let’s have a chat about Vaginal exams

A brief word before we dive in: I just want to make it very clear that vaginal exams are not compulsory. Without consent, you have as much right to put your hands inside your midwife as they do you. Consent is everything, and feeling forced to have exams can really impact on your experience of birth. There are other ways to assess dilation (purple line, temperature of legs, rhombus of Michaelis) as well as just listening to what you - how you are describing the sensations your are feel as well as any noises you might be making instinctively.

What is a vaginal exam?
A vaginal exam is when your midwife or obstetrician inserts their fingers in to your vagina to feel for the cervix. By doing that they will then be able to estimate how dilated & effaced your cervix is and feed this information back to you.

The biggest thing to consider with vaginal exams is that, in a physiological birth, that is where labour has started spontaneously and you have not had any medical intervention to augment the process, how dilated you are at one point doesn’t tell you anything about when your baby is going to be born. Labour progresses at different rates for everyone. Some people will sit at 4cm for hours before quickly progressing to fully dilated, others will steadily & gradually dilate. Just because you’re 5cm at one moment, doesn’t mean you won’t be fully dilated in an hour or two. And the best thing to do to encourage physiological labour & birth to continue to unfold, is not to interrupt it (…to poke the cervix!).

The idea that birth should be efficient originated in the 17th century when men used science to re-define birth. The body was conceptualised as a machine and birth became a process with stages, measurements, timelines, and mechanisms. This belief continues to underpin our approach to childbirth today, and if you want to read more on this I highly recommend getting yourself a copy of Sara Wickham’s ‘In Your Own Time’ and/or Rachel Reed’s ‘Reclaiming Childbirth As A Rite of Passage’.

The tool used to measure labour by medical professionals is called The Partogram - a graph which measures dilation against timeframe. The Partogram is largely based on a study carried out in the 50s by a man called Friedman. Friedman plotted the cervical dilatation of 500 women having their first babies in an American hospital. He found that the average rate of cervical dilation was 1.2cm per hour, but that this rate was not linear. In other words, most women gave birth within twelve hours of the commencement of labour, but there was variation in their individual dilation patterns - they did not dilate 1cm every hour, however, that is generally the modern medical expectation. The majority of these women also were on their backs, in bed, with epidurals and contractions driven by synthetic oxytocin. These were not phsyiological labours, however the results of this study form the basis of what we use to monitor all labours.

A recent Cochrane review found that actually what evidence shows is that labour length & dilation progress varies hugely from person to person, and recommended that routine use of Partogram should not be standard maternity care, though this recommendation has yet to filter down in to mainstream care.

So it’s really worth thinking about what this knowledge a vaginal exam can provide means to you - throughout labour will it benefit you to know how dilated you are? Will it give you energy or bursts of power? Or will it make you feel stressed or pressured? If so make it clear on your birth plan A) whether or not you consent to vaginal exams and B) whether or not you want the midwife to then tell you how ‘far along’ you are. You could also say that you will ask for exams when you want to know. It is all entirely up to you - remember we want to be gatekeeping that oxytocin so if you’re not comfortable with exams you do not need to have them.

What it’s really important to remember is that these assessments don’t always, or even often, determine ‘how far along’ in labour you are. Your cervix could go from 4 - 10 cm in 30 minutes or a day. Vaginal exams do not predict when your baby will be born - but what they may do is put you on the clock as to when you are expected to be at certain points in your labour, which is a bit ridiculous because birth in incredibly unpredictable.