juno midwives

A vaginal examination is a procedure used during labour to assess the dilation, effacement, position, and consistency of the cervix in addition to feeling where the baby’s head (or bottom!) is in the pelvis and what position they are in. It involves a midwife or a doctor wearing gloves and inserting two, lubricated fingers into the vagina. It is an incredibly intimate procedure and should never be performed without consent, however there is both anecdotal and published evidence showing that women around the world (including the UK) do experience vaginal examinations without their consent.

A quick overview on the language used when assessing the cervix:

• Dilation – how open the cervix is, usually recorded in centimetres
• Effacement – how thin/short the cervix is; during pregnancy the cervix is a long, closed and tube shaped
• Position – the cervix can be posterior (pointing towards your back), central (in the middle) or anterior (facing towards your front)
• Consistency – the cervix can feel firm or soft, or somewhere in between 

During an uncomplicated pregnancy, the cervix remains firm, long, closed and usually posterior. During labour it undergoes several changes to become soft, short and more anterior facing. Usually, it has to do these things before it starts to dilate and this is what is generally happening in early labour. Vaginal examinations can be a useful clinical tool in certain situations, however they cannot predict when a baby will be born. Current NICE guidelines advise that a vaginal examination should be offered to ‘diagnose’ labour and then every four hours when labour is considered ‘established’ (when the cervix is 4cm dilated and there are regular contractions). 

The evidence to support the four hourly recommendation for vaginal examinations is based on out-of-date evidence from the 1950s and serves to ensure that women and birthing people meet the time frames for labour that have been agreed by the medical profession. In a fragmented maternity system (the norm in the UK), where women are cared for by midwives they don’t know and who work shifts, it is not surprising that vaginal examinations are heavily relied on to assess labour progress. If you don’t know someone before labour, it can be really hard to assess behaviour changes and other ways of knowing labour is advancing. Additionally, in the context of medical interventions such as inductions of labour and epidural analgesia – regular vaginal examinations are often needed to assess that labour is progressing because these interventions alter the physiology of birth. For example, the lack of sensation that the epidural provides means that women don’t move instinctively or display the behavioural changes seen in women birthing without an epidural and labour can slow down – so vaginal examinations in this scenario may be helpful to ensure labour is progressing. 

There are however other ways of knowing if someone is progressing in labour including:

• behavioural changes
• becoming more vocal
• noting the Rhombus of Michaelis 
• the presence of a purple line between the buttocks (observed in lighter skinned women)

These other ways of knowing can be used by midwives working within mainstream maternity services of course, but the culture of maternity services is such that vaginal examinations are heavily relied on. Frequently women are not ‘allowed’ to access maternity services in labour unless they have had a vaginal examination to ‘ensure’ they are in active labour. The thing is that anyone who works in birth will tell you that women and birthing people do not always dilate in at a linear rate – that is to say they don’t follow what the text books say (2cm dilation every 4 hours is the accepted rate of dilation in obstetrics). We have countless stories of who dilate significantly faster than the textbooks would suggest, surprising everyone! And in the same breath, there are also many women who dilate significantly slower than the textbooks suggest and whilst this is often seen as a problem in mainstream maternity care, research has shown that (surprise, surprise) some women have much longer labours than others with no adverse outcomes. 

The importance of completing a holistic assessment cannot be understated – and this applies to both women who are progressing faster than expected and slower than expected. A slower labour is not automatically abnormal in the absence of any other concerning signs – so if the woman’s observations are normal and she feels well in herself, if there are no concerns with the baby’s wellbeing and there are no signs of obstructed labour (e.g. minimal urine output despite drinking to thirst) – then it is reasonable to await events and observe. Anecdotally, we have cared for women in the hospital who are progressing slower than expected and who have been offered (but declined) a caesarean section who then go on to have a straightforward vaginal birth after having more time for their labour to progress. Speaking to faster labours, it is so important to listen to women and birthing people when things are progressing faster than expected. We hear stories of first time women and birthing people being told that they can’t possibly be ready to push or that it is going to take hours for them to have a baby, when in fact they intuitively know their baby is coming. This dismissal of women’s experiences by healthcare professionals can be incredibly damaging.

Continuity of care – having the same midwife throughout the pregnancy, labour & birth and postnatal period – means that a relationship exists before labour. This means that a midwife really knows the woman or birthing person and therefore can more easily assess the alternative signs of labour. Additionally, in the antenatal period, there is time to discuss vaginal examinations and alternative methods of assessing labour progress. There is time to understand how a woman or birthing person may feel about having vaginal examinations and decide if they want to be offered four hourly vaginal examinations in labour or have these offered based on the clinical picture or their preferences, or indeed not at all. Midwives who are experienced in supporting physiological birth don’t need to rely on vaginal examinations to know if labour is progressing or not, instead they’re a tool to be used if the clinical picture changes or perhaps when the findings would support decision making. Ultimately, it should always be the choice of women and birthing people to choose if they want to have a vaginal examination or not. 

There are some general principles that should be applied when offering and doing a vaginal examination:

• an explanation of the potential risks and benefits of the procedure 
• an explanation of the purpose of the examination
• a discussion of alternative options
• ensuring the woman is aware she can change her mind and/or ask the examination to stop at any point
• ensuring consent has been freely given prior to any examination (sometimes someone can verbally say yes, but their body language is saying no – pay attention to that)
• respecting someone’s decision if they decline an examination
• never coercing someone into having one
• ensuring that dignity is maintained throughout the examination (for example by not exposing someone more than is necessary, ensuring curtains are pulled / doors are closed)
• offering a chaperone

Vaginal examinations provide information about what a cervix is doing and where a baby is in the pelvis at that point in time. They do not predict when a baby will be born – no such tool exists. Having a known midwife, who both understands and respects physiological birth and knows when a vaginal examination is truly clinically indicated, will likely result in a woman or birthing person experiencing minimal, if any, vaginal examinations during labour.

We can support you to have a great birth experience, wherever you’re planning to birth, get in touch to find out more.