12 alternatives to a vaginal exam (#4 will make you sing)

Cervical dilation: a modern obsession

In a technical hospital setting, cervical dilation is often at the center of the staff's preoccupations. While it can give serious information about the progression of labour, it is not the only criterium that predicts the imminence of the baby's crowning.

If you are at all familiar with Spinning Babies®, you know how the position of the baby has a great importance and how focusing on the cervical opening only is counterproductive.

Normal labour progress assessment used to be dictated by Friedman's curve. This "gold standard" is outdated and should no longer be a reference for assessing what is normal or abnormal labour. Too many labours labelled "failure to progress" consequently led to unnecessary C-sections and birth traumas.

Each birthing person labours on a different pattern, each birth follows a different scheme. Labour can pause in a totally healthy and normal way and resume on its own.

Labour often stalls when it is disturbed: induction, epidural, lack of privacy, stress, pressure, restricted movements, incessant vaginal exams.

What do you need to know about vaginal exams?

Vaginal exams have been used to assess the cervical ripening, effacement and dilatation, as well as to check for the baby's station and an eventual cervical lip at the time of "pushing". Some birthing people can feel encouraged to know that they are already reaching 8 cm. It can help them to distribute their remnant efforts. These could be considered as the benefits of such an internal exploration.

What are the risks? Once the water has broken, each vaginal exam carries a risk of infection, even if sterile gloves are used. Indeed, bacteria at the border of the cervix can be accidentally pushed inside. Another risk is discouraging the labouring person. If, after long hours of labour, the midwife announces 5 cm, this can be welcomed with a lot of disappointment. There is also a small risk of a "wrong" assessment. It happens that a first midwife says the cervix is 7cm dilated and a second midwife coming one hour later finds out 6-6,5 cm. How disturbing and confusing for the birthing person! These different assessments are understandable. People have different finger size or position can affect the evaluation.

So the question is: What are the alternatives?

Gentle alternatives to "fingers in the cervix" or non-invasive ways to know your labour is progressing

I found a lot of information while reading The Doula Guide to Birth: Secrets Every Pregnant Woman Should Know by Ananda Lowe and Rachel Zimmerman. I recommend this book written by two dedicated doulas, with all my heart.

1. Change in contraction Contractions are regular, become closer to each other or contractions become more intense. The behaviour and moves of the birthing person can change in function of the intensity or phase of labour. Different sounds, chants or moans can as well indicate the progress of labour.

2. Belly is higher With labour progressing, the fundus goes higher. In the beginning of labour, you can place a full hand between your plexus (bra line) and your fundus (belly top). The more the labour progresses and the less fingers you can fit. At 3 fingers, you are about 5 cm dilated. At one finger you are probably fully dilated.

3. Bloody show What is tenderly named "bloody show" is actually a small tinted (pinkish, red or brownish) vaginal discharge. All birthing folks are different, of course, but some experts tend to notice two types of bloody shows. One bloody show would appear before the onset of labour (one week, 24-hours, or on the D day) when the cervix is about 2 cm dilated, and a second bloody show would appear in the heat of labour when the cervix is about 8cm dilated. These are general notes.

Just a tiny amount of bloody discharge, although the smallest amount might seem scary at first. If it's more than a little, consult immediately.

4. The Purple Line I never meant to cause you any sorrow I never meant to cause you any pain I only wanted one time to see you birthing I only wanted to see you birthing with a purple line Purple Line, Purple Line...

Just like the "linea nigra" growing on the pregnant belly, the "linea purpura" grows habitually between your butt cheeks during labour. The colour varies from red in pale skin tones to purple or even silvery in darker skin tones. Some call it the "bottom line" and the bottom line is that it can indicate your labour progress.

