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A Brief History of Vaginal Exams, Why They Started Being Used, the Evidence Behind them, and Your Rights.
First things first, let's tackle the word HAVE...
Human rights laws give you the right to make your own choices about your maternity care.
They say that the care that health professionals give you in maternity must respect your dignity and your freedom to make decisions about yourself (this freedom is called autonomy).
In the UK we also have more legal freedoms as our baby doesn't have rights before it is born, this gives us total freedom of choice over our own body when pregnant.
You can make decisions that put both you and your baby in danger, even at the risk of death, this is your legal right.
That sounds like a huge overreaction to cervical checks right, but my point is, no you don't HAVE to consent to anything during pregnancy and birth.
So why cervical checks? A brief history of childbirth.
Before the medicalization of childbirth, our births were attended by our female family and friends, maybe a wise woman or two, and latterly a traditional midwife.
The women were there to support the mother emotionally and physically during labour, not intervene medically.
In the 1700's a French midwife wrote 'Too much vaginal meddling is bad too: the best thing is to wait patiently, alert to all cues.'
Once birth moved into a hospital in the 1900's the body of a birthing woman was seen as different parts, that fit together like a machine to birth the baby. 'Parts' of this machine could break down, or work inefficiently, and the doctors felt if they took over they would 'save' the women and baby from this broken and ineffective body.
Women were mostly sedated into 'twilight sleep' and tied to a bed to prevent their thrashing from hurting the baby.
Doctors started looking at ways to monitor a woman's body's progress, so they could step in at the earliest possible moment to prevent disaster.
In the 1950's a surgeon called Emanuel Friedman subjected a small group of women to hourly cervical checks (via their rectum) throughout their birth.
He found that most women had birthed within 12 hours and on average their cervixes dilated 1cm per hour.
One important thing to note is that this was one small group of women studies in highly medicalized hospital conditions.
The average age of the women was 20.
95% were sedated (therefore tied down on their back in bed).
More than 50% of the babies had a forceps delivery once it was possible to do so.
14% were induced or augmented with artificial oxytocin.
In the 1970's this graph became known as the Partogram which was described as Friedman himself in a medical textbook: 'The phase of maximum slope is a good measure of the overall efficiency of the “machine” with which we are dealing.'
Since that point, the partogram has been used to measure how effective our bodies are during labour, if our cervix does not dilate the required 0.5- 1cm per hour, we face pressure to augment our bodies with artificial oxytocin, in fact to make this easier 'action lines' were added to the partogram to tell Dr's exactly when to intervene.
Modern-day cervical checks
These days cervical checks are done by a midwife or a Dr placing their gloved hand into our vagina and using their fingers to estimate how dilated our cervix is.
Studies have shown that even experienced clinicians are only accurate 50% of the time when they estimate cervical dilation, the more dilated you are the more accurate they become, and the measurement can vary by 50% between examiners.
Cervical checks also carry risks to both mum and baby.
One study showed that the number of vaginal examinations was directly related to the risk of infection.
It has been found that 'performing 5 VEs or more independently increased the risk for febrile morbidity. For intrapartum and peripartum febrile morbidity the risk was higher with an increase in the number of VEs.'
There is also a risk that your waters may be accidentally broken during a cervical check, not to mention that do one you must be on your back, a position more women feel is more painful during labour.
We must also consider the effect the interruption in our labour has on our hormone cascade, and the impact a 'disappointing measurement' may have on our emotional state.
The NICE guidelines state:
When conducting a vaginal examination:
be sure that the examination is necessary and will add important information to the decision-making process
recognise that a vaginal examination can be very distressing for a woman, especially if she is already in pain, highly anxious and in an unfamiliar environment
explain the reason for the examination and what will be involved
ensure the woman's informed consent, privacy, dignity and comfort
explain sensitively the findings of the examination and any impact on the birth plan to the woman and her birth companion(s)
advise the woman that she can decline the examination before it starts, or ask to stop at any stage during the examination.
In active labour:
Offer a 4‑hourly vaginal examination, or in response to the woman's wishes if there is concern about progress (after abdominal palpation and assessment of vaginal loss).
In the second stage
Offer a vaginal examination hourly in the active second stage, or in response to the woman's wishes (after abdominal palpation and assessment of vaginal loss). To assess progress, the vaginal examination should include:
position of the head
descent
caput and moulding.
What does the evidence say about cervical checks during labour?
A Cochrane review is one of the easiest ways to see a summary of available evidence on a topic, they also assess the quality of the studies they include in the summary.
When asked about the effectiveness of using Friedman's partogram to assess labour progress they conclude:
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, is most effective. Further trial evidence is required to establish the efficacy of partograph use per se and its optimum design.
