PELVIMETRY

I made a decision to risk failing my “Practicum exam” – one of the four required board of exams I had to take in order to obtain my midwifery license.

Yep, you read that right!! One of the four exams I had to take to get licensed, one of the exams that I would have waited 6 months to retake if I’d failed it – I willingly and knowingly CHOSE to risk failing it. Why would I do such a thing? For me, it was an ethical decision.

Let me back up a little and explain. I know how controversial it is for a midwife to say what I’m about to say, but here it goes. I DON’T BELIEVE IN PELVIMETRY. There, I said it – publicly and loudly – and I’m prepared to deal with the wrath of the midwifery community. You see, pelvimetry (or “measurement of the dimensions of the bony birth canal (to determine whether vaginal birth is possible)”) is something we are taught, something that we know we will be tested on….it is heavily covered in most midwifery texts and something that many midwives do on the first appointment. And I don’t agree with it in principle.

The theory is that if you determine the pelvic shape (these are divided into 4 basic defined shapes) and, by using the fingers to measure the internal bones of the pelvis, measure the opening then you can determine whether a baby will be able to be born vaginally.

My problems with this are PLENTY!

In the absence of a severe abnormality (which the mother would certainly be aware of since she would have had a birth defect or a pelvic injury or notable rickets), why do we feel that we have the ability (or need) to determine this ahead of time?

Instruments that USED to be used for pelvic measurements during pelvimetry

First the ability – we used to X-ray women during the end of pregnancy to measure the baby’s head and compare it to the pelvis to see if it would fit. The problem with trying to PREDICT if the baby will fit is that everything is so dynamic during the birth that our previous measurements become totally and completely irrelevant!! Our pelvic bones open and can actually SEPARATE during the birth (and it’s meant to do that! There is even a specific hormone that is created in high levels during pregnancy for just that purpose – the hormone is Relaxin and it loosens up the pelvic ligaments and cartilage so that it can safely stretch open without lasting damage). Baby’s head is made of multiple bones (unlike ours) specifically so that it can mold and shape to fit the mom’s pelvis.

Second the need – what are we going to do with the information we think we are gathering? Would a midwife really turn someone away because she has a pelvis that she feels is questionable? How very sad. There are so many other factors involved (for example: the actual position of the baby’s head) that I think it’s rather arrogant for her to assume that she has the ability to predetermine who can and can not have a vaginal birth. If you aren’t going to turn her away, then why are you looking? What are you going to do with that information?

Here is the thing….her pelvis is her pelvis, we aren’t changing it for her! We can’t change the shape of her pelvis, it is what it is. Knowing that….she will either be able to birth her baby vaginally or she won’t – and us trying to determine that ahead of time is, in my opinion, of no benefit to her.

I had a long discussion with a midwife once whose basic argument was, “I want to know ahead of time if there is likely to be a problem.” My response was: WHY? Why do you want to know ahead of time? She said that way she could get the mother into favorable positions to help facilitate the birth. My response to that was: Moms will naturally assume favorable positions – and if she does not and labor does not progress normally, then that issue will present itself and at that point we can make suggestions.

That midwife said, “Well, don’t you want to know if she will have problems birthing?” You know what…I don’t…I really don’t. I don’t want to go into that birth with any thought other than excitement that she will be welcoming her baby into her arms soon. If problems crop up, we will work on fixing the problems (whatever they may be) – but no, I do not want to go INTO a birth EXPECTING problems!! Like all other aspects of her care, I prefer to assume that everything will be perfect and only respond to those problems that present themselves. To that end I say NO….I do not want to try and guess that she will have problems birthing, I prefer to enjoy the beautiful birth experience without preconceived notions or restrictions.

I feel like a traitor to my profession in some ways, as it seems like I’m the only midwife that doesn’t believe in the benefits of pelvimetry, but it is something I feel strongly about. How strongly?

I made a decision to risk failing my “Practicum exam” – one of the required board of exams I had to take in order to obtain my midwifery license.

I worked for 8 years to become a midwife – with as much passion as I think a person can have for such things. After passing the NARM, after passing my state rules and regulations exam, after passing the oral exam…..it was time for my FINAL exam before receiving my license – the Practicum exam to test my practical skills.