The appearance of the purple line is caused by the vasocongestion in the sacrum resulting from the baby's head putting pressure on the cervix. The first mention of the purple line goes back to 1990 with Byrne and Edmonds who sent a letter to The Lancet. They attributed the first observation of the purple line to Sister H. Lake. Their little study focused on 48 women. 89% of them had a visible "purple" line. Some had no line at all. Fast forward to 1998: This is the turn of Lesley Hobbs, a British independent midwife, to write about the phenomenon. Last update about the mysterious line dates from 2010 when Shepherd et al published the results of their research study. They observed 144 women in labour and noticed the presence of the line in 76% of them. Their findings showed a medium positive correlation between the length of the purple line, the dilation of the woman’s cervix and the station of the baby’s head.

5. Descent of the baby through external palpation Experienced midwives can palpate the abdomen with their hands and identify the baby's station in the pelvis.

6. Descent of the baby through external foetal monitoring When the baby goes down, their heartbeat can be caught lower on the birther's abdomen.

Photo by Sharon McCutcheon on Unsplash

7. Spontaneous Rupture Of Membranes (SROM)

SROM is the spontaneous rupture of membranes. When "the water breaks". This term describes the normal, spontaneous rupture of the membranes at full term (after 37 weeks). The rupture usually causes a gush of fluid. This gush may be quite small or significantly large depending on the amount of fluid in the amniotic sac, and to what extent the foetal head is plugging the hole and retaining fluid in the sac.

The membranes don't always rupture. Sometimes, rarely, the baby is born delicately in its little amniotic cushion, "en-caul".

Not that Niagaresque IRL. Is that the Parliament House?

8. Ultrasound

For twins or other multiples, ultrasounds are used during birth to identify the position of the babies. For singletons, ultrasounds are used with more parsimony.

9. Rectal pressure

With the baby's head descending in the pelvis, a significant pressure will be felt, followed soon enough by an irresistible urge to push and the famous "ring of fire" next door (burning sensation in the vagina when the baby is crowning).

10. Involuntary bowel movement Yes, we talk about "uncontrolled poop". The baby's head is pressing like a thumb on an almost empty toothpaste tube. Such a beautiful omen.

11. Opening of the back The tail bone sticks out. Sometimes the rhombus of Michaelis (a kite-shaped/diamond-shaped area in the lower back) is visible if the birthing person is in an upright position or on all-four. This opening enables extra space for the baby's passage, which is impossible if the birthing person is lying on the back.

12. Seeing the head! (Or the bum or the feet of the baby)

No kidding?!

La Vie En Rouge

Review of Dear Scarlet, the story of my postpartum depression by Teresa Wong

Dear Scarlet is Teresa Wong’s first graphic novel, her postpartum chronicles. The Canadian author calls Dear Scarlet her graphic memoir, revealing the autobiographic nature of it. “Graphic” because illustrated but also “graphic” in the sense of “detailed”: raspberry-nipples and grape-haemorrhoids come as starters. The author warns regularly: "not for the faint of heart!"

The narration takes the form of a letter to Scarlet, the author’s first born daughter.

Scarlet, this bright red, colour of fresh blood, colour of the maternal haemorrhage that took place after Scarlet’s birth. Red, like the apples Teresa dreams of: she visualises them raining down over her body at the grocery store, burying her into a bin. Red is symbolically the colour of extremes: love and violence. Red represents that bloody contradiction: the joy of meeting this innocent baby and the inadequacy, the uneasiness of being a new mother. Teresa delivers her deeper feelings to her daughter, to her readers. She questions the maternal instinct, the pressure to perform. She recalls her dreams as a child, her aspirations as a woman. Spoiler alert: becoming a mother wasn’t initially one of them.

This is raw, funny, emotional, heart-breaking, heart-melting and so sincere! We witness the first signs of depression, the self-doubting, the guilt, the excessive crying, the anger, the fantasies of vanishing, the impression everyone is staring, the emotional rollercoasters, the moments of relief, of hope too.

