It is a question that comes up all the time with Mums-to-be – Do I have to have a vaginal exam during labour?
And the simple answer is, no. You do not need to have a vaginal exam during labour. Or pregnancy for that matter.
It is important to remember that no-one can insert their fingers into your vagina without your consent.
If something is being withheld from you (ie admission to the labour ward or being seen by your obstetrician) until you have had a vaginal exam – then your ability to say ‘no’ has been taken. This is not informed consent.
It is your decision entirely whether you consent to a vaginal exam or not.
A vaginal exam can be useful in some settings – particularly if there have been other interventions. For now, we will focus on the routine use of vaginal exams to measure cervical dilation in an uncomplicated birth.
The problem with vaginal exams
Vaginal Exams are subjective
There is no ruler for cervical dilation. Vaginal exams rely on your caregiver measuring your cervix using their fingers. This makes it more subject to human error or at least differing opinions.
One study looked at the accuracy of measuring cervical dilation using soft and hard models. In the study, only 19% of practitioners were exactly correct using the soft models, and 54% on the hard models. This accuracy decreased with the increase in cervical dilation on the hard model. The effacement measurements were correct 49% of the time on the soft versus 58% on the hard model.
So at their best, examinations were accurate 54% of the time on a model.
Imagine what that accuracy looks like on a woman in labour.
Vaginal exams are not innocuous
For some women, vaginal exams are not harmless, innocuous procedures. They are invasive and can be painful. For some women, the exam itself may be a source of trauma – especially if there has been a history of abuse or assault.
Accidental rupture of membranes
The VE itself may lead to an inadvertent artificial rupture of membranes. This may have flow-on effects and interventions such as being offered antibiotics if your baby hasn’t arrived within a certain timeframe after this.
Artificial rupture of membranes (AROM) can increase the risk of cord prolapse – moreso if baby isn’t engaged.
‘In this large, multi-institutional cohort of women who underwent AROM with a singleton gestation and cephalic presentation, we found that cervical dilation < 6 cm with any fetal station at the time of AROM, cervical dilation 6 to 10 cm with station −3 or higher, and earlier gestational age were associated with higher risks of cord prolapse.’³
Vaginal exams can increase the risk of infection.
If your waters have broken, having a VE can increase the risk of infection.
Vaginal exams do not accurately predict how your labour will progress going forward
Our birthing culture is one that focuses on what the cervix is doing as an indicator of what labour is doing. We birth in a system that relies on the outcome of a VE to try and predict what will happen next.
Unfortunately, your cervix is not a crystal ball and every woman (and every labour is different). More about that later!
As many midwives will tell you – labour is unpredictable. What might take one woman days might take another a matter of hours (or less!).
So, why are vaginal exams suggested?
The main reason that a vaginal exam is performed is to check the dilation of the cervix, either during your pregnancy or labour. This involves your midwife or obstetrician inserting their fingers into your vagina to measure how dilated, or open, your cervix is.
It may be offered during pregnancy as a ‘let’s just see what your cervix is doing’ as if it is going to be a great indicator of when your labour will start and how it will progress.
Vaginal exams are routinely done as a way to measure how your labour is progressing and predicting how your labour ‘should’ continue to progress.
The problem with vaginal exams is that they only provide a snapshot, at a particular moment in time, of your cervical dilation. It doesn’t tell you the timeline for getting to that point. Nor does it accurately predict a timeline for how your labour will progress.
Your cervix is not a crystal ball.
Let’s say you get a vaginal exam when you get to the hospital or birth centre and you are 4 cm dilated. That doesn’t tell you how long it took your cervix to go from closed to 4cm. It may have been hours or days (or longer). Nor does it tell you how long it will take to get from 4cm to 10cm.
What it does is put you on a clock. Once that ‘baseline’ has been established, it is then expected that your labour will follow a particular pattern
That’s where the Friedman Curve comes in.
The Friedman Curve
This is based on a 1955 study by Dr. Friedman which documented the average time it takes for a woman to dilate by centimetre during labour (the Friedman Curve). His study, which is still very much in use today, was based on the observation of 500 caucasian women in one hospital. The study included mothers ranging from 13 to 42 years of age and included caesarean births, forcep births, and women who were induced using pitocin. 481 (96%) of women had twilight births (where the woman was lightly, moderately or heavily sedated. The use of epidurals was not common.