Throughout the exam I was required to perform several different tasks – go through the protocols for shoulder dystocia, how do you put on sterile gloves, how do you do a urine dips, take this pregnant woman and do a medical history, do a blood pressure, etc etc etc….8 hours of hands-on practical skills. The examiners marking things off on their papers like a checklist – whenever I got something right, CHECK. They were grading me on my performance.

I knew it was coming, and while I’d like to feel self-righteous and tell you that I knew all along what I would do, I can’t say that. I knew they were going to ask me to perform pelvimetry on a pelvic teaching model….I had studied it, knew how, and yet philosophically disagree with it. What would I do when asked to perform the exam?

Holding a pelvic model in her hands, one of the examiners told me to perform a pelvic exam as I would normally on a first visit with a new clients including bimanual exam (feeling inside and outside at the same time to check for any masses or abnormalities) and pelvimetry. I began going through the steps of the exam visually, then inserting my hand and explaining bimanual exam and cervical exam.

I stopped…withdrew my hand…and said, “And I do not do pelvimetry because I do not believe in it.” There…I did it!! My heart was BANGING in my chest. I felt empowered, I felt true to myself, and I felt scared to death that the amount of points I just chose to forfeit would deny me a goal I’d worked 8 years for (we didn’t know ahead of time how many points each skill would be offered or anything like that at all). What I did know is that I just forfeited all of the pelvimetry points on the exam and would have to do extra-well on all remaining sections in order to possibly pass my exam.

But I was true to myself…and true to the midwife inside myself. I still do not do pelvimetry and never will.

And I passed my exam.

29 Comments

  1. Amy Lynn Drorbaugh wrote:

    Amen.

    Saturday, August 14, 2010 at 1:22 am | Permalink
  2. Diana J. wrote:

    Very interesting! And I know at least one other MW who doesn’t believe in pelvimetry. 🙂 I read “Heart and Hands” and noted Davis’s belief in pelvimetry, when contrasted with how unimportant my MW friend considered it to be, and I found it an interesting dichotomy. Glad to hear your points on it!

    Saturday, August 14, 2010 at 1:31 am | Permalink
  3. Alison wrote:

    Yep, I’ve seen babies born through pelvises who weren’t supposed to be able to fit. Pelvimetry is, at best, guess work.

    Saturday, August 14, 2010 at 1:57 am | Permalink
  4. Cherise wrote:

    It’s SO true!!! Birth is not so simplistic as taking an x-ray – or manual exam to judge whether the baby will come out the vagina!! There are MANY aspects of birth, MANY things must go right – and most often will if allowed to. There are ALWAYS exceptions to every rule, but the rule is, (in my book) women’s bodies aren’t “good or bad” for birthing… the same woman may require a cesarean for one birth, and experience a vaginal birth for another. It’s just too complicated to be so black and white, or presumptuous.
    After my cesarean with my first, the doc walked in and said “this is great, you [I] don’t have to wait around for the next one, we’ll just schedule it!” stunned, I asked: “well won’t you let me try again?” equally stunned, she replied: “well…. if we know you make babies too big for you to give birth too… why put you through it?” I knew at that moment what I should’ve figured out long before, she would not be the one assisting me for my VBAC – a 7lb 4oz baby which I birthed naturally, on baby time, 22 months later.

    We are ALWAYS changing… we must embrace our future with HOPE and great LOVE.

    Perhaps my favorite post of yours, Stephanie, thank you.

    Saturday, August 14, 2010 at 4:20 am | Permalink
  5. Cherise wrote:

    And a BIG CONGRATULATIONS for sticking to your guns!!! You are an example to me, most of us would’ve gone along with it all. I love it.

    Saturday, August 14, 2010 at 4:22 am | Permalink
  6. Rachel wrote:

    Stephanie, I had never thought about pelvimetry in this way. But it totally makes sense! We choose to trust birth; we believe women know how to allow their babies out. I agree — it’s detrimental to both the midwife and the mom to expect something to go wrong. I am a long way from taking any midwifery exams (though someday in several years, I hope I am at that point!), but your example is very inspiring to me.

