labor nurse has been reborn and shares her experiences as a new nurse-midwife, woman, and blogger

Tuesday, April 15, 2008

Shock and Fear

There's been a lot of talk in the blogosphere in the past few days about traumatic gynecological experiences. I've read stories of women who had horrible first exams, made to feel dirty, abused, and violated. There are stories of providers who are just plain inconsiderate. Or so rough that a woman who had no problems going for her exams suddenly became terrified. Some have even posted their stories here on this blog in my previous post. As a provider (or shall I say soon to be) I listen to this stories with shock and fear. Shock because I can't imagine anyone perpetrating such horrible "care"; fear because I hope to never make anyone feel remotely violated.

I've been hypersensitive at the office my last few clinical shifts, trying to be as gentle as possible. And it's not like I am not typically, but I guess what I wasn't aware of was that I wasn't aware. I assumed that women that I have cared for and performed pelvic exams on who had a difficult time keeping their knees open and their butts on the exam table despite informing them of what I was going to do before I actually did it was just a variation on the feeling that pelvic exams are just not fun. I've had women tell me upfront that they have fear and anxiety about the exam because of a past experience, and again I assumed that women would just be honest ahead of time with me about such fears and those who said nothing were likely fine.

Oh, how wrong I am.

In just one clinical day at the office, I had several women with severe anxiety in some fashion. One woman spoke so fast I had a hard time keeping up with her. I left the room feeling like I was spinning in a cloud of dust. When I went back to do the exam, she said over and over, "I am so afraid of this exam, but I force myself to do it." Another was sweating so badly that she soaked through the "hygienic" paper (that's a joke- like a thin sheet of paper will make things clean) that it disintegrated. A third was a phone call by a 60 year old woman who kept self treating for a vaginal infection that just kept getting worse; when I went into her records her last gynecological exam was in 1993. After a long discussion of her symptoms, and my explanation that I couldn't diagnose this problem over the phone and that it would be best to come in, she broke into a long story of physicians ignoring her long history of heavy bleeding that resulted in a hemoglobin level of 4 and an emergency hysterectomy. The physician covering the emergency room at the time belittled her for not having done something sooner and went on to perform an exam that left her screaming out in pain, her pleas for him to stop ignored.

So, I am asking you to tell me, as a soon to be new midwife caring for women with a wide range of gynecological histories, what things should I be doing, big or small, that would make you feel comfortable?

29 comments:

Amy said...

I am a nervous talker... I tend to joke a LOT when I feel uncomfortable, which has led to some really awkward pelvic exams ("You're going to do what? Usually someone takes me out for dinner, first..."). The thing that put me most at ease was when my doctor admitted that he had, without thinking, told another patient, "I'll be out of your hair in just a minute," during a pelvic! I guess knowing that it was awkward for everyone helped me a lot.

I think it's best to base your bedside manner on the person you're dealing with. If someone is really anxious and stressed, be calm. If someone is a nervous joker like me, joke back with her so she doesn't feel like an idiot. If someone is tense, acknowledge the tenseness and promise to be "out of her hair" as fast as you can. :)

I think as you practice, you'll find that there's a right way to deal with each sort of patient, and your natural empathy will guide you toward the attitude that will make each patient comfortable. What would work for a highly anxious patient TOTALLY wouldn't work for me. Know what I mean?

Elizabeth said...

I don't generally have problems with pelvic exams, particularly if the caregiver takes the time to explain what she is checking for.

I would suggest that you ask permission to do what you are about to do, ie, "I need to insert the speculum, is that ok?" so that the women feel as if they are being given some control.

Making some small talk can help.

I think the thing I dread most is judgment from the caregiver. I was so nervous going to see my midwife for the first time; I hadn't had a pap or pelvic exam done in about 4 years because of fears and judgmental physicians. She took some time to just talk to me and get to know me bit, which was relaxing. She made an effort to relate to me as a person, asked what my goals were, asked about my history, and allowed me to tell her why I hadn't been for an exam and sympathized with me.

She also didn't talk down to me about my weight, which was really big for me. She spoke with me matter of factly about it, but no lectures, no condescension, no avoiding my eyes or anything. So it was a lot better.

Basically - she made me feel I could trust her and she treated me with respect and kindness, as a human being, instead of as a patient or another number. I still had my dignity intact when I left - despite being naked in a room with all my private bits in the air.

Marie-Baguette said...

I had a great ob gyn in Paris who would ask me lots of questions about my school, work, trips, whatever that would make me forget what she was doing. And she was excellent at remembering our past conversations. It was great. The worst experience I had was when a male doctor inserted a Cervidil without telling me first what it was (he must have assumed I knew). I felt extremely violated. Plus my husband was there, and it was just awful.

