“Vaginal examinations done by many different people.” A woman said this about her birth experience, and that will forever be etched in my memory.
What is a vaginal examination?
The vaginal examination is often done routinely on women, in the context of pregnancy and childbirth care. The health professional inserts two fingers into the woman’s vagina. This is a procedure done to determine the degree of dilation and/or effacement of the cervix, the position of the baby, and how deep it is in relation to the mother’s pelvis. However, the truth is that the vaginal examination does not allow us to guess the future. It merely defines how the cervix is at that. precise. moment. So, let’s stop fooling women and saying that we can predict anything.
What does the evidence say?
There is no evidence that vaginal examinations lead to better outcomes for both mothers and babies, as we can see here. And it has even been concluded that the dilatation of the cervix in physiological birth is something impossible to predict, since it does not follow a linear pattern, as we are told here.
Many women find vaginal examinations invasive, uncomfortable, or even painful. And have we ever stopped to wonder if that woman has a history of sexual abuse, and that this procedure can trigger traumatic memories? There are also some associated risks, like introducing an infection in the womb and / or the baby.
The vaginal examination is a symptom of our hurried culture. We stopped listening to women and acknowledging that she is a complex individual, who needs privacy, security, and to feel confident, so she can give into the process of labour and allow her hormones to do their (wonderful) job. But where did this impatience come from, this need to “measure” the progress of labour, or the ripeness of the cervix in the last weeks of pregnancy? The American obstetrician Emanuel Friedman was one of the major contributors to what is one of the biggest fallacies of modern obstetrics. Friedman analysed women in labour in the 1950s and from then on, came up with a chart, that to this day we call “Friedman Curve”, which described how long a woman should take to reach 10 cm. Friedman distinguished between primiparous and multiparous. But on average, he decreed that a woman should dilate at a rate of 1cm per hour. Although obsolete, this restrictive view of women in labour is still widely used and referred to in current medical textbooks, and is embedded in what is considered to be “normal.”
In 2010, one study came up with some new curves: Zhang´s curves, and the conclusion was that “allowing labour to continue for a longer period before 6 cm of cervical dilation can reduce the rate of interventions and subsequent caesarean deliveries”. These “curves” are much more sensible. However, here we have it once again, that word that does not go with woman-centred care: “allow“. As it turns out, women are not machines to obey a predictable pattern, which can be demonstrated in a graph. They are not mere incubators of their babies. They are mammals. And complex ones at that. And these labels, these “deadlines” and impositions we place on their bodies are responsible for many unnecessary interventions that women end up being subjected to. How many women have been induced because the cervix was not yet “ripe”? How many women went on the have a C-section for “failure to progress”? How many had their labour augmented with syntocinon because they ought to be progressing “faster”?
We are not machines. Some women take several hours to reach 4 centimetres, and then in a half hour things happen at the “speed of light.” Some dilate 10 cm in an hour. Others in 48 hours. At 40 weeks, the cervix may unreachable, but the next day they go into labour. Or they may be quite effaced, but little or nothing happens during the next few days.
How do women feel?
It is important to have a sense of the impact that these “predictions” and “statements” have on women. Apparently harmless and common phrases at a late pregnancy appointment such as “I can´t even reach the cervix.” Or “The baby is not yet engaged” or during the birth “You´re still only 2 cm dilated.” (said to a woman who had been coping beautifully with her contractions for the past 8 hours). These observations can have a tremendous impact on a woman’s anxiety levels. There she is dealing heroically with frequent contractions but now she feels like she has achieved so little. This constant evaluation of the labour progress can cause a lot of disappointment. Forcing a woman to fit into a mould, or an expected result, doesn´t take into account her individuality, complexity, and humanity. And it can make her feel as if somehow, her body is not up to it. That it is not effective / good / fast enough. Childbirth is not a race. Why is it that faster and more advanced, tends to equal “best”? Instead of measuring progress quantitatively, let’s look at that woman. Let’s encourage her. Let’s prepare her. Let’s work to demystify her expectations (and that of those around her). Let’s really talk about what matters: how is the baby? How is she? If both mother and baby are well, and remain well, what´s the hurry? If labour does not progress at the expected rate, so what? If that baby is not engaged, what does it matter? It does not mean it will not happen. A supported woman, who feels listened to, is a woman who is well on the way to going into her birth journey with confidence. If we connect with that woman she will give us “tips” on how things are unfolding. By the sounds she makes. The frequency of the contractions. If she is looking for comfort, if she wants to be alone, if she must stop talking during a contraction. By the position she is in if allowed to just be… etc, etc, etc …
Of course sometimes the woman herself may want to know “how things are”. And that is more than enough reason to have a vaginal examination done. It is her body. Her choice. And that is valid.
On the other hand:
The vaginal examination has its usefulness and its place. It can and should be used when due to foetal or maternal distress, we need more information. When we act in an emergency, this is not impatience. It’s professionalism. The problem is that it is being done routinely, most of the time.
Do I have to take it?
Going back to the initial statement that struck me: “Vaginal examinations done by many different people.” – In no other circumstance in life, would it be acceptable, to insert fingers inside a woman´s vagina, without her consent, without her wanting it. In any other context this sentence would be classified as assault. Why does this change when she is pregnant or in labour? Does a woman lose her dignity, self-determination, sensitivity and reason when she becomes pregnant? Or when she is in labour? Most certainly not.
The vaginal examination is not mandatory. And like all interventions and tests during pregnancy and childbirth, it can be refused. Don´t ever forget, it’s your body, your baby. Know your rights, which are above any hospital procedure.
Let’s leave the cervix alone. It does not need to be “examined”, manipulated, pulled, or extended manually to do its job. Quite the opposite. Let’s give it time. Privacy. And we’ll see the wonders it can do. And you, who are pregnant or in labour: your body is capable. The 10 cm, the measurements do not matter so much. You will get there. Surround yourself with those who support you, bring with you whom you trust. You’re doing so well. You got this.