Are Vaginal Examinations Ever a Good Idea?
I was spectator to a debate this week around whether the advice to decline all vaginal examinations in labour could potentially be dangerous? Do vaginal examinations cause harm.. or prevent it?
Vaginal examinations involve a midwife or doctor using their fingers to feel your cervix (usually fairly deeply inside your vagina) to assess ‘what it feels like’. In the way that many people are familiar with, they are looking at ‘how many cms it is’, but may also be able to gather further information such as how long it is, how soft it is, which way it’s pointing, where it is in the pelvis (high or low), which part of baby’s body is there (eg head/bottom/something else) and occasionally they can feel what position baby is in (is their head tucked down, which way are they facing).
Sometimes, this might reveal something about the unfolding of birth that could be helpful in decision making or ongoing care (such as deciding which type of pain relief you might like or to offer biomechanical techniques to rectify malposition); but contrary to popular belief, your cervix isn’t a crystal ball and ‘the number of cms’ it is means absolutely nothing when it comes to predicting the future course of labour. (Yes really.. you can be 2cm and have a baby in 15 minutes.. or 8cm and still have hours left.. and neither is directly related to poorer or better outcomes if you and baby are otherwise well). You’ll probably still struggle to convince your brain of that when you hear ‘a number’, but the evidence is irrefutable. It means nothing.
“Vaginal Examinations don’t inhibit oxytocin production”
Mmm.. Ready for the speediest lesson on hormones? Contractions in labour are largely controlled by the production of the hormone oxytocin. In order to produce oxytocin you must feel safe, relaxed, unobserved and undisturbed. If you don’t feel those things, then your body can stop producing oxytocin, and may start producing adrenalin, which in turn may stall or slow contractions. If a vaginal examination is done in labour, in a private and familiar space where you feel safe, by someone you know and trust, with fully informed consent, in a position of your choosing and at a moment you feel happy with; it may well not disrupt the course of labour (though the chance of a vaginal exam being of any value anyway in those circumstances is much lower in itself). The chances of those being the circumstances in which it is offered however, are slim to none. So it’s pretty likely that having a vaginal examination will disturb the flow of labour in some way, be that slight or more noticeably.
“Vaginal Examinations shouldn’t'/don’t hurt”
This just simply isn’t true. Because women say so. Who are we, as someone not experiencing the examination, to decide whether or not it is fine, uncomfortable, painful or excruciating. Usually vaginal examinations are done with a woman laying on her back on a bed; which in itself many women find to be more painful than say standing or sitting in labour. There are many things that affect our experience of pain- from previous trauma to fear, physical position to firmness of touch. Some women will feel unbothered by vaginal examinations, others will refuse under all and any circumstances.. and neither should have to justify their decision.
“Midwives won’t do more than is absolutely necessary”
Necessary for who? What benefit is each of the VE's going to have to you, and what benefit is it having to the maternity team? Yes, the NHS and the maternity system is overstretched, understaffed and there often isn’t time, space or staff to simply sit and observe you labour; to offer support, pain relief or your own room because you say you need it rather than because you’re 4cm dilated. Vaginal examinations offer an unreliable shortcut. But these aren’t reasons for YOU to consent to a VE if you don’t want one. The trouble is, if all women comply to the shortcuts many midwives are forced to take to make care easier (VEs, continuous monitoring, laying in a bed, birthing in hospital), then it looks like the money and staff aren’t needed, and down we spiral into a system with even less staff and less money.
But no more than ‘absolutely necessary’? I’ll keep this one short because its just untrue. Hospital guidance suggests offering VEs every 4 hours in labour. Even when things are unfolding as expected. Based on no evidence. That’s what the majority of women are being given, leading to higher rates of infection and higher rates of intervention (when they don’t fit the expected and non evidence based timeline).
“It shouldn’t be a blanket ‘no VEs’”
This I agree with. Because there shouldn’t be a ‘blanket’ anything in maternity care. (Except a nice familiar snuggly one around your shoulders in labour and around you and your baby after the birth!). Trouble is, there IS a blanket ‘rule’ in maternity care.. or at least a blanket expectation.. and that is that ALL women ‘should’ have Vaginal Examinations in labour. Despite there being practically no evidence to suggest they improve outcomes when used as a routine part of maternity care. Every day I hear stories from women who were withheld pain relief, access to the maternity unit, partner attendance, pool access or midwife attendance unless they accept a vaginal examination. It happens. It happens every day. At best you could call this coercion, at worst it’s sexual assault.. both of which are illegal.
If you’re rolling your eyes at this, just for a moment consider what a vaginal examination is. A person (could be a man or a woman.. most likely someone you don’t know) placing their fingers inside one of your most private and intimate body parts when you are in labour, probably the most vulnerable moment of your life. This isn’t to say there may not be occasions where the benefit of having one out weights the downsides, but we need to consider and understand the gravity of what that feels like for many people. No one should be able to do that without your explicit, voluntary consent.
As both a society and a maternity workforce we are not used to hearing birth stories that aren’t milestoned by arbitrary measurements. Most midwives aren’t used to assessing the progress of labour without touching someone’s cervix. But believe it or not, babies are safely born every day without it. They have been for millenia. There are midwives providing safe care who rarely touch anyone else’s vagina. Yep. Really.
I’m not saying everyone should decline vaginal examinations; but I am saying that should be the default. No vaginal examinations until they are requested or a genuine need presents itself, at which point an offer can be made. Not vice versa. Not ‘vaginal exams for all, unless they’ve decided to decline’.
It is not my position to decide whether you should or shouldn’t have them. Only you can decide that. But it is my position to shine a light on what they involve, the inaccuracy of them as a tool for assessing ‘progress’ and to empower you to decide for yourself whether they might form part of your birth experience or not. (And of course, you can change your mind in the moment too!)