Anonymous said...

Why can't you be my provider? You are so thoughtful.

I was one of the anonymous posters below who felt abused and violated at my first exam. Since then I've seen therapists and used zoloft because of my pelvic exam phobia and my fear of doctors. I'm the one who opted for a c-section instead of having to endure the exams and exposure/touch during delivery.

I wish I had an easy answer. I think the providers who made me feel the best never pushed an exam on me and don't act annoyed or rushed, even when I know they have a full day of appointments. Several times, I've had someone talk me into an exam, probably thinking once it's over I'll be fine, and I'll have depression and flashbacks for months. Just be aware of how violating exams feel for many women and decide in each case if the stress of the exam is really worth it.

Another tip, keep the patient covered as much as possible. If you walk away from the table, drape a sheet over her. And consider not using stirrups unless totally necessary.

Anonymous said...

I'm curious...how do health professionals usually feel about patients who are terrified of exams? Do they think of the patients as drama queens, annoying, etc? Is anxiety around pelvic exams typically thought of as legitimate and serious?

PE Mommy said...

Bedside manner and how the patient likes you. I have always had pelvic exams by women. Until I had my ob. I have never ever gone back to a woman again. The women providers that I have had were rough, told me to just deal with certain gyn issues. They deal with their gyn issues, so I should be able to deal with mine. Quite frankly I didn't really care for any of their bedside manners. I know not all women providers are like this, just the ones I have encountered.

My ob delivered my last daughter. I was turned over to him by the midwives in the office because I was high risk. I have NOT gone back to them for exams. My ob has listened to my issues and he has an awesome laidback bedside manner. He cracks me up. I have never had an uncomfortable exam with him.

Anonymous said...

never forget that while to you a pelvic or breast exam is 'no big deal' it may very well be to the girl/woman even if she seems outwardly Ok with it.
I have never told any care provider of the abuse perpetrated on me by a gyn and his female partner who told me to stop crying, it was no big deal. Over the years and many children I am now pretty comfortable with pelvics, I also pick my care providers VERY carefully. It's not gender either that makes a caring provider. I've had some awful women take care of me and angelic men and vice versa.Even a whiff of disrespect for me and I am gone.
I expect it is hard to take your time and tune in to every patient when you may be seeing 30+ women a day but please try, a compassionate, listening, competent nurse-midwife is worth her weight in gold!

One more thing. Don't ever have a conversation about a woman's condition or symptoms when she is half dressed. talk to her before the exam and/or after the exam but it is only respectful of the patient that both of you have your pants on during an important conversation.

Angi said...

If you wear prescription glasses, invest in non glare coating. It's really bad to have your Gyno/Midwife talking to you during the exam and seeing what's happening in the reflection of his or her glasses.

Labor Nurse said...

Angi, I never would have thought of that!

Anonymous @ 8:07pm: that's a good question. All of the preceptors I have worked with have been very patient and calm with women who were petrified. I have worked with on physician who would be very obviously annoyed. So I guess my answer is that I think most providers try to be understanding to varying degrees, and some just clearly have no tolerance.

I am a Monkey's Mama said...

I honestly don't know what I need at this point. The last time I had a pelvic exam was when I was in labor with my daughter 2 1/2 years ago. I felt violated, invalidated, and invisible during those moments--I've now come to realize that I was birth raped.

I can tell you this much...my midwife and I had a long discussion about pelvic exams because I declined the pap at the beginning of my prenatals. I opened up to her the best I could at the time to explain *why* I didn't want to have one done and she was quite understanding. She did explain that in the long run she will probably need to see my vagina (in labor, afterwards, etc) but that she understands that I need to build a trust in her first.

So, I guess my long winded point is, if a woman feels uncomfortable with a pelvic exam, please take the time to get to know her and let her get to know you. I know that trust is a huge issue for me and many other women in my shoes. Maybe offer her an additional appointment to have the exam done so that she is not allowing a stranger to talk her into anything she isn't comfortable with.

Anonymous said...

I would say have a humble attitude with your patients and don't come off as a know it all with a high and mighty persona. It works.

Anonymous said...

I hate having my provider rush through everything. I have so many questions and I have a hard time using the right "lingo" but I am still a human. I hate being dismissed and having to go home and google everything I don't understand-- for example, I had a preterm birth and now I want to know if there are risks for having another child. Three different doctors won't discuss it with me and just skirt the issue.
You could do wonders for women simply by sitting down and, even if you have ten more patients waiting for you, try to make sure they have their questions answered before you leave the room.

Laura said...

