The Big Picture: Understanding Vaginal Examinations in Labour

I’m going to start off today’s blog post with a brilliant quote from Emma Ashworth (Birth Rights Consultant)…

“You have the same right to put your fingers in the vagina of your midwife or doctor, as they do to put theirs in yours, i.e. NONE, without consent."

Vaginal examinations (VEs) are often thought to be a mandatory part of labour, something you have to endure if you want to be allowed into hospital to give birth. Spoiler alert - they’re not! It may be hospital policy, but it’s still your decision. It’s important to learn what these examinations are, why they might be suggested, and the pros & cons, so you can make an informed decision and include this in your Birth Plan. Luckily for you, I’ve summarised some key points below to help you decide!

Let's understand what vaginal examinations are

A vaginal examination is an internal examination performed by a midwife or doctor, to check labour progression. They do this by inserting two fingers into your vagina to feel for several things:

1 - how dilated your cervix is. Full dilation is 10cm, roughly the size of a baby’s head at term (all women are different and full dilation might be 9cm for you). Remember, just because you reach full dilation it doesn’t mean your baby will be born immediately or that it’s time to push. Your baby might still need to make their way down the birth canal fully to be ready for birth. You will know when baby is in the prime position as there will be no stopping your body taking over with that pushing feeling - known as the fetal ejection reflex.

2 - how effaced your cervix is (how thin and short your cervix). This is described in percentages; when your cervix is 100% effaced, your baby is ready to be born.

3 - fetal station: how far your baby’s head has descended into your pelvis. The stations range from -5 (head is high and not yet engaged in the birth canal) to 0 (baby’s head is engaged) through to +5 (baby’s head fills the vaginal opening, just before birth).

4 - position & consistency of cervix - is it forward or backward, soft or firm? This can give more detail in understanding how your labour is progressing.

When might vaginal examinations be recommended?

A VE may be recommended at various points during your labour. Some of the most common are:

• Upon arrival at hospital to check progression and see if it is appropriate for your to stay at hospital (remember, midwives won’t want you to stay in hospital if you are in very early labour, because they know the best place for you to progress is at home, where you feel safe, calm, relaxed and familiar. See it as a positive if you are sent home - go home, relax, and embrace early labour!

• Throughout labour - hospital policy is likely to recommend a VE every 4 hours to check progress. If you are in the throws of labour, fully in your zone and everything seems to be progressing well, consider whether a VE is really necessary.

• If labour slows down to see what’s going on and what could get things back on track. Very slow labours can be a sign that there are problems that might need intervention to speed up labour (known as augmentation). However, it’s also important to bear in mind that slow labours or labour plateaus can be very normal and, recent evidence suggests that, if mum and baby are both well then the length of labour or cervical dilation should not be used to decide whether labour is progressing normally.

• Before pain relief - it may not be recommended to have certain pain relief (e.g. an epidural) if you are very close to giving birth, to minimise effects on baby.

So what are the pros of having a vaginal examination?

• Long labours: VEs can provide useful information if you have been labouring for a very long time with no outward signs of progression.

• Baby’s position: a VE may tell the midwife that your baby is in an awkward position, which may help her suggest a change in position for you to help birth baby.

• Reassurance: some mums like the reassurance that comes with having a dilation number, it might just be the boost in motivation you need!

• Transfer to hospital: you’re having a home birth and would like to see if it’s more appropriate to transfer into hospital.

And the cons?

• Most common risks are infection, pain, discomfort and bleeding.

• This in turn can hugely reduce your oxytocin levels, your all important birth hormone, and lead you to start producing adrenalin instead, which is likely to slow down / stall labour. Being told that labour is ‘not progressing’ can be really disheartening and upsetting.

• VEs are not a crystal ball - two women might have a VE and both be 5cm dilated, one might have her baby within an hour, the other may still be in labour the next day. They do not tell you how long you’ve got left until your baby will be born.

• Midwife / doctor accidentally breaking your waters whilst performing a VE. This can then lead to pressure to be in labour within a certain timeframe (some hospitals recommend 24 hours and then recommend induction), which  hinders your body’s natural rhythm and timescales, and causes you unnecessary stress.

