Respectful Vaginal Examinations Project - Co-Production in Action

AIMS Journal, 2022, Vol 34, No 2

To read or download this Journal in a magazine format on ISSUU, please click here.

By Kelly Sawyer

The Respectful Vaginal Examinations project is an ongoing quality improvement project at Maidstone and Tunbridge Wells (MTW) NHS Trust. The project aims to improve practice to reduce the amount of unnecessary and unwanted vaginal examinations (VEs) being performed in labour, make sure those that are necessary are being performed in a dignified and compassionate way, and educate women and pregnant people about their rights and their choices around VEs in labour.

The project is being completely co-produced between midwives at MTW and members of the Maternity Voices Partnership (MVP), led by MVP chair Nina Rickman and Deputy Consultant Midwife Kelly Sawyer. Co-production between clinicians and service users ensures that all problems, and the required solutions for those problems, are understood and worked upon from both service user and clinician’s viewpoints. Utilising the expertise and knowledge of service user reps also encourages the voices of marginalised and vulnerable groups to be heard, ensuring we are focusing on the topics that matter to all. Nina has done a lot of work mapping out the demographics of our catchment area to target those voices and ensure their views are incorporated into the project.

What are the issues?

Vaginal examinations have become a common intervention during labour. The examination has a variety of important uses, including diagnosing a cord prolapse (a rare emergency when the umbilical cord is being born before the baby), deciding on the best method to start an induction of labour, and checking the position of the baby during labour. VEs are also often carried out routinely to diagnose the start of the first and second stages of labour, and to assess how labour is progressing. The World Health Organisation (WHO)^[1] recommends that if a birthing person is low-risk, VEs should be offered at least every 4 hours to assess progress and rule out ‘labour dystocia’- the abnormal slowing or stopping of labour that can increase the likelihood of trauma to the birthing person and baby.^[2]

Critics of the VE claim that modern-day maternity care has become too ‘cervix-centric’ and the VE is relied upon so heavily because it is the only way to quantify labour in numerical terms, not because of its accuracy.^[3] A Cochrane review in 2013 concluded that there is no evidence that routine VEs in labour improve outcomes, with the authors displaying concern at how widespread the use of routine VEs have become without a solid evidence base to back it up.^[4] This Cochrane review was updated this year; despite there being nine years between reviews, the authors still came to the same conclusion.^[5]

Evidence from around the world has emerged suggesting that the VE can actually cause harm rather than prevent it. Two recent large-scale studies by Gluck et al. (2020a^[6]; 2020b^[7]) found that having five or more VEs increases the chance of experiencing a raised temperature (which may be a sign of infection) during labour, and can also increase the risk of a serious (third- or fourth-degree) tear.

In addition, numerous studies have suggested that the experience of the VE for the birthing person is often a damaging one, with some reporting feeling pain and embarrassment during a VE.^[8],[9] Worryingly, several studies have found that some women and birthing people felt coerced or intimidated into having VEs without giving their full informed consent.^{[10],[11],[12],[13],[14]}

Very little is known about the lived experiences of healthcare professionals and how they approach the VE within their clinical practices; Mary Stewart carried out a study in England in 2005 to understand how midwives negotiate the tensions that exist around the VE. She found that midwives often remove all language that can sexualise the procedure or cause embarrassment to either party - both during pregnancy and labour.^[15] Not discussing the implications of a VE thoroughly can result in the creation of an unequal power balance between practitioner and birthing person, increasing that person’s risk of being coerced into a procedure they do not want or need because they do not understand it.^[16]

What is happening locally?

At the beginning of the project, I audited 55 sets of labour and birth notes, ensuring the sample contained a mixture of births from those having their first babies and those who have had babies before; both spontaneous and induced labours; and labours that took place in both midwifery-led and obstetric-led settings. The findings mirrored those found in the wider research - that VEs were taking place during labour more than twice as frequently than the 4-hour intervals recommended by the WHO.^{[17],[18],[19],[20]} The audit also found that on average, each person in labour had 6 VEs performed by 4 different practitioners, also indicating that continuity between clinicians was not being achieved, increasing each birthing person and baby’s risk of developing an infection.

In order to understand it from the birthing person’s perspective, Nina Rickman and fellow service user representative, Nadia Higson, developed a survey which was released on the Trust and MVP social media pages. The survey received a staggering 150 responses within 24 hours- the biggest hit-rate the MVP or MTW have seen from a patient experience survey, seemingly indicating how passionately women and birthing people feel about the topic. The findings were mixed- although many reported that they were given excellent, compassionate care, many were left feeling otherwise. Only 17% of respondents knew about the alternatives to a VE, including their right to decline, and 54% felt that they didn’t have a choice whether to have a VE or not. This raises issues around how informed the consent given for a VE truly is within maternity care, and how well practitioners discuss the risks, benefits and alternatives of a VE in comparison with other interventions.

Objectives of the Respectful VE Project

The Respectful Vaginal Examinations project aims to break down these communication barriers and encourage midwives and obstetricians to become comfortable discussing VEs during pregnancy and labour. Information will be created for women and birthing people in a variety of formats, including incorporating the discussion into parent education classes, to help increase the accessibility of that information. Posters will be displayed in clinical areas reminding women and birthing people of their rights to receive more detailed information about the VE, as well as their right to decline a VE at any point in labour. Work is also ongoing to develop a training package for staff, encouraging them to critically analyse their practice, make improvements to their care, advocate for women and birthing people and support informed decision-making. Training will also include increasing midwives’ confidence in alternative, holistic methods of assessing progress in labour, so that they can feel less afraid of caring for those birthing people who choose to decline routine VEs.

We really hope that the work we are doing within the project will go on to improve the experiences of women and birthing people at MTW. We are aware that the issues we face are not isolated to our Trust - the over-reliance on VEs is a common problem across the globe, but we feel proud to be one of the first Trusts in the UK to address the issue head-on. Co-production has so far proved to be an invaluable component of the project, and we wholeheartedly believe that working on the project together will only make it stronger and more likely to succeed in improving the outcomes and experiences of everyone who uses our services.

Author Bio: Kelly Sawyer is the Deputy Consultant Midwife at Maidstone and Tunbridge Wells NHS Trust. She has a particular interest in promoting physiological labour & birth in high- and low-risk labours and advocating for choice and personalisation in maternity care. Her interest in VE practice started during her time working as a caseloading home birth midwife in South London, and she is about to embark on her first research project further exploring VE practices in the UK.