A vaginal examination is a procedure in which the midwife or doctor will insert 2 gloved, lubricated fingers in to the vagina. Usually they will have you lie on your back, with your heels together and legs flopped to either side. If your cervix is quite far back (posterior) they may ask you to make 2 fists with your hands and put them under your bottom, this tilts the pelvis forward to make the cervix easier to reach.
They should gain consent first and have you say if you want them to stop at any time. The procedure can be uncomfortable or painful, though some women are not phased. It is different for everyone, you should be able to have gas and air (entonox) to help if you need it.
The midwife will then move her fingers back into the vagina to locate the cervix. It can take several minutes, especially if the cervix is posterior.
They will be feeling for:
1. The length of the cervix – during labour it thins so this can be a good indicator of whether things are beginning to change. You may hear them say it is ‘effaced’ which means thinned
2. The consistency of the cervix – during pregnancy the cervix is hard and will soften towards and during labour
3. The dilatation of the cervix – the muscles in the uterus draw up during a surge (contraction) and never fully return. This is why the cervix gradually dilates (opens). When the cervix is fully dilated (10cm) the baby will fit through to be born
4. The position of the cervix – the cervix begins posterior (back) and gradually moves to the front (anterior) during the early stages of labour so examinations should become less uncomfortable as it comes forwards
5. The position of the baby – the midwife can feel how engaged the head is into the pelvis, the head should become lower ready for birth. They can also feel the landmarks on the head to determine which position the baby is lying in. You may have heard of back to back baby, this is one position the baby can be in (there are many). They can also tell if the baby is breech!
6. To see if the waters have released
Current NICE guidelines state that vaginal examinations should be OFFERED every 4 hours once you are in active labour, to assess progress.
1. They can give your midwife an IDEA of what is going on inside your body and she can link this with any external signs. For example, sometimes late in labour the baby’s heart rate can change, which could be a sign you are nearing the final stages. She could find that the cervix is fully dilated (although not guarunteed!)
2. They can give you an idea of the position of the cervix and baby. This can be important for labour and birth and can impact how things change, your surges and the length of the labour. Sometimes the baby is not pressing on the cervix effectively which can delay labour
3. They give you an idea of what is going on at that moment in time. No more than that! This can be useful if there were to be an emergency situation
1. As above, they only tell you what is happening there and then, so cant be a good predictor of how the remainder of your labour will progress
2. They may be uncomfortable and interrupt your natural flow of oxytocin
3. They can pose a chance of infection, especially if your waters have released, so will be done in moderation in this case
4. They can be very misleading. One minute your cervix could be 2cm dilated, the next you can see the head coming! That or you can be told it is 8cm and still be waiting hours to meet your baby. You just can’t tell and that can be very disheartening sometimes
It is your decision to make with your midwife and you may have second thoughts during labour. You should decide whether it is necessary each time it is offered to you as situations can change. Your midwife SHOULD allow you to make an informed choice. Otherwise, it is effectively assault if they go ahead without your say so.
But what if you decide not to? How can labour progress be assessed then?
1. Your behaviour will change as labour progresses. You may begin to make different sounds or think you can’t do this anymore. This is the transition stage and it comes right before your baby is almost coming!
2. Your instincts. You may feel the baby moving down low, you may feel sensations which are new to you. You might just feel your body bearing down and you can’t stop it!
3. Your waters may release if they haven’t already
4. You might feel nausea or vomit, perfectly normal response
5. The purple line – this appears on your buttocks/back and is supposed to correspond with how dilated your cervix is. Not shown in all women
6. Rhombus of Michaelis – this is part of your sacrum (a bone of the pelvis) and as the baby begins to move lower, you may see it sticking out in a kite shape. This usually happens mostly if you are in an all fours position
7. Changes to the baby’s heart rate – there may be normal physiological changes due to the head or being compressed as it is moving through the birth canal
8. Poo! When the baby is low in the birth canal it may press on your rectum (where poo is stored) and push it out. Don’t worry, the midwife will quickly dispose of it without you even knowing
9. Changes to your genitalia – everything will begin to visually open up
10. We can see the baby! Sometimes they will come with little warning, especially 2nd time mummas
That is your crash course in vaginal examinations during labour, what are your thoughts? If you want to know more about this interesting stuff, your local Little Birth Company instructor will be able to help! Find them here…