Just like in a fairy tale, the protagonist encounters obstacles (a long and traumatic birth, a postpartum depression), opponents (the nurse calling her “emotional”, the doctor dismissing her symptoms of depression) but also adjuvants (her supportive husband, her nurturing mother, the comforting lactation consultant, the non-judgmental postpartum doula, postpartum counselling, little thoughts from family and strangers). In the end, we wish the heroine gets self-confidence and realises all the powers reside in herself. I appreciate a lot the depiction of the traditional Chinese “sitting the month”: a one-month postpartum confinement sponsored here by Teresa’s mother (Poh-poh). The grandmother comes to take care of her daughter, feeds her (pickled pig feet, red date soup, poached chicken and pork liver soup), and cuddles with the baby while Teresa can sleep.

It seems that Teresa has a love-hate relationship with these traditions: wearing a hat indoors and not washing her hair are not her favourite rituals. Nevertheless, she understands what it means for her mother who travelled from China to Canada to meet Teresa’s dad, worked in a factory and learnt English while pregnant and spent her first month postpartum all alone.

Matrescence, we call it. This is a real time for metamorphosis, just like adolescence. A time for vulnerability. Teresa Wong was not a professional illustrator, initially. Her friends convinced her to use her own illustrations, simple and fresh, to reflect that vulnerability and sincerity. This is her, strong enough to show the world her “naked”, raw and real drawings.

In different cultures, the postpartum first forty days are often described as an open tomb, some kind of limbo. Your old self dies and you are born again. The transition can be scary, painful, destabilising. All your marks are shuffled.

“I wanted to show you that you don’t always have to be strong. And that you can come back after losing yourself.”

This books comes with an original soundtrack that you can sing in your head starting with Anthem by Leonard Cohen and ending up with Calendar Girl by Stars.

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Notes:

The introduction of the grandmother comes after a short anecdote of a tiger mother and her cub. I can’t help thinking of the tiger parenting phenomenon. Strict parenting can lead to socially prescribed perfectionism: the belief that one needs to meet unrealistically high expectations, possibly resulting in higher risks for depression and anxiety. I also think back to Rachelle Seliga’s class about postpartum dis-ease, weeks ago: perinatal mood disorders are the symptom, not the problem. Postpartum depression can be a healthy way of expressing, releasing one’s emotions that have been prisoner for too long. The teacher talks about disturbed birth, obstetric violence, postnatal depletion, lack of community support, true nurturance, separation (dyad or families) and intergenerational trauma. So many subjects to investigate, fight, resolve, heal.

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Do you suspect you suffer from postpartum depression? Edinburgh Postnatal Depression Scale can help you identify it. Seek help as soon as possible.

In Finland, you can contact:

• Neuvola

• A public or private doctor or psychiatrist

• Psychologist or psychotherapist

• Psychiatric polyclinic or emergency cover

• Family counselling (Perhe neuvola)

• Äimä ry’s peer support or any postpartum peer support group

6 keys to boost oxytocin during labour

Oxytocin, commonly known as the love hormone, is secreted by the hypothalamus, a part of the brain shared by all vertebrates.

While a lot of people hear of oxytocin for the first time in the context of childbirth, the hormone is actually involved in all kinds of intimate feel-good situations like nursing, sex or a really nice dinner with friends in a safe atmosphere.

The origin of the word “oxytocin” is Greek: ὀξύς (oxús, “swift”) + τόκος ( tókos, “childbirth”) Oxytocin helps make the childbirth swift, fast, fluid and smooth.

Oxytocin's chemical structure

Oxytocin makes the uterus contract, slowly, gently, regularly, then progressively stronger and with shorter intervals as the labour progresses. Oxytocin also activates the brain’s pleasure and reward centres in preparation for bonding with the newborn baby.

The more relaxed and safe a person feels, the more this person will secrete oxytocin. It's a shy hormone so we need to respect and support the birth process, to hold space, for it to show up.

