During labour, it is normal NHS policy to offer vaginal examinations (VE) - but it is important to know that they are entirely optional. A VE involves a midwife or doctor inserting their fingers into the vagina to feel the cervix, and to estimate how dilated it is. The estimate is arbitrary and can vary significantly between examinations and between practitioners. VEs are often done with the labouring woman lying on her back, but it is possible to do a VE in any position, which may be preferable as lying down in labour, even for a short time, can be very uncomfortable. It is important to know that while VEs are offered to almost every woman, and they are often seen as an essential part of labour, there is actually a lot of evidence to support women considering not having them at all - this will be discussed below.
It’s different for every woman. Some women don’t mind them, others find them uncomfortable or sometimes very painful. For some women, having fingers inserted into their vagina can be a very distressing experience, especially if they have previously experienced sexual abuse.
The midwife or doctor is checking to see how many centimetres dilated the woman is, and they also feel whether her cervix is thinning, which is a necessary part of labour progression. Sometimes, a VE is done to try to help to determine the position of the baby, by feeling the “presenting part” of the baby, that is, the part which is pressing on the cervix. Sometimes, VEs are done as part of a check to see whether a woman’s waters have broken when they believe that this has happened. It is really important to know that in this case, VEs may be something to decline completely because if your waters have broken, VEs can be the cause of an infection which may affect you and/or your baby. Furthermore, a VE can cause the waters to break and in some cases midwives and doctors have deliberately or accidentally used a VE examination to break the waters despite the woman deciding not to have them broken.
Often, a woman is asked to have a VE to “obtain entry” to hospital, or a birth centre, or when the midwife arrives to a home birth. They are then usually offered around every 4 hours during labour. Sometimes, a VE is offered to check to see how dilated a woman is before using a birth pool, or receiving pain relief. This is unnecessary and it should not be used as a condition for use of the pool. Very rarely, a VE is offered during antenatal care, before labour starts, although this not normal practice in the UK.
It is very important to know that no one can ever put their fingers into your vagina without your consent - ever. To state to a woman that she must have a VE before she is provided with access to care of any kind (for example, access to an obstetric unit, use of the pool, access to pain relief) does not provide her with the ability to say “no” if she wants that care, and therefore she is not giving informed consent.
When a midwife first arrives at the labouring woman’s home, or the woman arrives at the birth centre or hospital, it is normal practice for a VE to be offered. The general thought is that it is useful to know how dilated the woman’s cervix is in order to judge whether she is in “active labour”. However, this has very limited value, if any, because one woman’s cervix may be 3cm dilated for 3 weeks before she gives birth, and another woman’s may go from 1cm to 10cm within 2 hours. Being at 5cm does not mean that a woman is halfway through labour. Knowing what the cervix is doing now does not tell us what it will be doing in the future. While some women do find it useful to know where they are, others find it unhelpful, especially if they are less dilated than they expected to be (even though this means nothing too!). Therefore, it is important for you to decide for yourself how useful it will be to you to know that information. If you would be concerned that the answer would be disheartening, then you can decide to either not have the VE, or have the VE and not be told the answer.
If it is suspected that the baby is in a position which may make it more difficult for them to be born, then sometimes an internal examination, to feel the part of the baby which is at the cervix, can be helpful to better determine what the baby is doing. If a midwife or doctor wishes to check your baby’s position internally, this is different to checking the dilation of the cervix, and this should be clearly explained to you. However, it remains your decision whether or not to allow the examination.
The most common problem that VEs cause is pain and discomfort, and for some, embarrassment. However, they can also be a source of infection – and for women whose waters have broken it is often advised to avoid VEs completely, for this reason. Sometimes a woman’s waters can be broken by mistake during a VE. For some women, the act of someone putting their fingers into their vagina can be hugely distressing. Any form of pain or distress in labour can adversely affect labour, because this can release the hormone adrenaline, which inhibits a key labour hormone, oxytocin. This can slow labour down for some women, and sometimes stop it for a period of time. In addition, being told that you are “not progressing”, or not as fast as expected, can lead to women feeling disheartened and upset, yet given that the dilation of the cervix at that moment gives no information as to the length that labour will ultimately be, this could be a pointless discouragement. The dilation measurement is not even necessarily accurate, and the estimate can differ from caregiver to caregiver.
While it may be arguable that knowing the dilation of the cervix by any method has limited value, due to the fact that it does not open at a linear rate, sometimes it may be useful to have an indication of progress. For women who decide to decline the offer of a VE, there are a number of other ways to estimate how labour is progressing.
1) Watch and listen! While every woman labours differently, it is generally possible to judge by a woman’s behaviour how her labour is progressing. While this can be more difficult where a midwife might be caring for a number of women, huge amounts of information can be gathered by just listening and watching.
2) The purple line – In some women (not all), a purpleish line can be seen, starting from her anus and developing up between her buttocks. This line tends to approximately reflect cervix dilation, without about 1cm of line equalling about 1cm of dilation of the cervix. This is not always the case - some women have the line and it does not relate to dilation - but it might be a useful indication in some cases.
3) Hot legs – as a women progresses through labour, the extra blood needed by the uterus to do its hard work pulls blood away from the woman’s extremities. This can lead to her legs getting progressively colder, from the foot to her knee. When the colder part is at her mid calf, that equates roughly to 5cm dilated. This works less often for women who have had an epidural or some other pain relief, and if she has been in a pool or warm bath, it will take around 20 minutes or so for the effect to be felt.
From the AIMS Journal: http://aims.org.uk/Journal/Vol22No1/VEsDiagnostic.htm
Purple Line references
Written by Emma Ashworth
Reviewed by Beverley Beech
Review needed: 11/2018
AIMS supports all maternity service users to navigate the system as it exists, and campaigns for a system which truly meets the needs of all. AIMS does not give medical advice, but instead we focus on helping women to find the information that they need to make informed decisions about what is right for them, and support them to have their decisions respected by their health care providers. The AIMS Helpline volunteers will be happy to provide further information and support. Please email firstname.lastname@example.org or ring 0300 365 0663.
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