80% of the women appreciated having someone to listen to their problems; there was little change in the physical outcome of the pregnancy.21 In addition, I suspect that midwives and doctors are haunted by the fear that they might miss something (or at least be accused of missing something) if they don't conform to the expected ritual.Current moves to demedicalise and decentralise childbirth, potentially providing more continuity of care, are necessitating radical changes in the organisation of maternity care.22 They should be seen as an opportunity to discard outdated rituals, rather than simply to transfer them from doctors to midwives. The time saved could be channelled into prospective trials of more promising interventions, such as programmes of smoking cessation, and increasing the time available for training in counselling about the many new screening tests becoming available in early pregnancy. The routine six week postnatal vaginal examination Forget it We have been schooled to believe that routine postnatal vaginal examinations at six weeks are necessary, and current obstetric and midwifery textbooks perpetuate this teaching. We are told how to examine for supposed abnormalities and what correction may or may not be needed. This advice is based on supposition and has now been challenged. Strube pointed out that this routine vaginal examination is illogical.1 Bowers found that women viewed discussion concerning their baby and how they felt and contraceptive advice as more important than a physical examination.2 Sharif et al studied the case records of 150 women attending their doctor for postnatal checks.3 Although only 25 had a specific indication, they all had a vaginal examination. An "abnormality" was found in only six of the 125 women who had a routine examination without any specific indication: three had an asymptomatic "bulky" uterus and three had cervical ectopy. None ofthese patients had any treatment.
PHILIP STEERSome doctors and midwives recommend that women should not have sexual intercourse until after the routine vaginal examination at six weeks but most women resume sexual intercourse before the postnatal visit-usually between two and four weeks after birth.45 Some women experience discomfort or bleeding from their vaginal or perineal wounds, but they do not experience important harm.Some women may have been conditioned to think that a vaginal examination is important, but most see it as a necessary evil rather than a helpful experience.6 The examination consumes resources, requires a chaperone for male doctors, and uses time that would be better spent on counselling; it should therefore be done only when a specific indication exists. These are mostly obvious and include abnormal discharge and dyspareunia. Women wanting reassurance and those who wish to combine their postnatal visit with the insertion of an intrauterine device or a repeat cervical smear test should also be examined. In addition, those few women complaining of stress incontinence should be examined, mainly to ensure t...
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