1) If you're going to do something that requires a bit of force/pressure, please say so. I had the *cough* pleasure of having a student midwife practice her bimanual exam skills on me during my last appointment and she was more than a little rough. If she had said that she needed to use pressure for some reason (feeling for something, I don't know), that's fine, but I would have liked to know if I should have asked her to be gentler or not.
2) I know you're concerned for your patients well-being in general, but if I'm there for a pelvic, I probably don't want to discuss my other medical conditions. It's hard enough being fat and having borderline high blood pressure as it is; I don't need to hear about it from the nurse AND the doctor AND the tech who's reviewing my file with me. I follow up on it with my primary, that should be sufficient.

michelle said...

I have ptsd from years of molestation.Exams and instruments put inside me continue to be upsetting. When I try to briefly explain (I don't want to take up a bunch of time - I've been through years of therapy) that it's hard - I always get shut down when the response is something like it won't be that bad, or afterwards, you did just fine. Well, I did just fine because I finally dissociated. I also don't like small talk - so maybe just ask whether she wants you to be quiet or does chit chatting make her uncomfortable. I know everyone is pressed for time - but just asking instead of putting words in my mouth or assuming goes a long way. And, keep me covered up. And, understand I know my butt needs to be at the end of the table, I'm working on getting it there, and yes I understand I need to let my legs open, don't get frustrated w/ me - I'm trying.

Best response I ever had, a male ob/gyn after I told him in about 10 words that I had been molested, got teary eyed and said, I can't imagine someone doing that to my daughter (his baby girl was about 2).

And, when I went in to be induced w/ the same dr at nearly 42 weeks w/ prosta gel - the nurse whipped off the sheet as he came in, he took the sheet out of her hand, covered me back up, and went through the side so that I stayed covered up. We had never discussed it again, but he remembered.

Anonymous said...

This is a subject I feel strongly about. I think that by simply asking this question you have come much farther than your professional peers. My worst experience was with a gyn surgeon with a strong reputation for his surgical skills. He expected all his patients to be waiting in stirrups, including ones he's never seen before. He got annoyed with me that I insisted in keeping my pants on initially. His exam was extremely rough and he yelled at me that I had my Nuva Ring in (no other gyn had a problem with that). After diagnosing me with severe endometriosis and bullying me into a laporoscopy, he casually remarked that it will take me years to conceive. He refused to discuss my concerns about surgical complications and infertility. I went for other opinions. I canceled the lap two weeks prior to the date - he yelled at me in front of my husband. I did not trust him his cavalier attitude towards my supposed infertility. He was wrong. Two weeks later I conceived my beautiful daughter. A year postpartum my ovaries are clear of cysts and my menses almost non-painful - I suffered mind numbing pain before.
My other negative experiences have been not with OBs (I have never seen a midwife) but with ultrasound techs who tend to be rude or silent as they dig around your vagina. I hated that factory line feeling I had. Thankfully I had a highly positive birth experience by an OB and a wonderful L&D nurse (another Nurse Ratchett thankfully went home)...
As an incest survivor, I find the exams unpleasant at best and horrifying at most. Feeling respected as a human being is what makes the most difference for me. Good luck with your career...I wish you practiced in my area...

Anonymous said...

I have had 4 exams/Pap smears in my life (I'm only 24, don't worry) and am due for my next in a couple of months. The problem is, that over the last few months I have begun therapy, finally confronting the fact that I was sexually abused as a teenager and facing all of that has me nervous of my next exam.

I have been battling panic attacks since the beginning of the year, and when I went with some friends to a spa for a massage I was taken by suprise at my reaction. I am afraid that with an even more "invasive" poking and prodding, that I won't be able to hide my anxiety.

Is this something I should bring up? I mean, I've had previous exams with no problems, so I know it's possible to get through one.. it just scares me to think that it may be so much harder for me now.

Anonymous said...

Be gentle and experienced enough to know how to be gentle. I had a male PA convince me that I didn't need a separate OB/GYN appointment for my routine exam/pap. I thought "Well, I trust him for my other health issues, why not this?" It was the most excruitating exam I've ever had. It was obvious he was rather inexperienced and uncomfortable. His discomfort and roughness made me uncomfortable. More than unpleasant, it felt like a violation, even though logically I knew he was doing his job. My take - if it isn't something you do often enough to be comfortable, don't! Also, don't use me as practice if you are a student or inexperienced without informing of such. I should be allowed the information to get to determine who is comptent to touches my body.

Jawndoejah said...

