Vaginal Examinations – Making an informed choice.

Following @millihill’s recent @telegraph article on vaginal examinations and ‘Covid Coercion’ I felt compelled to make a note of my thoughts and feelings about vaginal examinations in labour; their benefits and pitfalls, human rights in childbirth and holistic midwifery skills.

I was shocked and saddened when I read the article, focussing on how restricted visiting in UK hospitals due to Covid has led to women being told they cannot have their partners present unless that have an examination to ‘diagnose’ established labour. There are huge issues with this statement, not least as vaginal examinations are incredibly limited in their use of assessing labour. 

There are many reasons a woman may choose to decline a vaginal examination, and as everything that we do in maternity, if something is offered or recommended and subsequently declined – we must respect and honour this choice. I was shocked to learn that a 2016 study by the Positive Birth Movement showed that 35% of women did not know they could say no to routine examinations offered during labour. For me, this raises a whole host of questions, mainly – how are women being consented to these examinations? My most used and loved phrase at work is ‘informed choice.’ Informed choice does not mean telling a woman what is routine in the hospital and therefore they must accept. Informed choice is not “you must” or “thats what happens” or “how it works.” Informed choice is; this is the recommendation/offer, this is the reason, these are the risks, these are the benefits, do you have any questions, do you need some time to think about what I’ve told you, how would you like to proceed? Informed choice is giving the birthing person the power to make a decision based on their own thoughts, feelings, fears and desires, regardless of hospital policy and practitioner preference. 

There are a number of reasons a woman might choose to decline vaginal examinations. Women who have been subjected to sexual trauma including female genital mutilation or who suffer from vaginismus may struggle with vaginal examinations due to physical or psychological discomfort. Women may have had a previous birth experience where they found vaginal examinations uncomfortable, or that they didn’t aid their birthing experience in anyway. Women may be imploring methods of coping during labour which don’t lend themselves to vaginal examinations, and would rather follow their body’s natural urges, and use these to dictate progress in labour rather than a numerical value of their cervical os. Research has shown that vaginal examinations can cause discomfort, embarrassment, emotional trauma, and can be a risk factor for neonatal infections.

Women may also choose to request vaginal examinations, they might find them a useful tool to encourage them, knowing how far they have come or how far they have got to go, or some women who are having subsequent births may have had examinations during their first labour and expect it as part of their birthing process. 

Whatever the reason someone declines or requests an examination, they are entitled to an honest view of why they are offered, and what they can tell us.

So what does informed choice about vaginal examinations look like?

Midwifery assessment of established labour takes on a holistic approach, we look at the behaviours of a labouring person, their coping mechanisms, their support system, their reported experiences and clinical assessments – abdominal palpation to determine position and engagement, palpation of contractions, assessment of vaginal loss and cervical examination. 

A cervical examination tells us far more than just ‘how many centimetres dilated’ somebody’s os is, it tells us about the position of the cervix, the length and consistency, the application of the baby’s head to the cervix, and the position of the baby’s head. Vaginal examinations are a useful part of a complete assessment and practitioners use them to make an assessment of progress or onset of labour, using every piece of information available. We may have made an accurate assessment on progress of labour based just on everything else, excluding a vaginal examination, and an internal exam gives us the final piece of the puzzle.

It is often preached that to be in established labour you “have to be 4cms dilated’ and while this is a good rule of thumb when it comes to dilatation of the cervical os, it has great limitations when it comes to assessment of established labour as a whole, and prediction of the length of labour thereafter. What matters a great deal more is the length, strength and frequency of contractions. I have carried out vaginal examinations on women who’s cervical os’ are 2cm dilated and have given birth rapidly after, conversely women’s os’ may be 6 or 7cms dilated but with poor uterine activity will not give birth for some time. It is therefore important that vaginal examinations are used as part of a holistic assessment, and cervical os contributes to diagnosis, not makes it for you. 

Assessment without vaginal examination is also limited. Sometimes we do struggle to complete an assessment without that final piece of the puzzle, which is where we may recommend an examination. This is to ensure we are able to offer the most appropriate care for the mother and family. We know that, in the most part, women in early labour progress better in their own, home environment, with good support systems around. Here they can use their own comforts, baths, showers, TENs machines, massage and movement to aid them through the latent phases of labour. We know that admission to hospitals in early labour increases medical interventions such as epidural uptake, syntocinon augmentation and artificial rupture of membranes having a knock on effect on an increased probability of caesarean section.  

However, as previously mentioned, we must respect the wishes of the birthing person when it comes to offering intimate examinations. If, following explanation of the recommendations for vaginal examination, someone chooses to decline an examination, this is to be respected, and we must make the assessment of established labour based on all the other aspects. 

Assessment of a woman during her contractions, paired with palpation may give us a good indication of the strength, as well as being able to time the length and frequency. Changes in behaviour, be it observed by the practitioner, or reported by the birthing partners can give us a good idea of the changing intensity of uterine activity as someone moves through the stages of labour. The ‘purple line,’ reported sensations of rectal pressure or involuntary pushing may give us an indication of progress into the second stage of labour. Vaginal loss, such an increased mucous discharge or a ‘show’ may tell us that there is some changes occurring to the cervix. 

I preach to my colleagues and my students the importance of women making choices based on all of the evidence we have available to share. In the case of the ‘admission vaginal examination,’ we must respect women’s choice to decline this after they have been educated – preferably in the antenatal period and not during labour – on the reasons that they are offered and may be recommended. 

Read Milli’s article here: https://www.telegraph.co.uk/women/life/pregnant-women-feeling-forced-violating-vaginal-examinations/

For advice regarding your pregnancy please consult your hospital or healthcare provider.

Ying Lai, C., Levy, V. 2002. Hong Kong Chinese women’s experiences of vaginal examinations in labour. Midwifery, 18. Pp 296 – 303. Clement, S. 1994. Unwanted vaginal examinations. British Journal of Midwifery, 2. Pp 368 – 370.  
Seaward P.G., Hannah, M.E., Myhr, T.L., Farine, D., Ohlsson, A., Wang, E.E. 1998. International multicentre term PROM study: evaluation of predictors of neonatal infection in infants born to patients with premature rupture of membranes at term. American Journal of Obstetric and Gynaecology, 179(3). Pp 635 – 639  
National Institute for Health and Care Excellence (NICE). 2014. Intrapartum Care for  Healthy Women and Babies. Clinical Guideline: CG190.   
Rota, A., Antolini, L., Colciago, E., Nespoli, A., Borrelli, S.E., Fumagalli, S. 2018. Timing of hospital admission in labour: latent verses active phase, mode of birth and intrapartum interventions. A correlational study. Women Birth, 31(4)  
Davey, M., McLachlan H.L., Forster, D., Flood, M. 2013. Influence of emoting of admission in labour and management of labour on method of birth: results from a randomised controlled triage of caseload midwifery (COSMOS trial). Midwifery, 29(12)

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