• Very subjective and different healthcare providers may conclude different dilation, which can be confusing and disturbing for a woman.

• Routine four-hourly VEs show an increased chance of women having their labour augmented (sped up) by breaking you waters or giving you a syntocinon drip.

• Slow but normal labours can be misdiagnosed as abnormal, this can lead to unnecessary interventions such as augmentation or c-section.

• Emotional and physical harm if you did not want the intervention, but felt like you had no choice.

• You will need to lie on your back, which can hinder the labour progress and interrupt your hormones.

• Negative language can be very detrimental. If you are told you are “only 3cms” this can be really un-motivating and disheartening, especially if you feel like you’ve been labouring a long time.

• VEs bring the attention and focus to measuring, tracking, results, plotting on graphs rather than tuning into your instincts and letting your body do its thing.

Let's consider some alternatives

There are various other ways to assess labour progression. Below are some alternatives to have a think about:

• Watch and listen: every woman labours differently, especially if they are using hypnobirthing techniques which help you keep more relaxed and calm. It is generally possible to judge by a woman’s behaviour how her labour is progressing. So much information can be gathered by just watching and listening, to how you are moving, what noises you are making, the frequency/intensity/duration of contractions.

• The “purple line”.  In some women a purple, silver, brown or red line can be seen, starting from the anus and developing up between their buttocks. The line appears due to the increased blood flow brought about by the pressure of your baby’s head descending. The longer the line is, the more dilated you are (roughly 1cm of line equals 1cm dilation).

• Opening of the back. Sometimes the Rhombus of Michaelis (a kite-shaped / diamond-shaped area in the lower back) is visible if you are in an upright position or on all-fours. This opening enables extra space for baby’s journey, which is impossible if you are lying on your back.

• Hot legs: the further you are through labour the more your uterus needs extra blood to do the hard work of giving birth, so it pulls blood away from your extremities. This can lead to your legs getting colder, from the foot to the knee. When the colder part is at the mid calf, you are about 5cm dilated.

Why do we need to know labour progression?

Have a think about what benefits a vaginal examination or any other sort of assessment would give you. If you feel you are labouring well and there are signs that things are moving in the right direction, then tune into your instincts and follow your body's lead.

In the words of Natalie Meddings, in her incredible book ‘Why home birth matters’, “if you can feel changes for yourself, and feel encouraged by that, you might want to consider what it will add. Internal exams are not a reliable indicator of how birth will progress and they can put the focus back on the clock. Besides this, you are awaiting a result, the measure of how you were doing and the rationalising those results which can bring you to your senses and affect oxytocin flow. 4 cm and your demoralised. 10 cm and there’s a drumroll. No news is good news and wary of the idea that a number presents an incentive”.

Remember it is entirely up to you whether you have vaginal examinations or not, no one can insist on them.

Can you have a comfortable vaginal examination?

If you do decide to have an examination during labour here are some tips to make them more comfortable:

• Relax: try and relax, there is a big link between a relaxed jaw and relaxed pelvis.

• Breathe: practice your breathing techniques that I’ve taught you in our sessions.

• Communicate: talk to your provider about your preferences and any concerns you may have.

• Support: have a trusted partner, doula or support person by your side, this can help you stay calm and focussed.

• Focus on something positive and zone out; it’ll be over before you know it!

The Bottom Line

The Birth Plan session of my antenatal course covers vaginal examinations and loads of other parts of labour you may need to make decisions about. It’s always best to express your wishes around examinations in your Birth Plan, knowing that you can change your mind at any moment. Even if you put in your Birth Plan that you don’t want any vaginal examinations in labour, you might decide to change your mind on the day to see “where you’re at” and that’s absolutely your decision! Check out my courses to see how I can help you prepare for birth and feel calm, in control and powerful!

Remember, you’re in control of your body and your birth experience, so don’t hesitate to speak up about what you want.

Thanks for reading - let me know if you've got any questions on vaginal examinations or any other aspect of birth - I often can't stop talking about it once I get on to the subject!