    Saturday, August 14, 2010 at 7:42 am | Permalink
  7. Erika Obert wrote:

    Stephanie, you are not alone. I don’t believe in pelvimetry either. This goes along with I don’t believe in routine prenatal cervical exams and I don’t believe in scheduled cervical exams during labor.

    One aspect of doing pelvimetry is what do you tell a mom who has a ‘marginal’ or ‘inadequate’ pelvis? Then I wonder how knowing that her midwife thinks her pelvis is barely adequate or, worse yet, inadequate will affect her labor? Along this line of thinking, then, does anyone else wonder if pelvimetry sets a mom up to fail?

    Glad you passed your exam Stephanie. The midwifery world is definitely better for it 😉

    Saturday, August 14, 2010 at 9:53 am | Permalink
  8. elfanie wrote:

    thanks Erika….and I absolutely believe that it sets a woman up for failing. If she DOES have a “more challenging” pelvic shape to work with, then it could possibly mean a little bit longer of a labor – if the midwife (and/or the mother) have a preconceived notion that she will be unable to birth her baby, then I think it’s almost inevitable that BOTH of them will throw in the towel much much sooner – after all, they now have PROOF of what they suspected all along rather than working with the current situation. I think women have enough problems with self-doubt without adding THIS to the mix…and they deserve a midwife who believes in them entirely, without reservation…..not one ready to jump to interventions because she already think there’s going to be a problem. (and even suggesting position changes, to me, is an intervention)

    Saturday, August 14, 2010 at 10:01 am | Permalink
  9. Tiffany wrote:

    I remember being taught pelvimetry when I was in school. I learned that stuff so I could pass the tests. How often do I actually use it in practice? NEVER! And I certainly wouldn’t dream of telling a women ‘wow, you have a narrow pelvis’, etc. I’m right there with ya girl!

    Saturday, August 14, 2010 at 10:37 am | Permalink
  10. Amy Lynn Drorbaugh wrote:

    The part of this post I loved the most was not about pelvimetry but your desire not to go into a birth with any preconceived notions. How many births have had complications because a midwife (or doctor) expected something to go wrong. Your absolute faith that everything would work perfectly gave me the ability to have the same confidence.

    Saturday, August 14, 2010 at 12:22 pm | Permalink
  11. Well said! And if we take your theory about bringing “expectations” of problems “into” the birth experience, we are inserting our beliefs into the process and affecting outcomes…in my never to be humble opinion. I’ve seen it! I’ve come to know what to expect as a doula when I attend different local midwives’ clients births based on the beliefs and biases I’ve heard them express to their clients! Self-fullfilling prophecy?

    Saturday, August 14, 2010 at 12:51 pm | Permalink
  12. Katie B. wrote:

    Wow, there are *midwives* who believe in that nonsense?!

    Now, it’s probably obvious just looking at me that my pelvis is more than “adequate”… but I see HMO CNMs for my prenatal care, and not one has even SUGGESTED pelvimetry – and I know enough to recognize the motions, even in retrospect. If hospital-based CNMs working for a large HMO don’t think about it, what business do homebirth midwives have clinging to the idea?

    Saturday, August 14, 2010 at 9:44 pm | Permalink
  13. Rachel Reed wrote:

    Wow – is pelvimetry still out there? I’m pleased to say it doesn’t happen here in Australia (plenty else does though). I have issues about how we learn about the pelvis too. I am supposed teach A&P of the pelvis to students but refuse to teach ‘diameters and numbers’ because it is nonsense. I also don’t teach the ‘mechanism of birth’ because it is simply not true unless the woman is on her back having the baby removed.
    Thanks for the great post!
    Rachel

    Sunday, August 15, 2010 at 12:21 am | Permalink
  14. Kelli wrote:

    There is a reason I told you I admire you, that sums it up. Even if someone doesn’t agree with you, I think they should definately respect your intentions of keeping total faith in your clients, your honesty in sharing your raw opinion, and your remarkable resolve. Thank you for giving us all something to think about.