When non-human mammals are about to give birth, they first isolate themselves. The Bighorn ewe, for example, reaches the most inaccessible place in the mountain to feel safe. Nocturnal animals usually give birth during the day whereas diurnal animals prefer to give birth at night.

No wonder that when it comes to humans, the privacy of home seems to be the ideal setting to secrete the love hormone during child birth – while it is by no means the only one.

To facilitate natural oxytocin release in case of a hospital birth it's worth considering:

• Staying at home in early labour as long as possible (except in case of complications)

• Create or recreate a peaceful or familiar atmosphere (in the delivery room or in the recovery room)

How to support oxytocin release?

N.B.: We are all different, with a different cultural background, a different personal history and different phobias or traumas. Oxytocin is love, trust and consent. Only do what feels good, comfortable and right to you.

1. Privacy

Gentle lights for a gentle birth, Photo by Rebecca Peterson-Hall on Unsplash

Dimmed lights: This is relaxing for the eyes. The neocortex (part of the brain that enables analysis, sensory processing, decision-making, reasoning, and problem-solving) can more easily switch to sleep mode. It also preserves the intimacy, the privacy of the birthing person. Candles can calm the mind and set up a warm and cosy atmosphere. In hospital, you can use electric candles.

Doors are closed and curtains are shut: nobody should come uninvited. The birthing person doesn’t feel observed, exposed (or listened to).

2. Safety

It is important to feel safe in your nest, Photo by Jeremy Wermeille on Unsplash

Trust: Knowing that each person present in the room supports you, respects you, listens to you, doesn't hurt you. You feel confidence in you, your baby, your body, your birth team.

Food and drinks: it is important to feel nourished and hydrated. Hunger and thirst don’t make us feel at peace. And if these food and drinks are delicious, bonus!

Elimination needs are met: How to totally let go if your bladder or bowels are full or ready to move? Free access to the toilet or simply allowing your body to release different types of fluids, is rather liberating.

Physical comfort: Loose clothes, no clothes at all, soft fabric, cushions, towels, peanut ball, all props are welcome to reach a nice and ergonomic position.

3. Connection

Connecting, feeling part of the whole, Photo by Jeremy Bishop on Unsplash

Feeling loved: Hugs and kisses, soft looks, sweet words.

Petting an animal. The company of your own dog, cat or other furry friend can be comforting. See how protective of you and your baby they can be.

Closeness to nature: walking barefoot in the grass, stroking the bark of a tree, feeling the sun kissing your hair, breathing the smell of fresh forest after the rain, letting the sand vanish between your fingers. If there is no nature around, natural elements can bring peace: seashells, stones, a feather, a flower.

All this procures the feeling (conscious or not) of being part of the universe, the history. This unexpected communion can bring unconditional comfort.

4. Ambience

Nice and quiet, Photo by Kristina Flour on Unsplash

Silence, or at least no interview: Some words of encouragements and compliments can be welcome. Though, questions can become too much to process and force you to switch on your neocortex and burst your birth bubble.

5. All 5 senses are very receptive

Touch:

• Massage: Massage is a nice way to disconnect, let go, let the oxytocin flow.

• Caress: Gentle and light touch all other the body.

• Hair brushing or hair braiding: It feels so good to be taken care of. It can give goose bumps.

• Nipple stimulation: this can simply been achieved by the birthing person, the partner, an older child breastfeeding or even a breast pump.

• Clitoral stimulation: this can be performed by the birthing person, the partner, or with the help of a sextoy (waterproof if used in the tub). It is possible to ask privacy to the midwives in case of a hospital birth.

• Warmth: The temperature of the room, a warm bag of wheat and a blanket and wooly socks if needed. If you have access to a sauna, you can also sit there and relax at a comfortable temperature for you. The idea is not to sweat but liberate tensions. Don’t use sauna if you have high blood pressure.

• Water: Shower, tub, a bucket of warm water (about 37,5 degrees Celsius) falling on the shoulders and all along the back like a waterfall, the feeling of floating and defying the laws of gravity, can be ecstatic.