I've never had a problem with vaginal exams until my last birth, the nurse had me flat on my back (as I've written in here) and she kept her hand in my vagina between contractions pushing the cervix back. She also stretched the area between vagina and rectum during contractions, kept taking her hand out and putting it back in. She checked my cervix every 20 minutes (she said this out loud otherwise I wouldn't know, just that it was often). She didn't really put a drape on me or anything, I was flat on my back and scared of the decels. I felt very open and embarrassed, very violated. Since she and I had already "argued" I was apologizing for questioning her, and that made me feel vulnerable. She told me what she was doing, but wouldn't understand that some of my questions like, "should I be flat on my back" were actually cries to get off my back. When I said, "ouch" as she pushed my cervical lip back during a contraction, she didn't acknowledge the pain. It was all unneeded. I felt she gave me no options, was doing what she wanted to do, and gave me no voice. My shirt was up because of the monitor, so I could feel the open air on my pubic area and lower belly. No curtain, so if anyone came in they could see a full view. She sat down on the end of the bed as she did this too, not allowing me to sit up (can you sit up during a vaginal exam?). Since I was scared due to O2 on my face because of decels, I was scared of the time she was taking having me flat backed with fingers inside me pushing on cervix or stretching peri area. This was my 6th born, did she need to stretch me? It's been 7 months, I still feel a bit of anxiety thinking about it to this day. Usually, a quick exam is best, and then cover me back up after you take your hand out. If there is a monitor, can they still put a drape on or sheet below the monitors so a person doesn't feel so naked? And why all the internals? I was afraid of infection, afraid of the decels, and flat out embarrassed...

My OB is good about telling me what she's doing, and getting in and out fast in my case. I'm sure if someone expressed anxiety, then you would ask if it's better to take each step slowly or to get it over quickly....

Blessings!
Dawn

Anonymous said...

Two things that drive me crazy: Saying "you'll be just fine" before the exam. The dr. doesn't know that. And it minimizes how traumatic the exam is for some people. And afterward, saying "see, you did fine." They have no way of knowing how I'm doing. A PA said this to me at my last exam, and a year and a half later I still think about the exam all the time and have flashbacks and anxiety. She assumed that since I was quiet and my crying had subsided that the exam was a success. I think I was in shock. That PA doesn't realize how much the exam affected me, and if she would have asked how I was doing instead of assuming, I might be willing to actually have an exam again.

Anonymous said...

I never really had a problem with a vag exam (either during labor or pap smear) until I was in labor with my third son. My nurse was sooo rough, that was the first time I ever crawled off the bed, so to speak. I now work on that unit with that nurse and realize that is her personality. Very hard and loud.
Anyway...my only advice to you is to be gentle. A caring, quiet and gentle attitude goes a very long way! From all your posts, you seem to be very kind and caring, so I am betting that you will have no problems making your patients feel comfortable!

mamaloo said...

I was 2 cm, PROMed, in labour with my second at a homebirth (that my very medical midwife did not want me to have as she's anti-homebirth).

The student midwife did an exam as gently as she could but had to dig a bit and wasn't certain if she could feel the broken membrane. Her preceptor, my primary, went in and felt around and when I started to crawl backwards up the bed she scolded me, "I have to find the membrane". Then I felt excruciating pain and barked, "what are you doing!" To which she replied sweetly, as she removed her gloves, "I was just stretching your cervix a bit. You do want to have this baby today, don't you".

I slapped her arm and shouted back at her, still in pain, "you are supposed to ask a woman to do that!" I was in shock that a midwife would actually stretch an already dilating cervix without once informing her client.

Of course, just like my previous labour, which she didn't trust me about either, I had the baby about 9 hours after my fist labour twinge and my PROM (about 4 hours of active labour). My second stage was 3 minutes long. My midwife sat on my front porch while I laboured inside. If I weren't a doula who wants to preserve my relationship with the busy practice my primary works at I would have made formal complaints to the appropriate licensing and registry associations.

My advice: ask permission before doing anything. "Is it OK if I put the speculum in now?" "May I stretch your cervix a little?" "I need to collect some cervical cells now, may I swap your cervix?"

Joyce said...

Boy, this topic has gotten lots of responses. I guess you've hit on something here. I have to say the doc I see in a big teaching hospital is very matter of fact and says what she is doing as she does the exam. She also comes in and inquires about my health in general even before she gets to the "take your clothes off and put this johnny on with the opening in the front." Maybe her being a woman gives her an advantage of knowing what makes another woman comfortable.

Anonymous said...

I feel for all the pain these women have posted about. I don't have the history that they have. I could not imagine having an exam with this type of pain.

One recommendation that I have is that my new ob had a 2-week postpart appt. for me. No undressing or checks, just discussion and questions. I didn't have that with my first birth/first ob; it allowed me to bring up some issues I had had with the nursing staff during my labor.

