Vaginal examinations, information about choices and rights.
When we hear women and people discussing their births, there are two sets of numbers we tend to hear about: Dilation* – as in how many centimetres open their cervix was at different times in their labour, and the baby’s weight.
“I was 6cm at 4.30, then two hours later she was in my arms – all 7lbs, 2 oz of her”.
Weights, lengths, head size, bump size, all measured and recorded. Where does the measurement of our cervix come into this?
Before labour, our cervix, the neck of the womb, is either closed, or open just a little bit (being slightly open is more common if we’ve previously had any vaginal births). During labour the cervix gently opens (and changes in other ways as well), to allow the baby to be born. During labour, almost all women and people are offered what’s called vaginal examinations, or VEs, perhaps around every 4 hours. This involves the midwife or doctor putting their fingers, with your consent, into your vagina, up to your cervix. They then use their fingers to work out roughly how dilated your cervix is. The measurement is given in centimetres, but there’s no ruler up there, and it’s not really an accurate measurement. Furthermore, different midwives or doctors examining the same woman or person may decide that the cervix is dilated to a different amount, so it is somewhat subjective.
What do vaginal exams feel like?
Vaginal examinations done with care and with gentle hands can be acceptable to many women and people. However, they can be uncomfortable and for some women and people they can be very painful. Some people can experience them as traumatic, which can be more common for people who have previously experienced sexual assault, but this can affect anyone.
Midwives and doctors are obliged to stop a VE immediately if they are asked to, so don’t hesitate to tell them that they need to stop if you want them to. They also can’t do the examination if you don’t want them to, so it’s worth understanding the benefits and risks in order to make an informed decision about whether VEs are right for you.
Note: a stretch and sweep of the membranes is not a part of the vaginal exam to check dilation and must not be done unless the woman or person has agreed to it in advance, as an additional part of the VE.
So what are VEs actually for?
There are a number of reasons that a VE is offered, which include:
- Trying to work out whether labour is ‘established’
- Trying to work out whether labour is progressing as expected
- Trying to work out the baby’s position
The first two are based on how open the cervix is (to decide whether a woman or person is in active labour), and how quickly the cervix is opening (to try to see whether it is opening ‘fast enough’). The third, trying to work out the position of the baby, is done by trying to decide what part of the baby is on the other side of the cervix – eg head, bottom, foot, etc, and in the case of the head, whether it feels like it’s chin-down and flexed (ideal), head forward (forehead lifted) or pointing upwards or another position. It is worth also knowing that as labour continues your baby’s head will move into different positions, this is normal, to help with birth.
Sometimes midwives or doctors may draw pictures of what they can feel and this may help them see if these normal changes have been taking place in during your birth. However, this tool is only really helpful if your baby is not making the position changes. There are things that can help this, like movement and being mobile in labour.
Using a Vaginal Examination to see whether labour is ‘established’
If a woman or person chooses to birth outside their home, in hospital or a birth centre, a VE is often offered when they arrive to see if they are dilated enough to diagnose ‘active labour’. A VE may be offered at a home birth to look for the same thing, to see whether the midwives should stay or not.
‘Active labour’ may be defined as different dilation amounts at different hospitals, but is usually either 4, 5 or 6cm. Evidence is now showing that ‘active labour’ is more likely to be from around 6cm. The purpose of placing a number on the opening of your cervix is to try to encourage women and people who are in the earlier phases of labour to stay at home as long as possible, to reduce using hospital resources, or with a home birth, to more effectively allocate the home birth midwives to those more progressed in labour. However, if a woman or person needs pain relief, or feels more confident and safe in hospital, or with their midwife with them at home, then it is reasonable for this to happen no matter the dilation of the cervix.
Midwives and doctors are not legally allowed to insist on a VE in order to allow women and people access to the hospital, or a midwife at home. If you don’t want one and you still feel ready to access care, this should be supported.
Using a Vaginal Examination to check labour progression
VEs are often used to check how far through labour a woman or person is. As the approximate diameter of the fully opened cervix is 10cm, it’s therefore assumed that at 5cm, labour is halfway through.
This is not really necessarily true.1
Our cervix does not dilate in a linear manner, at a set amount of time per hour! We are all unique and our labours may be longer or shorter than other people’s. Our cervix can be a few cm dilated for weeks, days, hours or even minutes. Sometimes a slower than average labour can mean that there’s a problem (such as the baby not being in an optimal position to press on the cervix), but it can be tricky to tell the difference between everything being fine, and there being an issue which might benefit from intervention.
Back in 1955 a man called Emmanuel Friedman recorded the time that it took 500 caucasian women to progress to full dilation, and then recorded the averages on a graph. This graph of averages – remember that most women and people would not follow this average curve – was then used as a clinical tool that women and people would be expected to follow. If their cervixes did not dilate as fast as the graph dictated they would be considered to be experiencing ‘failure to progress’, a term which has haunted many women and people who thought that it meant that their body had failed them. Which is not the case.
Women and people whose cervixes were dilating faster than the graph allowed were not instructed to slow down their labours (!), but for those who were too slow, questions were raised and interventions – Syntocinon drips to strengthen contractions, waters being broken – were advised in order to try to speed things along. While the Friedman Curve itself is now rarely followed in hospitals, the concept of dilating ‘fast enough’ is still firmly in place.
