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.

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