The Friedman Curve gives women birthing for the first time approximately 14 hours to dilate from 0 to 10 cm. For subsequent births, this decreases to 8 hours. In the 1970’s additional lines were added to Friedman’s curve including an alert line, a transfer (to hospital) line and and action line. This partogram is used by hospitals today.
Women who ‘fail’ to fall within this curve, based on measuring cervical dilation with a vaginal exam and plotting the results on a partogram, are often diagnosed as ‘failing to progress’ (isn’t the language of birth fun??). Failing to progress then often leads to other interventions like the use of syntocinon to help labour progress, assisted births (using forceps or ventouse) or caesarean section.
Is the partogram still applicable?
We need to understand that women are unique and labour doesn’t progress at exactly the same rate for everyone.
A more recent Cochrane Review (2017) on the use of partograms in normal labour concluded that: “On the basis of the findings of this review, we cannot be certain of the effects of routine use of the partograph as part of standard labour management and care, or which design, if any, are most effective. Further trial evidence is required to establish the efficacy of partograph use per se and its optimum design.”
In their recommendations, the World Health Organisation says’
‘For pregnant women with spontaneous labour onset, the cervical dilatation rate threshold of 1 cm/hour during active first stage (as depicted by the partograph alert line) is inaccurate to identify women at risk of adverse birth outcomes and is therefore not recommended for this purpose.
A minimum cervical dilatation rate of 1 cm/hour throughout active first stage is unrealistically fast for some women and is therefore not recommended for identification of normal labour progression.
A slower than 1-cm/hour cervical dilatation rate alone should not be a routine indication for obstetric intervention’
Many factors may slow labour down including;
- having an epidural (which may slow both labour and the pushing stage)
- lying on your back or being confined to a bed (which often happens with continous fetal monitoring)
- being overweight or obese
- being dehydrated or lacking energy (often as a result of hospital policy precluding eating or drinking during labour)
- advanced maternal age
- having your first baby
- being a survivor of sexual assualt
- baby’s positioning (e.g. posterior baby)
On the flip side, other factors may help speed labour up
- giving birth to your second or subsquent baby
- being upright during your labour and pushing
- use of syntocinon (synthentic oxytocin)
Even so, we need to recognise that cervical dilation during spontaneous labour is non-linear and unpredictable. Just as every woman is different, so too is every labour.
So let’s go back to the vaginal exam as you get to the hospital.
You are now on a clock
You’ve been at the hospital now for 4 hours and you are told that you need another vaginal exam (as this is hospital protocol). Your midwife announces that ‘you are only 6cm’ – indicating that your cervix hasn’t dilated ‘sufficiently’ in that time.
This then starts to have implications, and you may start to hear terms like ‘failing to progess’ and we ‘need to get things moving’. All suggesting interventions are necessary.
Imagine what this does to your mindset. The moment you hear things like ‘only x cm dilated’ and ‘failure to progess’ it can trigger fear and anxiety. Even more so if you have been labouring for some time.
Fear has a massive impact on your birthing body. It triggers your ‘fight or flight’ response, in which blood and oxygen are directed away from your uterus and towards your defence systems (including your heart, lungs, arms and legs). From an evolutionary perspective it does this so that if you were confronted with a sabre-tooth tiger during your birth, your labour would slow down or stop enough that you could escape to safety.
The catch is your body doesn’t care whether it is a sabre-tooth tiger in front of you or a caregiver saying something that has caused you fear. Fear is fear – and your body will slow your labour down to protect you and your baby. Which then leads to further discussion around ‘failing to progress’ and further interventions – and so the cycle continues.
Other reasons vaginal exams are suggested
Sometimes vaginal exams are suggested to check the position of baby. Or they may be suggested to see if your membranes have released (waters broken).
If your membranes have released, making an informed decision about a vaginal exam becomes more important as the risk of infection increases. This can impact both you and/or your baby. The vaginal exam itself may also lead to your caregiver releasing your membranes, accidentally or deliberately, which further puts you on a clock.