Smell:

• Agreeable smells: Lavender essential oil (with a carrier oil, on the skin), fresh flowers, pancakes, whatever brings positive thoughts or pleasant memories. It can also be the plush toy of your older child or your own bedroom pillow.

Taste:

• Nice taste in mouth: if you hungry and thirsty, eat and drink. Dark chocolate is a good relaxant. I encourage the use of coconut water, filled with electrolytes and an exotic island trip. If you are not thirsty: drink or suck ice. If you feel nauseous, peppermint can help: essential oil drops on an handkerchief or a pastil to suck. You can of course brush your teeth to keep fresh (and offer a chewing gum to your support person). I wouldn’t recommend a chewing gum during labour (it tends to develop tension in the jaws) but according to studies it can be beneficial right after birth (the digestive system is activated faster, the recovery is accelerated especially after a c-section.)

Hearing:

• Silence brings clarity and transparence for most people. It brings serenity and calm.

• For some people silence can create anxiety, brings back memories of loneliness or emptiness. For those people, and some others, music can help fill the room with a vibrant energy. Notes can be a gentle and non-invasive company. They can also support the 3 Rs in labour: Relaxation, Rhythm and Ritual. It can help entering the “labour transe”.

• Lyrics can disturb if they differ from mantras. The idea is to let the brain rest, let the mind escape.

• Hospital sounds can inhibit this evasion. Sensors can slide, monitors can beep and worry unnecessarily. The monitoring sounds can be shut while still recording the baby’s heartbeat. In most cases monitoring doesn't have to be on-going. Studies show that continuous foetal heart monitoring during labor (vs hands-on listening) increases the rate of c-sections.

Sight:

• At home, you have your marks and the place is yours, you feel free. You can decorate as much as you want, you reign in your realm.

• In an hospital setting, the room is usually white, which brings calm and neutrality. But a few artefacts can make you act in a conditioned manner: if the first thing you see is a bed in the middle of the room, you might be tempted to lie on it as if it was expected from you. If the light is on, you might feel unauthorised to switch it off. If you are given an hospital gown you might feel owned by the institution you stepped in and unconsciously act in accordance to this idea. To be at ease and feel “at home” you are allowed to bring along personal items: your own nightgown, your socks, a picture of your grandmother, an amulet, a lucky charm, your electric candles, your ukulele or your hummus sandwich if you feel like it.

• Sight is a sense that easily activates the neocortex, triggering memories or suggesting the interpretation of a vision. Closing the eyes or using an eye mask can help you stay in tune with your instinct.

6. Mammal instinct: your 6th sense awakes

Be wild! Photo by David Clode on Unsplash

• The archaic brain rules: Thoughts can block the process. Let’s make room for intuition and spontaneity. The birthing person often develops a sort of omniscience during labour and birth. If sight becomes blurry or sounds become diffused, the birthing person feels the energies, the synergies and knows what is happening in the room.

• Liberation of sounds: Feel free to express your emotions with sounds, mammal sounds.

• Liberation of the body: Feel free to move, rock, dance, undulate, vibrate and shake. It is ok to lose control and let the process guide you.

What about synthetic oxytocin? Isn't that just the same? Natural oxytocin is stocked in the posterior pituitary gland and liberated in the blood stream, in a discontinued and pulsative way. Synthetic oxytocin is on the contrary administered intravenously (IV), and in constant, high doses, which can lead to maternal oxytocin levels that are more than double those in a physiological labour.

As a consequence, synthetic oxytocin causes contractions that are longer, stronger and closer together than the body would naturally produce. Synthetic oxytocin inhibits the secretion of endogenous (naturally produced) oxytocin. Although both synthetic and endogenous hormones share the same chemical structure, the synthetic one is not released in the brain so it doesn’t bring along the same soothing effect as the natural one. More info about the effects of synthetic oxytocin.