    Sunday, August 15, 2010 at 1:54 am | Permalink
  15. Enjoy Birth wrote:

    I too loved that you don’t have preconceptions about a birth. Assume things will go great and if problems arise then deal with it then.

    Sunday, August 15, 2010 at 10:11 am | Permalink
  16. becomingpurple wrote:

    I’m currently in DE midwifery school and we ever so briefly went over pelvimetry at the very beginning. I’m with others who say “is this really still a pervasive philosophy?” So far, the midwives I’ve worked with (both for my own homebirths and as preceptors)have never brought it up. Heart and Hands, while being one of the beautiful Bibles of midwifery, has a few things that are outdated in some regards. (I know,I know….blasphemy..;-) Much of the foundational literature of that time was reflected (albeit minimally) on the mainstream OB approach.
    In my area, you will find OB’s that still do pelvimetry but they are usually older and have one foot out the door. Ironically, the 21st century OB environ is emulating the midwifery model of care, ever-so slowly but surely. I think the young midwives are going to see some very significant changes in their careers! And, ultimately we can thank Ms. Davis (and many others) for her huge contribution to creating that slow-as-molasses shift.
    Thank you for mentioning to not go into a birth with preconceived notions. I wholeheartedly agree with you and thank you for reminding me. Whether spoken out loud or not, it creates an energetic presence that a laboring woman can pick up on during the incredibly “open” time of labor.
    Finally, Relaxin is such an important hormone for pregnancy and I appreciate you bringing that up as well. It not only works on the sutures of the mother’s pelvis to open wider, but also on the ligaments and muscles that surround the area. Our bodies were designed for birth and they are designed for survival. We each have protective measures that are initiated according to our needs. Most of the time it works, but there are times where having the watchful eye of a midwife to suggest positions, maneuvers or bodywork for assistance is crucial.
    Thanks for this thought provoking commentary!

    Sunday, August 15, 2010 at 11:41 am | Permalink
  17. Melissa wrote:

    I was SO relieved to read this post! I have never given birth before but at a routine OB/GYN visit during an exam my doctor looked up and said to me “You’ll never give birth vaginally, your pelvis is too small. I’ve been delivering babies for 20 years and I’m telling you’re going to need a c-section.”

    I went home and cried. I still get choked up thinking about it because I have always wanted a home birth and for the past few years thought it was not a possibility. You have given me hope!

    Friday, August 20, 2010 at 2:23 pm | Permalink
  18. Mandy wrote:

    I have always believed that pelvimetry is bunk, ever since I first read about it in Spiritual Midwifery. We have no way of knowing how much the pelvis will spread or how much the baby’s head will mold or even how big the pelvis has to be to have a baby anyway. Barring severe pelvic injury or rickets, I am of the belief that a woman’s body will not build a baby too big for her to birth and also that FAT IS SQUISHY! So why are we so worried about the bigger babies? Their bones are not generally that much bigger, they’re just a bit fatter.

    I’m working on becoming a midwife and I plan to refuse to do pelvimetry as well. It gives us no useful information whatsoever and does nothing but place doubts in the minds of both mother and midwife.

    Saturday, September 4, 2010 at 5:51 am | Permalink
  19. Stephanie, this is your the first post of your blog that I read and I like it! I have read about pelvimetry in some of my midwifery books and I always skip it… and ignore it. It never made sense to me if you truly knew how the pelvis works and the relaxin and the baby’s skull and everything so it never made sense to me that this info was in a homebirth midwifery text! Weird. I always thought it was outdated info that no one paid attention to. I am very disheartened to hear that homebirth midwives are expected to know this, to use it and that it is somehow a normal thing.
    I completely admire you for standing your ground, for risking failing your exam, and for sticking to what you believe. Good for you!
    You would be a midwife I would love to have had at my birth! :]

    Monday, September 6, 2010 at 3:06 am | Permalink
  20. Allie wrote:

    Ok,
    I would love some feedback on this comment if anyone is up to it! I had my first baby a year ago. 15 hours of induced labor. I stopped contracting at 8 cm and after about an hour of nothing happening they made me have a c-section. They said the baby was too big and my pelvic bone too small. I had never even thought that was possible. She was 9lb 5oz. I want with all my heart to have a VBAC this next time. I’m honestly scared to death of it though. Thinking about it gets my heart racing and my head fills with all of the things that could go wrong and I start hearing the Dr (and my mother) telling me to not even bother trying for a VBAC because I was induced at 41 weeks and my body stopped contracting after 15 hours and 8cm. I just dont know what to do about it. I wanted to get my pelvic checked but everything you wrote in this blog makes so much sense! Help! 🙂

    Thursday, October 14, 2010 at 1:08 am | Permalink
  21. Adel wrote:

    Allie, I’m not a midwife, but I think I have an answer for you. Many women are induced before their bodies are truly ready to go into labor. It is only natural then, that they may not labor effectively, hence the higher c-section rate following inductions.
    ******

    I loved reading this! When I had my first MW appoint for my first son, the MW nearly went through the roof when I refused the internal exam. She asked why and i said I didn’t believe it was necessary. She said, “How are we going to deliver this baby without an internal exam?” I said, “The baby will be born with or without the exam.” She refused to see me after that! whew!

    Thursday, December 30, 2010 at 2:00 pm | Permalink
  22. Jennifer wrote:

    First I want to say – kudos for standing up for what you believe in! It is so hard to do that – especially when something so incredibly important is at stake.

    I am a midwifery student and I just want to clarify something. Not all midwives use pelvimetry as a diagnostic tool, nor are they taught it as a diagnostic tool in all schools. When I first saw it on the syllabus, I had a knee jerk reaction about it – no way am I learning that! I believe in the ultimate capability of the woman and her beautiful pelvis! But how it was taught to myself and my cohort is that it is not meant to be used to determine whether a baby *can* be born out of the pelvis, but rather to give us information about her pelvis so that should her birth be prolonged, or the pushing stage seem to not be going as we might feel comfortable with, we might remember “Oh yeah! Her ischial spines were a little prominent – she would really benefit from this position instead,” or something like that. Its not at all to determine her abilities – but rather to give us the tools to best help her work best with her pelvis, and avoid transfer to the hospital as much as possible.

    Congratulations again on doing what you felt was ethically right and for becoming a midwife!

    Sunday, November 13, 2011 at 11:05 pm | Permalink
  23. elfanie wrote:

    That was a point that I had heard several times..(that we could use that information to give suggestions during birth if she runs into challenges)…
    but my response to that would be this: wouldn’t that information be found out during the birth? In other words…in a prolonged labor, wouldn’t you discover her prominent ischial spines during the internal exam that was used to determine that the labor was prolonged and dysfunctional? How does it benefit mom for us to go into the labor with that information?

    Sunday, November 13, 2011 at 11:14 pm | Permalink
  24. Alyssa wrote:

    I’m a midwifery student and we’re learning pelvimetry today. The instructor made sure to tell us that she rarely does them, often times if a woman seems concerned about her pelvis or has been told by another provider that there is an issue it’s an opportunity for her to reassure them that their pelvis is great and roomy!

    Friday, November 18, 2011 at 3:11 pm | Permalink
  25. Jennifer wrote:

    Elfanie, you have a really good point. But wouldn’t it be nice to know that before the woman is in a labor going wonky? Wouldn’t it be better to do something that internal when she is not in labor and you are already in there doing your bimanual exam? As a birth-worker I do not believe in numerous internal exams, and so in my practice an extra internal during labor isn’t as favorable as performing the work during the initial prenatal exam. I think, though, that what we are talking about are different styles in practice. I would never ever use pelvimetry to determine the “worthiness” of a pelvis – because I believe that all pelvises are made to have babies (unless proven otherwise 🙂 ) but I would like to go into labor with as much information as possible so that there is less “new” information to process in that moment, and so that the lady might be “spared” a prodromal labor simply because I looked to see that her pelvis *might* favor one position over another. It takes less than 10-15 seconds of an internal exam… which on a woman in early pregnancy getting an internal exam anyway doesn’t seem bad at all, but that on a woman with only 30 seconds between contractions could be traumatic.