The big question here is why there is a concern for women and people whose labours are slower than the average. One issue is that a slower labour can be an indication that the baby isn’t yet in the optimal position for birth. Keeping a woman or person on their back, strapped to monitors, means that the baby has less opportunity to twist and turn into a better position, so upright, forward leaning positions are better, or walking (up and down stairs is good – although can be tiring!). Sometimes, babies simply can’t get into a better position, and if this means that birth is really going to be challenging, or, sometimes, impossible without intervention, then instrumental assistance (forceps or ventouse), or caesarean, may be a necessary alternative. By tracking the progress of dilation it is hoped that these babies will be spotted sooner rather than later, which is likely to lead to better outcomes to both women and babies than if they are left without assistance for a longer time.
Unfortunately, and ironically, breaking the waters or strengthening contractions with drugs can make it harder for the baby to adjust their position. The cushion of waters provides a space for babies to move, and pushing a baby harder into the cervix can sometimes have a similar effect. That isn’t to say that these interventions shouldn’t be used – they certainly have their place – but in this situation they can sometimes make things worse.
All of these issues centre around the cervix – and the examination to check how dilated it is, which in turn influences whether these interventions are offered (remember: it’s always your choice as to whether you accept them). The aim is to try to work out which labours may be experiencing problems, in order to intervene appropriately, but the foundation that this is built on, the Friedman’s Curve, is flawed. Women and people do not follow a graph, especially one that was based on so few people, and all of the same ethnic origin. Therefore, using repeated VEs to see how fast the cervix is opening may lead to interventions being offered which might be unhelpful, could be harmful and for many women and people will be unnecessary.
Are there other ways to track labour progress?
There are a number of signs that may be seen as labour progresses, which can be a reassuring sign that things are moving on. Darkening line – This is sometimes called the purple line, although this refers to women and people with light coloured skin. On women and people with brown or black skin it may appear as a line that is darker than the surrounding skin. The line doesn’t appear on everyone, but if it does, it will start at the anus and progress upwards between the bum cheeks, towards the tailbone, at very approximately 1cm per 1cm dilation of cervix!
Leg temperature – The uterus needs a lot of blood flow in labour, and this can lead to a change in heat (related to blood flow) at the extremities. For some women and people, their legs can get progressively colder from the foot towards the knee. When the change of temperature reaches the middle of the calf, that very approximately relates to the cervix being 5cm dilated. This is less obvious for women and people who have an epidural, and doesn’t work in the birth pool.
Watching! – As labour progresses, women and people go further into their ‘birth zone’, and the movements and sounds that they make change. Midwives should be able to simply observe those in their care to see how labour is progressing. This is easier to see when one midwife is caring for one person, rather than the midwife coming in and out which can happen in a hospital birth. It is harder to do this when a woman or person has an epidural as this affects how labour looks and feels.
Vaginal examinations and infection risks
Our vaginas are self-cleaning – downwards. Putting anything in the vagina can push bacteria up towards the cervix and possibly into the uterus, even if a gloved hand or a sterile speculum is used as it’s not necessarily the bacteria on the fingers, or the speculum, but natural skin bacteria on the vulva and labia which can be pushed upwards. The more VEs that are done, the more chance there is of an infection risk3.
This is of extra concern if the waters have broken, or been broken. If you are in this situation you may wish to reconsider whether or not you want to have any VEs at all, or to minimise them, even if you had previously decided to accept them.
Can Vaginal Examinations be reassuring?
Some women and people do find that it’s reassuring to find that their cervix has opened to a certain amount. Bear in mind that the ‘number’ you are given may not feel reassuring! However, remember that your cervix can dilate from a small number to a big number in minutes, hours, days and even weeks and so while you might be at a 2 now, you could have your baby in your arms in an hour – or not for weeks!
Can I decide to not have vaginal examinations?
Your vagina, your rules. No one can put their fingers in your vagina with your consent – and that includes when you’re in labour. We almost never do vaginal examinations on other mammals in labour, and women and people have been giving birth without VEs for millennia. Plenty of women birth without them, and declining VEs is becoming more common as women and people learn more about what’s right for them.
What does the evidence say about Vaginal Examinations?
Cochrane, an organisation which produces useful summaries of medical evidence, states:
“It is surprising that there is such a widespread use of this intervention without good evidence of effectiveness, particularly considering the sensitivity of the procedure for the women receiving it, and the potential for adverse consequences in some settings.”4
They also said that there is no evidence to support or reject the use of routine VEs to improve outcomes for women or babies.
Vaginal examinations can offer useful information in some situations, but as a routine intervention they can be uncomfortable or painful, and for some women and people, cause distress or even trauma.
While they may have their place in some births, there is very poor evidence to support their routine use, and yet they are offered to women and people throughout their births and sometimes people find themselves under huge pressure to comply, especially if the VE is use as a requirement to access care. In this case, consent for the VE is not being given freely, and so the midwife or doctor who does it may be committing an assault. There are other methods, as suggested above to help assess how far along in your birth your are. It is always your choice whether to accept or decline a VE. Your vagina, your rules.
*The word ‘dilatation’ is the clinical term used by midwives and doctors, but most people refer to the dilation of the cervix, which is why I have used this term in this article.
- Ferrazi et al, Progression of cervical dilatation in normal human labor is unpredictable: https://pubmed.ncbi.nlm.nih.gov/26230291/
- Shepherd et al, The purple line as a measure of labour progress: a longitudinal study: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2954951/
- Gluck et al, The correlation between the number of vaginal examinations during active labor and febrile morbidity, a retrospective cohort study: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7183634/
- Cochrane 2013, Routine vaginal examinations in labour: https://www.cochrane.org/CD010088/routine-vaginal-examinations-in-labour