Sometimes, the combination of my travelling and reading of the midwifery and obstetric literature highlights areas where there is variation in what is seen as standard or usual practice in different areas of the world. There are lots of obvious examples of this – fundal pressure, starving women in labour, putting up routine IV fluids – but this week I encountered an article which made me think about one that is less obvious: the practice of offering vaginal examination routinely at the 6-week postnatal check.
The research which brought this to my attention was a small study carried out in Detroit, Michigan. Mahesan et al (2016) explored whether it was useful to offer pelvic examination at the 6-week check to healthy women who had caesarean sections and who did not have symptoms of vaginal infection, and they primarily considered whether this was a useful means of identifying an asymptomatic infection. They concluded that it wasn’t, and I’ll post the abstract of the study below if you’d like to follow it up and read more.
Of course, there are other possible reasons for offering pelvic examination at the 6-week check, and women who have had a vaginal birth may wish to have one in order to have someone check that everything is looking normal, especially if they were sutured after giving birth or had an instrumental delivery. But not all women will want this, and I know that this practice also differs in different areas of the world. Some practitioners will offer pelvic examination to all women, some will ask lots of questions about how the woman feels and then consider whether or not to offer it or not, and some will ask the woman straight out what her preference is. In some countries, women will see different people for this check depending on where and how they gave birth.
It’s not a case of simple yes/no, right/wrong dichotomies. When we are considering offering this kind of a screening test – and pelvic examination is a screening test, because we are using this to determine whether or not something is within normal limits and, if it is not, to offer further testing and possibly intervention – there are a number of questions we need to ask. What are the problems that we might be screening for? Is this test effective at identifying women who might have those problems? Do we have evidence that the test is effective at identifying those with problems? How many people who have the problem get missed (false negative) and how many people who don’t have the problem get misidentified as having it, and potentially over-treated (false positive). Does the screening test itself carry other risks or have the potential to harm or cause discomfort?
I’m not saying that we should throw everything out, and a careful 6-week check can be really important. Indeed, an arguably bigger problem in some areas is that women aren’t getting offered enough time, testing and support at this point. But it doesn’t hurt to ask questions about some of our established practices and to consider whether and how well they serve different groups of women.
Mahesan AM, Ilceski DM, Paul ABM et al (2016). Pelvic Examination at the 6-Week Postpartum Visit After Cesarean Birth. JMWH DOI: 10.1111/jmwh.12422
Introduction: The objective of this study was to assess the utility of the pelvic examination at the 6-week postpartum visit after cesarean birth.
Methods: Data were collected from retrospective chart review in an obstetric resident clinic in Detroit, Michigan. Women included were those who had a cesarean birth between January 2012 and June 2014.
Results: Of 388 women who had a cesarean birth, 211 (54.4%) presented for the 6-week postpartum visit and underwent pelvic examination. Of these women, 185 (87.7%) were asymptomatic, and 26 (12.3%) reported vaginal discharge. No other concerns were elicited. Of those with symptoms, 4 (15%) had no finding, 13 (50%) had bacterial vaginosis (BV) alone, 2 (8%) had BV and Candida sp, 2 (8%) had BV and Trichomonas vaginalis, 2 (8%) had T vaginalis alone, and 3 (11%) had Chlamydia trachomatis. One woman with C trachomatis had tested positive during pregnancy and possibly had treatment failure. Of the 185 asymptomatic women, 91 (49%) were deemed to have vaginal discharge on examination and underwent testing for Neisseria gonorrhoeae and C trachomatis; results were negative in all cases.
Discussion: In this population, it appears unnecessary to perform routine pelvic examination on asymptomatic women at the 6-week postpartum visit after cesarean birth. When vaginal discharge was noted during pelvic examination of asymptomatic women, no pathology was identified.