    There is also a prevailing thought in our society – as constantly confirmed by the raising c/s rates and that Alyssa alluded to – that our pelvises are no longer able to pass our babies. And pelvimetry is an awesome time to reassure the lady that you have checked and she is perfectly built for baby-having. It might sound silly, but many of the very smart women I have labored with have expressed doubt that their baby would fit.

    Even if you choose to do it in labor, however, you still have to know it and you still have to learn it.

    I am not trying to argue in any way because I truly believe this is not right/wrong, that it is a difference in practice style. I guess I posted again just simply to express an answer to the question posted in response to my post.

    Friday, November 25, 2011 at 7:49 pm | Permalink
  26. elfanie wrote:

    Jennifer: Like I said…I don’t believe there is any way to tell who will have a wonky labor and who won’t. I don’t do bimanual examinations…so it’s not convenient to ‘just’ do pelvimetry while in there..
    and even if I did do a bimanual, I don’t believe I (or anyone else) can determine ahead of time who will have a wonky labor. I don’t do a lot of internal exams, either…so doing an extra internal exam while she is pregnant isn’t favorable, either. I believe that if her pelvis favors a certain position, SHE will be a lot more able to determine what that would be than I could with any amount of pelvimetry. And how do you know if she’s having a prodromal labor if you haven’t done an internal to determine what her cervix is doing?? Why would a woman in early pregnancy need an internal exam at all? And it would be great to reassure her she is perfectly built for baby-having…except I don’t need an internal exam or to do pelvimetry to tell her that. 😉

    Friday, November 25, 2011 at 9:46 pm | Permalink
  27. Etahl wrote:

    I think that as an Iyengar yoga student I learned that there is a lot to do for deformed bones, organs, and all kinds of problems. For me pelvemitry is another way to see into what shape a pelvic is and what exercises can help if her structure is not aligned to the physical lines of symmetry. There is lots of work to be done ahead of time, but not if its late in pregnancy.

    Saturday, November 26, 2011 at 1:05 pm | Permalink
  28. First time preggo wrote:

    Thank you for writing this. I know this is an old thread, but I hope you can come back to my comments here. I am 12 weeks preggo and recently decided I really would like to give birth at a birthing center. I have high anxiety about invasive exams and am very distressed often to the point of panic attacks at the possibility of them due to some childhood trauma. Therefore I wanted to go the MW way for a less medically focused pregnancy and to feel more in control and respected in this process. I was instructed that the birthing center I’m interested in the first exam includes a pelvimetrey. They luckily will let me put it off to the second visit so I can establish some trust with my new MW, however– they use it as a diagnostic tool. They said it is needed to determine if you can give birth at their facility. If I refuse it then I most likely will have to find a new facility. Unfortunately this is the only birthing center in the state. From what I read here and other sites it’s not necessary. Also, from an external evaluation I hope they can see I will be fine. My mother delivered 5 children with no problems and both of my sisters all naturally. I’m not petite. I’m hoping they will listen to me and respect my desires to not have any more distress than needed… But I guess I will need to have a back up plan. I never thought my current Ob/Gyn might be more understanding than a MW practice. It seems going to the birthing center I might be giving up my right to refuse certain tests. Do you have an suggestions for me as I face my first exam? I love everything about this place except for the antiqated pelvimetry requirement. I just don’t want to do anything that is an unnecessary source of strife…

    Tuesday, June 26, 2012 at 6:44 am | Permalink
  29. Student Midwife wrote:

    Hi,

    Thank you for this article on pelvimetry. I am a midwife student and came across this website in search of a real reason to do pelvimetry, I certainly don’t believe in it and have never done it to my mothers. I agree 100% with you.

    Friday, December 23, 2016 at 12:47 pm | Permalink

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  1. NHBS › Prenatal Perineal Massage on Monday, July 18, 2011 at 11:21 am

    […] is a dynamic event – our muscles smoothe away, our pelvic bones open up (remember my blog post on Pelvimetry?)….and our tissue changes with the hormonal changes of labor. I get asked to check a woman’s […]

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