When asked about the use of routine cervical checks for assessing labour progress:
Based on these findings, we cannot be certain which method is most effective or acceptable for assessing labour progress. Further large-scale RCT trials are required. These should include essential clinical and experiential outcomes. This may be facilitated through the development of a tool to measure positive birth experiences. Data from qualitative studies are also needed to fully assess whether methods to evaluate labour progress meet women's needs for safe and positive labour and birth, and if not, to develop an approach that does.
Essentially the data very clearly tells us the current evidence is not sufficient to inform practice, however, because vaginal exams are so engrained in the culture of medicalised birth this is not enough to change things.
What is my cervix actually doing in labour?
EVERYONES CERVIX IS DIFFERENT, AS IS THE PATTERN OF THAIR LABOUR!
.... ahem sorry about that, but honestly if you can hold that sentence in your head during your labour it will help!
How your labour progresses depends on many things, the position of the baby, the position of their head on the cervix, and the strength and pattern of your contractions.
Your body is so clever, that many believe it modulates the strength of the contractions to ensure it is never more than the baby can take, your hormonal feedback cascade certainly works to keep them in check to what you can cope with.
For example, if your baby is low, and its head is in an optimal position on your cervix, as your uterine muscles contract and pull up, it can gradually pull the cervix up and over your baby's head, giving you a nice steady increase in cervical dilation.
If your baby is higher up, the muscles are still doing the work, but they do not have anything to pull the cervix up around, in this example, the cervix may not appear to be dilating (but your muscles are still doing what they need to) eventually the baby will move down and cervical dilation will suddenly jump up!
If your contractions are irregular or spaced apart, your cervix could open, then pause, then open some more!
If your contractions are coming thick and fast your cervix could dilate quickly!
If your baby's head is in a slightly different position on the cervix, or if they are breech, this can affect the rate of cervical dilation as well!
The problem with using cervical checks to assess labour progress.
So we know cervixes can dilate at varying speeds and varying rates, therefore a cervical check cannot possibly tell you how long you have left until your baby is born.
You have a check and you 5cm, URGH but things feel SO intense, you don't know if you can carry on that much longer, so you ask for more pain relief, and an epidural possibly, or transfer into hospital from a homebirth! But there is nothing to say that had you not transferred or had interventions, your cervix could have dilated at the speed of light and your baby could have been here in a few hours.
You have a check and you are 6 cm, 4 hours later you have another check and you are STILL 6cm, how can that even be?! You've had so many contractions, how can things not have moved forward? Your midwife uses this as evidence towards 'failure to progress' or 'labour dystocia' you are offered and accepts augmentation to get things moving along. Again you have no idea how quickly your cervix may have dilated on its own in the next few hours!
Alternatively, it can work the other way, you have a check, you are 6cm but 1 hour later you have the urge to push, and your midwife tells you, you can't possibly be ready yet, to ignore the urge, you try but you can't. Baby is born in a few pushes and the midwife has to push the call buzzer as they havent got enough people in the room.
Or you can have a check and find out you are 10cm, but then find yourself on the second stage of labour 'clock' now being offered hourly exams and being pressured to 'push' even though you don't have the urge.
Of course, you could have one of those labours that works exactly how they think it should with a textbook cervical dilation.... but we simply do not know!
What about a cervical check to confirm you are in labour?
This is another way we are separated from our instincts by the medical model.
You will know when you are in labour.
There is no such thing as 'false labour' it is all just your body making the changes it needs to, to allow your baby to be born.
If you are having regular contractions and are told you 'aren't in active labour' as you are only 2 cm dilated, this can be really demoralising!
It totally ignores all the hard work your body has done to get you to that point, your cervix has moved forward, softened, shortened AND dilated to 2c, that is a huge amount of work already done!
Some data shows if you go to the hospital before you are in active labour (the definition varies from 4cm-6cm dilated) you are more likely to have interventions during labour, so it IS a good idea to stay at home as long as possible.
But if you feel like you need support, you should get it, regardless of your dilation.
Midwives can tell if you are in active labour without a cervical check, it just takes more time than a cervical check, they can do this by observing your contractions and behaviour!
Some hospitals may have 'policies' that state you need a vaginal exam to confirm you are in active labour before you can be admitted/have a home birth midwife stay with you.
To withhold care because you will not consent to a medical procedure is coercion, and takes away your ability to give informed consent, as it can no longer be freely given, you must challenge this policy if you do not feel as though you want to consent.
Are Vaginal Exams ever needed / useful?
Selective vaginal exams can be used by midwives or Drs to gather further information if the clinical picture seems pathological (if something looks abnormal).
Knowing the baby's position and how dilated you are can help them give you additional information or suggest something to help resolve the situation.
Vaginal exams can also be used by you to make decisions on your care, as long as you know their ability to predict how long it will be until the baby gets here is limited.
They can give you the boost you need, say if you are 9cm you may feel releived and happy to continue!
If you know the risks of cervical checks, and their limited ability to assess progress, you can make an informed decision on if you want to accept routine exams during labour or selective ones, or only if you request them!
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