Vaginal Exams during pregnancy and labour

The word EXAM is enough to make most peoples blood run cold, so why on earth would one be part of pregnancy and birth?

Also known as a cervical check, vaginal check, internal exam, cervical exam, the vaginal exam – it is a medical procedure performed by a care provider to assess the cervix.

A cervical exam is performed by placing two fingers inside the vagina and touching in and around the cervix to determine a number of things relating to both the cervix and the baby:

  • Dilation 

This is how much the cervix has opened. The cervix is usually tightly closed during a normal pregnancy, especially a first pregnancy. In women who have had a baby before, it can be dilated as much as 3-4 centimetres from quite early in pregnancy. During labour, the contractions/surges help pull the cervix open to 10cm in order for the baby to be born.

  • Effacement

The cervix starts off being quite thick – up to about 3cm in length. Before and during labour the tissue of the cervix becomes thinner until it is almost paper-thin. In a first pregnancy, the cervix will usually soften and become thin before it opens but this isn’t always the case. The cervix can also thin as it opens.

  • Cervical position

At the beginning of labour the cervix is pointed more towards your coccyx (also known as the tail bone) and during labour it begins to point more downwards into the vagina.

  • Station

This refers to the position of the baby’s head in relation to a specific boney part of the pelvis (felt from the inside) called the ischial spines. The number of the station refers to whether the baby’s head is above or below this part of the pelvis.

  • Fetal position

By feeling the bones of the baby’s skull, the doctor can also determine which way your baby is lying. The position of the baby can also be felt through your tummy but this positioning can be confirmed by feeling the baby’s head during an internal exam. The internal examination of the baby’s head also helps the doctor or midwife determine if the baby has tucked it’s chin to it’s chest (easier for the baby to pass down through the pelvis) or if the forehead is the first part coming down through the pelvix (known as a deflexed head) or perhaps if the head is tilted to one side (asynclitic head).

Often the main things women want to know about an internal exam are:

Will it hurt? The answer is different for each person, but you can expect it to be anything from a little uncomfortable to quite painful. The majority of women report that it is very uncomfortable when done during labour and would prefer not to have it done.

Can I refuse an internal exam? YES. You have the right to make an informed refusal of any procedure you do not wish to have done. No one ever has the right to insert anything into your vagina without your permission first. All care providers are, by law, expected to seek your consent first.

When trying to decide if you should consent to a cervical check you should ask yourself the following:

Is this being done simply because it is routine or does it provide me/baby with benefit?

Women under the primary care of a Doctor are told that an internal check “will be done at 36 weeks”. In a normal, low risk pregnancy there is no benefit of an internal exam to either mother or baby and it often carries risk of introducing bacteria further into the vagina which can lead to infection. Doctors are taught to do this routinely for their own needs in assessing the dilation, position and effacement of the cervix for record keeping purposes.

What often happens when a cervical check is done at 36 weeks is that the woman is told the cervix is considered “unfavourable” (implying that labour is unlikely to start soon) which opens the discussion of induction and c-section and often leading to stress in a woman who is wanting a vaginal birth with no unnecessary interventions. The fact is that any information about the cervix at 36 weeks gives very little insight into whether she will go into labour soon, or how the labour will progress. Even in a mother who has had one or more babies before, the state of her cervix at 36 weeks gives no reliable information about labour or the progress of labour.

So, having an internal exam at 36 weeks may mean the doctor tells the mother that a) her cervix is unfavourable and labour is unlikely to start soon, and thus causing her some stress, or b) the doctor says the cervix is favourable and the mother feels slightly reassured.

Again during labour (in a hospital environment) a mother will be told she must have an internal exam done every 4 hours once she is in active labour. This is done because of an old “rule” which states that in a normal labour a mother should dilate 1cm per hour. If active labour starts when the cervix is 4cm dilated, in four hours time at the next check the cervix should be 8cm dilated (wide). The latest research has shown that this timing is incorrect and is responsible for unnecessary interventions in what is otherwise a normal, healthy labour.

The dilation is recorded on a document called the partogram, which has a line along which the labour progress is plotted with regards to dilation. When the plotting dips below a certain point it requires that the doctor or midwife take action. This is based on the flawed “rule” of 1cm per hour, when in fact it is quite normal for labour progress to “fall off the partogram” and so long as the mother is well and the baby is responsive and has a healthy heart rate then there is very little cause for concern. The truth is that some labours just take longer than others, this is okay.

What are the Risks and What if we just do nothing?

As you can see already, the cervical check has no real benefit to mother or baby during a normal, healthy pregnancy or labour. The risks are that it can introduce bacteria (and therefore infection), it’s uncomfortable or even very painful for the mother, if she is the survivor of sexual abuse it can trigger emotional distress which in turn slows or stops labour.

Not doing a cervical check doesn’t cause any harm to either mother or baby, so it is worth refusing one unless there is a compelling reason for it to be done.

When should you considering having an internal exam?

There are times when an internal exam can be a useful tool

  • When assessing the cervical dilation or position of the baby will help you avoid other interventions
  • When there is concern about the health of the baby or mother where information about the position of the baby or cervix will be beneficial
  • Assessing if there is a cervical lip when the mother otherwise appears fully dilated and wants to push
  • When true CPD is suspected during labour (this means the baby’s head is too big to fit through the pelvis)
  • When there is concern about a prolapsed umbilical cord

This is not an extensive list but perhaps the most common and most likely reason to have an internal exam is when labour stalls or the pushing phase becomes very long. The additional information gained about the cervix and position of the baby could help either the doctor or midwife guide you to move into a better position for progress to happen, or to see whether a small intervention is needed to help the labour continue.

sarahmeder
Author: sarahmeder