Updated: January 2023
This post is about routine vaginal examinations (VEs) during physiological birth ie. an uncomplicated birth without any medical intervention. The VE is a useful assessment in some circumstances, but it’s routine use in an attempt to determine labour progress is questionable. As birth knowledge evolves, and research challenges the current cervical-centric approach to labour progress, there is an opportunity to shift practice. I’m hoping this post will inspire readers to reconsider their beliefs and practices regarding cervixes and VEs.
History: the rise of the cervix
To understand why we go so fixated on what one small area of the body is doing during birth, we need to look at history. The following is based on content from my book Reclaiming Childbirth, where I explore history in more depth. Here is a quick overview:
98 AD to 1900s
Vaginal examinations were only carried out during complicated births, for example, to assess if the baby was mal-positioned. They were not used to determine progress of labour. Early midwifery textbooks warned against routine vaginal examinations. For example, in the 1700s French midwife, Madame du Coudray wrote: Too much vaginal meddling is bad too: the best thing is to wait patiently, alert to all cues.
1900 to 1970s
Social and cultural changes resulted in childbirth moving from the domestic domain of the home into the medical domain. Influenced by the development of industry and technology, the body was conceptualised as a machine, with distinct parts that could be studied and understood separately. The birthing woman was ‘broken’ into physical parts – uterus, cervix, baby – and a systematic, linear understanding of labour progress developed. This is still evident in modern textbooks. The woman has disappeared in favour of diagrams depicting her ‘parts’ (and the fetal skull) alongside precise measurements. This simplified and incorrect understanding has underpinned education about birth and practice during birth.
In the 1950s, an American obstetrician named Emanuel Friedman plotted onto a graph the cervical dilatation of 500 women having their first baby in a hospital. The study population included women who were sedated and had medication (Pitocin) to induce or speed up their labour, and 55% had forceps. The study found that most women had birthed within 12 hours and when averaged out cervixes dilated 1cm per hour. However, individual women’s cervixes did not do this in a linear way. Instead, some women dilated faster, then slower or vice versa. However, the averaged-out, neat and linear graph became established.
In the 1970s, based on this reductionist and linear approach, the partogram became established within medicalised maternity systems. In his 1978 textbook Labour: clinical evaluation and management Friedman describes labour assessment: The phase of maximum slope is a good measure of the overall efficiency of the “machine” with which we are dealing. The aim of the partogram was/is to measure and control labour progress by plotting cervical dilatation onto a graph, along with descent of the baby’s head. If the cervix does not open along the prescribed timeframe (1cm per hour or 0.5cm per hour depending on the hospital), labour will be augmented ie. speeded up with an ARM or synthetic oxytocin.
Now: new understandings and contradictions
In recent years, new knowledge about birth physiology and research has challenged the cervical-centric approach to labour progress assessment. A previous article/post discusses the research regarding labour patterns and partograms. In summary, the research shows that women’s labour patterns do not fit the timeframes prescribed by partograms. A Cochrane Review (2018) 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. The findings of a large study by Oladapo et al (2018) also challenged the accuracy of partograms concluding that: Averaged labour curves may not truly reflect the variability associated with labour progression, and their use for decision-making in labour management should be de-emphasized.
Partograms and VEs go hand in hand – filling out a partogram requires regular vaginal examinations to ‘plot’ along the graph. However, there is no evidence that routine VEs in labour improve outcomes for mothers or babies. A Cochrane Review (2022) concluded that: Based on these findings, we cannot be certain which method is most effective or acceptable for assessing labour progress. Another recent study (Ferrazzi et al. 2015) found that cervical dilatation during spontaneous natural labour is non-linear and unpredictable.
Without adequate evidence for the use of the partogram, or routine VEs there is increasing debate in academic circles about the way forward. Unfortunately we are so cervical-centric that the proposed solutions still involve cervical measurements, and therefore VEs. For example, Zhang et al. 2015) in their article state: …any labor curve is illustrative and may not be instructive in managing labor because of variations in individual labor pattern and large errors in measuring cervical dilation. With the tools commonly available, it may be more productive to establish a new partogram that takes the physiology of labor and contemporary obstetric population into account. At the ICM Conference in Prague (2014) and at the University of California it was proposed that the partogram (ie. the clock) should be started at ‘6cm dilated’ rather than the current ‘3-4cm’ to avoid unnecessary intervention.
There is also reluctance to change hospital policies, underpinned by a need to maintain cultural norms. The Cochrane review on the use of partograms on the one hand states that they cannot be recommended for use during ‘standard labour care’, and on the other hand states: Given the fact that the partogram is currently in widespread use and generally accepted, it appears reasonable, until stronger evidence is available, that partogram use should be locally determined. Once again, an intervention implemented without evidence requires ‘strong’ evidence before it is removed. The reality is that we are unlikely to get what is considered ‘strong evidence’ (ie. randomised controlled trials) due to research ethics and the culture of maternity systems. Guidelines for care in labour continue to advocate ‘4 hourly VEs’ and reference each other rather than any actual research to support this (NICE, Queensland Health).