The Purple line
Photo credit First Glance Photography
What are the alternatives to a vaginal exam
Although measuring dilation is not a good predictor of how your labour will progress, it can sometimes be helpful for your caregiver to have an idea of where you are at in your labour. A vaginal exam is not the only way to do this.
The Purple Line
The purple line is a red/purple line that starts at your anus and extents up your natal cleft (between your buttocks) as your labour progresses. As you are fully dilated, the purple line reaches the top of the crease between your buttocks. While it doesn’t appear on all women (one study documented it in 75.3% of women), it can be used as a way to gauge how labour is progressing so far. Like a vaginal exam, it won’t be indicative of how your labour will continue to progress, but it is a non-invasive way to check how you are going.
Observations
Simply observing a woman can give a good indication of her stage of labour.
The way you move, talk, the noises that you make. Whether you have an internal or external focus. Whether you are able to converse or not. These are all ways your caregiver can tell how far along you are in your labour. The way you are in early labour will be different to how you are during active labour, transition and the bearing down (pushing) phase.
Your surge (contraction) pattern will change as you progress during labour. Surges will become closer together, last longer and become more intense. How you deal with them will vary as you move throughout your labour.
Your vagina is yours – it is ok to say no!
It is entirely up to you whether you consent to a vaginal exam or not.
Do not feel that you have to consent because it is more convenient for your careprovider to do one.
Remember, just because vaginal exams may be a part of your hospital’s protocol, it does not mean you have to consent to one. Hospital protocols or policies are not law and no one can force you to have a vaginal exam.
You have the right to give or refuse informed consent. And informed consent is not your caregiver saying to you ‘we’re just going to do a vaginal exam, ok?’. This is not obtaining informed consent.
Vaginal exams – the choice is yours.
To find out more about what to expect during labour and birth and how you can make informed decisions that are best for you and your baby, join my upcoming Hypnobirthing Australia™ classes. Hypnobirthing Australia™ classes give you everything you need to have a positive pregnancy and birth experience. Done your way. Click here to learn more.
Kate Vivian is a self-professed pregnancy and birth geek who is finally learning to embrace the chaos of having 3 kids. It was the birth and ‘bringing baby home’ experience of her first baby, and the overwhelming guilt that went with it, that led her to start Bright Mums – and create a world where Mums matter.
A Certified Hypnobirthing Australia Practitioner, childbirth educator and postpartum doula, Kate works with Mums-to-be not only supporting them through pregnancy, and birth but also teaching them to honour themselves at a time when the world is telling them their baby is the most important thing.
With almost 2 decades in adult education, Kate has the ability to create a safe space, a non-judgey space. A place where Mums can relax and feel supported regardless of what their journey looks like.
A keen traveller in a former (pre-kids) life, Kate dreams of the day her kids are big enough to take skiing and they can completely show her up while she is busy falling down mountains.
Want to know more? Find out more about Kate or Hypnobirthing Australia classes
Effect of partograph use on outcomes for women in spontaneous labour at term, Lavender T, Cuthbert A, Smyth RMD https://www.cochrane.org/CD005461/PREG_effect-partograph-use-outcomes-women-spontaneous-labour-term
Accuracy of simulated cervical dilation and effacement measurements among practitioners, Huhn KA1, Brost BC. Am J Obstet Gynecol. 2004 Nov;191(5):1797-9. https://www.ncbi.nlm.nih.gov/pubmed/15547567
Preventing the first cesarean delivery: summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop. Spong CY, Berghella V, Wenstrom KD, Mercer BM, Saade GR. Obstet Gynecol. 2012 Nov;120(5):1181-93. doi: http://10.1097/AOG.0b013e3182704880. https://www.ncbi.nlm.nih.gov/pubmed/23090537
Friedman’s Curve and Failure to Progress: A Leading Cause of Unplanned Cesareans https://evidencebasedbirth.com/friedmans-curve-and-failure-to-progress-a-leading-cause-of-unplanned-c-sections/
Progression of cervical dilatation in normal human labor is unpredictable. Ferrazzi E1 et al Acta Obstet Gynecol Scand. 2015 Oct;94(10):1136-44. doi: 10.1111/aogs.12719. Epub 2015 Sep 3. https://www.ncbi.nlm.nih.gov/pubmed/26230291