Anonymous said...

What is it with the stirrups? I'd had yearly exams for 15 or so years before coming to this country and never seen stirrups. They are uncomfortable and dehumanizing. Neither have I had to have my "butt at the end of the table".

The practitioners I've seen here (had a pregnancy and miscarriage a few months back) have varied from really nice (the midwifes, and a terrific ultrasound tech) to v average OBs and the most awful nurse who insisted on referring to it as my VAJAYJAY, and not washing her hands after testing my urine. (Yuck! Glad I was the first patient of the day.) In general practitioners seem to be much rougher in the US. I had never been hurt by an exam before I came here but it seems almost par for the course here. Very sad.

Anonymous said...

I don't know, I figure it like this: Considering society's views on genitals, if a doc isn't already TRYING to be cool, then they aren't a good doc to start with. I've experienced one painful exam my whole life and I let him know about how much he sucked. During births I just missed slapping one nurse (my grandma was quick and caught my hand), kicked her and several others out because they were rude (one actually told me to quit crying), kicked a doctor out (my doctor was out of town), and walked out of the office of another refusing to pay because she started yelling at me the minute I walked in the door. WE are in control ladies, always. In all 5 births, I've always been in control. In all gyno exams, I am in control. My vagina, I'm the boss. We need to remember a doctor can only do what we allow. That doesn't mean be hateful, but don't hesitate to tell them, "you'll listen to me or I'll take my money elsewhere." even if you're feet are in the stirrups. WE pay THEM. I'm no doctor hater at all, but there's got to be a mutual respect there. My gyno shows a great deal of respect for me and I love him to death. I pay him very well for it joyfully. Just remember ladies, we are in charge and don't be afraid to say so. Doctors can only advise us, it's up to us how we take it.

Anonymous said...

I was sexually abused for many years, starting at an extremely young age. I also am a 32 year old virgin, based on religious principles. Those two things make for some really rough exams.

I am not good about going yearly, but I do go as regularly as I emotionally can, and I know that if I am ever sexually active I need to be better at this. I've been tested for STIs, so I feel fairly safe. My doctor isn't thrilled because my grandma died of ovarian cancer, but I do the best I can.

When I go I explain my history and tell the doctor I need to know what is going on, step by step and with some delay before it occurs. Sometimes there are false starts; I pull away and need a second to recover. I also ask that the nurse as well as the doctor work to keep me in the moment. At my first exam they tried a regular speculum and since then I've known to ask for a very small one to be used.

My current doctor is fabulous. She starts every touch at my knees, tells me that she's moving downward, walks her hands down my thighs, and then does whatever. That helps SO much because there is no time to focus on anything else.

This also is a small thing, but she uses real gowns at her practice, not paper ones. I could see her 10 minutes from home, but I drive 45 just for the real gowns at her main office. It's somehow a control thing.

Also, it is really important to me that I dictate how things go. My first exam was ok, I knew and liked the NP who did it, but I was also freaked out. My friend came with me, but the NP asked me to have the exam alone because she wanted me to make it through alone, or something like that. She didn't want me to have the chance to psychologically remove myself. I did fine, but I really could have used support as they did the STI swabs because that was one of the most angering things ever in my life; I had never once been close to sexually active and I was going to have to PAY for those tests.

Thank you for caring.

Anonymous said...

For me if the person performing the exam talks to me it goes a lot better because though I'm frightened I will focus on the conversation and not on the speculum or whatever else is occurring. It's better to talk about general things not personal things.

Also some patients just need more time. There's been times, at the beginning of a procedure, when I just need to stop and start over.

If someone seems visibly afraid, don't yell or get angry with them. It doesn't help the situation. I know that often times people are in a big rush and time is money, but if someone is scared hearing anger will just make them more uncomfortable and frightened.

Thanks for asking. I wish more people who did gynecological exams asked these questions.

Anonymous said...

I agree with the poster who mentioned real gowns. When my Mom had breast cancer, her reconstructive surgeon had real gowns and it went a long way in making her feel human. I remember her mentioning this to me several times. Since then, I've always wondered why obgyns don't have them.

Anonymous said...

I've been molested, am 40yo never had sex, never had an exam. I'm a nurse and have assisted with exams. Everything I can think of has been covered except after the exam is over go do something else for 5-10 minutes and let the patient get dressed and get her bearings without being rushed. So often the examiner covers patients up with a sheet and starts talking. I for one would never remember what they said, or have any questions. I would just want them to get out...

Anyway, thanks for asking. The fact that you ask says you are already doing very well.