In this blog post, we are going to look at the facts surrounding pelvic exams in pregnancy and labor
Although each doctor is different, and we shouldn’t assume that each doctor operates the same way, many doctors may make decisions based around interventions in birth based off their ideal timing and shift schedules, in my personal opinion. I also realize that doctors have to often take extra precautions to make sure their patient is well taken care of and nothing important gets missed.
I have found that in most of the “crunchy” or naturally minded communities, medical interventions are avoided at all cost. When it comes to birth specifically, it is understood that one intervention will almost certainly lead to another intervention… this is called the Cascade of Interventions.
It’s important, as a patient, to be bold enough to advocate for yourself and say no to any interventions you do not want and that are not medically necessary. If you feel unable to make these decisions based off knowledge or your personality, you may highly consider hiring a doula who can help educate you and advocate for you when you’re in the thick of labor!
One of the most common labor/birth interventions is pelvic/vaginal exams.
When most women tell their birth stories, their story is full of cervical measurements, such as “I was already 8 cm by the time I got to the hospital”… or “It took me 7 hours to go 2 more cm!” You might assume that prenatal vaginal exams are a normal and necessary part of care throughout your pregnancy. While there are cases where vaginal exams can be helpful prior to labor, in a healthy term pregnancy they don’t usually provide any necessary information. However, when in labor, doing the checks can give the doctors a vague idea of how your labor is progressing.
Unless there are health concerns or complications, there is no medical reason to have routine vaginal examinations as part of your regular pregnancy visits. However, this is not to say you may not need one for various reasons at some stage, depending on your health needs.
Why Are Pelvic Exams Offered?
In most cases, an examination – such as a pap smear—will be performed early in pregnancy. If there are no complications during pregnancy, usually there will be no further exams until around 36 weeks. After this time, it’s common for practitioners (especially in the US) to do exams at every visit during the rest of the pregnancy. The rationale for this is to check for changes to the cervix and to determine whether labor is likely to start soon. Some practitioners want to do a vaginal examination at every prenatal visit during pregnancy. Unless there are compelling medical reasons, this simply isn’t necessary.
Medical reasons you may need a pelvic exam during pregnancy may include...
History of infertility
Gynecological problems
Painful intercourse
Suspicion of cervical problems, such as scarring or premature labor
The need to check how favorable cervix is, if induction is necessary.
Checking for infection
Checking for cause of bleeding
Sometimes cervical checks can be helpful in determining the position of the baby, and to assess the progress of labor when things seem to have slowed, stalled, or progressed quicker than usual. It can also be helpful if the provider is able to apply pressure to certain pressure points in the vaginal vault to help the mother feel where to focus her pushes. (I can remember my midwife doing this for me in labor!)
It’s better to think of cervical checks like loose “progress reports” instead of real-time indicators for birth, but also remember that each birth is different and you may dilate slower or quicker than “average.”
Most commonly, cervical checks occur late in pregnancy and postpartum to monitor the health and progress of your pregnancy. During late pregnancy, cervical checks around week 36 will look for group B strep (GBS), which can be a serious infection if passed to a newborn during birth. Once your water breaks and/or during the first stage of labor, cervical checks can happen as often as once every two to four hours to check the progress of your cervix’s dilation. Your doctor will perform a pelvic exam that includes a Pap smear and cervix check during your 6-week postpartum visit, even if you've had a Cesarean section. But, again, remember that you can decline these, unless they are a requirement.
So what are they evaluating in a routine cervical check before or during labor?
Here are the terms you may hear providers use when they perform a pelvic exam, and a brief definition of what each term means. Knowledge is power! Understanding what the provider is explaining can help put your mind at ease!
Dilation- this refers to how wide the cervix has opened. 1O centimeters is the largest your cervix will get before you should push.
Ripeness- This refers to the firmness of the cervix. It starts out feeling firm like the tip of a nose, softens to feel like an ear lobe, and eventually softens further to feel like the inside of a cheek.
Effacement- This is how thin the cervix is. Think of the cervix as funnel-like and measuring about 2 inches long. 50% effaced means that the cervix is now about 1 inch in length. As the cervix softens and dilates, the length decreases as well.
Station- This is the position of the baby in relation to the pelvis, measured in + and -, ranging from +5 to -5. Changes in fetal station (Ex: -2 to a +1) indicate that labor is progressing and the baby is descending through the pelvis.
Negative Stations: A station of -3 means the baby's head is 3 centimeters above the pelvis.
Zero Station: A station of 0 means the baby's head is aligned with the pelvis.
Positive Stations: A station of +1 means the baby's head is 1 centimeter below the pelvis.
Engagement: When the baby's head enters the pelvis and is at or below the ischial spines, it's considered engaged (typically at or around 0 station).
Position of the baby: By feeling the suture lines on the skull of the baby, where the four plates of bone haven't fused yet, a practitioner can tell which direction the baby is facing because the anterior and posterior fontanels (soft spots on the baby's head) are shaped differently.
Position of the cervix: The cervix will move from being further back in the body toward the front, or from posterior to anterior.
If you are nervous about your pelvic exams for any reason, (anxiety, past trauma, first time) try your best to breathe deeply and relax your pelvic floor muscles to limit discomfort. Understanding the process can help ease any nerves, but make sure you share your apprehension with your provider and ask them to go slowly, and maybe even explain the steps as they are performing them.
It is important to remember that there are risks and information to be aware of when it comes to cervical checks/exams.
One of the biggest risks that comes with pelvic exams is infection. Although the care provider will use a sterile glove during the exam, there is always a chance that bacteria from the vagina can be pushed up into the cervix. This increases the risk of infection of the placenta, membranes of the amniotic sac, and amniotic fluid. The chance of infection increases as the number of exams increases. “Pregnant (women) who underwent eight or more cervical checks were 1.7% more likely to develop an infection than those who had one to three exams.”
There’s also the risk of stimulating the cervix and rupturing the membranes, which is known as premature rupture of membranes. If you are not due, or your baby is not ready to be born, this can lead to more interventions during labor, such as contractions beginning, pitocin being used, continuous fetal monitoring, induction, or even c-section. (the Cascade of Interventions!)
Here are some facts to remember about pelvic exams:
There is no evidence that routine vaginal exams in labor improve outcomes for mothers or babies
Vaginal exams are invasive and can be quite uncomfortable
Cervical dilatation during spontaneous natural labor is different from woman to woman and unpredictable
There are other, less invasive ways to determine the progress of labor, such as evaluating the woman’s behavior and vocal cues.
The measurements of a pelvic exam are subjective and inconsistent between each practitioners. The accuracy between practitioners is said to be less than 50%. This means the more people you have performing these cervical checks, the less accurate and concurring they will be.
Remember that you must give consent to vaginal exams. If you don’t want them, you have the right to decline them. In fact, if a practitioner were to do a cervical exam without consent, it is considered assault and battery and a breach of professional standards.
I hope this post has given you the knowledge to empower yourself to make educated decisions around pelvic/vaginal exams in pregnancy and labor. Please remember that if you feel like you need more support, consider hiring a doula who can help educate you and advocate for you!
If you have any experience or thoughts around pelvic exams, or advice for other mamas, please comment below!