The cervical-centric discourse is so embedded that it is evident everywhere. Despite telling women to ‘trust themselves’ and ‘listen to their body’, midwives define women’s labours in centimetres She’s not in labour, she’s only 2cm dilated. We do this despite having many experiences of cervixes misleading us ie. being only 2cm and suddenly a baby appears, or being 9cm and no baby for hours. Women’s birth stories are often peppered with cervical measurements I was 8cm by the time I got to the hospital. Even women choosing birth outside of the mainstream maternity system are not immune to the cervical-centric discourse. Regardless of previous knowledge and beliefs, once in the altered state of labour women often revert to cultural norms. Women want to know their labour is progressing and there is a deep subconscious belief that the cervix can provide the answer. Most of the VEs I have carried out in recent years have been at the insistence of labouring women – women who know that their cervix is not a good indicator of ‘where they are at’ but still need that number. One woman even said I know it doesn’t mean anything but I want you to do it. Of course, her cervix was still fat and obvious (I didn’t estimate dilatation)… her baby was born within an hour.
The idea that the cervix can tell us about progress in labour is underpinned by an incorrect understanding of birth physiology. Childbirth physiology is complex (I have an entire course just on this topic). The uterus transforms during labour rather than the cervix simply opening.
Vaginal examinations: not just a benign procedure
In order to gain consent for a VE, women need information about the lack of evidence supporting VEs, and about the potential consequences of VEs. I’ve started a list below and welcome any additions you can think of:
- VEs are invasive and often painful: There is limited research into women’s experiences of VEs (surprise, surprise). Most women report being ‘satisfied’ with their VE experience, some find it painful, for a few VE is associated with PTSD (Dahlen et al. 2013). I’d be interested in your comments about experiences of VEs.
- The findings can be misleading: What the cervix is doing at the moment of a VE does not indicate what the cervix is going to do in the future. Therefore, the findings cannot effectively inform decisions about pain medication or other interventions (although this is often the rationale given for performing them).
- The measurements are subjective and inconsistent between practitioners: The accuracy between practitioners is less than 50% (Buchmann & Libhaber 2008).
- A VE disregards the woman’s knowledge and reinforces the external expert. Often the findings do not match the woman’s experience and the result can be disempowering, for example in early labour.
- A VE can result in accident rupturing of the membranes: It is not uncommon to accidentally break the amniotic sac whilst carrying out a VE – this alters the birth process and increases risk for the baby.
- VEs can increase the chance of developing an infection (Dahlen et al. 2013).
Other ways of knowing
The truth is that women’s bodies are complex, unique and immeasurable. Birth is a multidimensional experience that cannot be accurately defined by anyone outside of the experience. We – those of us who give birth and/or attend birth – know this. Midwives already assess labour based on other (less invasive) ways of knowing. In my PhD findings midwives’ birth stories were filled with descriptions of mothers’ behaviour. One participant said: It’s like a performance… at this stage of this performance what is it saying? And… it’s not what she’s saying, it’s what she’s not saying. And it’s what she’s displaying, the way she’s moving, what her body is doing in a physiological sense. Other studies have also described this approach to labour assessment. Dixon et al. (2014) mapped their research about the emotional journey of labour with findings from previous studies, and integrated this with physiology. Duff (2005) studied women’s behaviour during labour and created an alternative ‘partogram’ based on her findings. There are also physical changes that occur to women’s bodies during labour that can be seen and indicate labour progress (eg. the shift of the Rhombus of Michaelis and the purple line). It is not within the scope of this post to discuss these behaviours in depth (perhaps a separate post?). I am just trying to point out that the cervix is not the only indicator of labour progress. Yes, women’s behaviours are individual and may not fit any expected patterns, therefore relying on these methods may be misleading sometimes. But VE’s are also inaccurate and misleading (see above)!
Suggestions for midwives
- Be mindful of language and how we communicate about labour to each other and women. Stop talking about centimetres and start talking about behaviours and other signs of progress.
- During pregnancy: provide women with honest information about VEs, their limitations and the potential consequences; and the alternatives. This should also include information about policies in their chosen birth setting, and their right to decline policy recommendations.
- Care in labour is influenced by the setting. For example, a hospital may have a policy of ‘4 hourly VE’s’ – and as an employee you are obliged to follow policy. However, your obligation is to offer a VE, not to carry it out. To do a VE without consent is assault and battery and a breach of professional standards. If you provide the woman with adequate information (see above), and make it clear that this is an ‘offer’ based on policy (not your own needs), and that from all external signs she is progressing well… some women will decline your offer. You can document her decision and carry on having fulfilled your duty to the woman and to the hospital.
- If you are in a setting where VEs are not routine (eg. homebirth) and the woman asks for a VE (which they do)… try to work out what she really wants. Does she want reassurance that all is well and she is progressing, or does she really want to know what her cervix is doing. If it is the latter, encourage her to feel her own cervix. If she insists do a VE with consent.
- When communicating the findings of a VE include other changes – “the baby has descended, rotated, flexed” and positives about the cervix “it is stretchy, soft, opening up nicely”. If she needs a number, give her one, but demonstrate that this is not important to you. Do not use the findings to dictate her behaviour, eg. pushing or not pushing.
Routine vaginal examinations during physiological birth are a symptom of a cervical-centric birth culture. There is enough evidence to support a shift away from this common intervention towards a more woman-centred approach to labour progress assessment. We need to value the ‘other ways of knowing’ that are already established, and reinforce the woman as the expert in her own birth experience.
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