand College of Midwives Journal 42, 21-26 Edwards, N. (2005). Birthing Autonomy: Women's Experiences of Planning Home Births. London: Routledge: Taylor & Francis Group. Enkin, M., Keirse, M., Neilson, J., Crowther, C., Duley, L., Hodnett, E., et al. (2000). A guide to effective care in pregnancy and childbirth. Oxford: Oxford University Press. Friedman, E. (1954). The Graphic Analysis of Labour. American Journal of Obstetrics and Gynecology, 68(6), 1568 - 1575. Hanson, S. (2003), To VE or not to VE? That is the question., Issue 97. Kirkham, M. (2004), Informed Choice in Maternity Care, Palgrave McMillan Publishers Kitzinger, S. (2005). The Politics of Birth: Elsevier. Lewin, D., Fearson, B., Hemmings, V. & Johnson, G. (2005), Women’s experiences of vaginal examinations in labour, Volume 21, Elsevier NICE. (2007). Intrapartum care, care of healthy women and their babies during childbirth. London: National Collaborating Centre for Women's and Children’s Health. Nursing and Midwifery Council (2004) Code of professional conduct: standards for conduct, performance and ethics, London: NMC. Available from: www.nmc-uk.org Royal College of Nursing (2004) Sexual health competencies: an integrated competency and career framework for sexual and reproductive health nursing, London: RCN. Publication code 002 469. Royal College of Nursing (2006) Female genital Stewart, M. (2005), 'I'm just going to wash you down’: sanitizing the vaginal examination, vol. 51, number 6, pp. 587-594 , Blackwell, London Thorpe, J., & Anderson, J. (2006). Supporting women in labour and birth. In S. Pairman, J. Pincombe, C. Thorogood & S. Tracy (Eds.), Midwifery; preparation for practice. Sydney: Elsevier. Tracy, S. (2006). Interventions in pregnancy, labour and birth. In S. Pairman, J. Pincombe, C. Thorogood & S. Tracy (Eds.), Midwifery: Preparation for practice. Sydney: Elsevier. Vaginal and Pelvic examination (2006), RCN http://www.rcn.org.uk/__data/assets/pdf_file/0011/78698/003036.pdf Ying Lai, C. & Levy, V. (2002), Hong Kong Chinese women's experiences of vaginal examinations in labour, 18(4):296-303, Elsevier Science Ltd. Read More