Written by Virginia Rivenbark, AdvCD(DONA), LCCE, CLC and Rachel Grimm, editor extraordinaire
I think we can all agree that pregnancy, labor, childbirth and the post-partum period are all very intense, interesting, important and life-changing times in a person’s life. Whether that person has an easy and pleasant experience, or a difficult and traumatic one, carrying and bearing a child leaves no one unchanged. The part that we may forget about is that it still connects to a woman that existed before that experience and will affect her long after a baby has joined the world.
There are so many details to pregnancy and labor, so it’s important that I bring up one that I can help with. I have lost count of how many times I have had a client call me after a prenatal appointment in tears about how painful the vaginal exam was that their care provider had insisted on. And often the next thing they say is, ‘How am I going to make it through labor if I can hardly handle a vaginal exam??’. Obviously, the one major thing that vaginal exam did was to create fear and anxiety! I reassure my clients that vaginal exams can be more painful than labor! But what can we do about it?
First of all, I remind my clients that they can always refuse any medical service that they want to! We often forget this. Medical professionals are at our disposal and our discretion to use as we need and want! If we do not want a service, we certainly do not need to submit to one, and that includes vaginal exams. Medical professionals would certainly like the information that they can get from such an exam, but what information does it give them?
A vaginal exam during pregnancy is done to determine what kind of a state the cervix is in. Is it dilated (opened) at all, and if so, how much? How about effacement (shortening)? Both of those things need to progress fully for labor to be successful. A cervix needs to go from completely closed to 10 cm open, and effacement from 0% to 100%. However, there is no consistency in how these things progress, all the way up until a baby is born! Women often start to dilate or efface well before labor starts, even weeks before! But that doesn’t mean anything at all, since it doesn’t predict when labor will actually start. It doesn’t help that the position the cervix is in prior to labor (posterior, pointed towards the back) makes checking it more difficult and uncomfortable. However, medical professionals like to have this information, since it’s measurable and can be checked.
So medical professionals like to have this information, but what does this information do for pregnant people? I tell people in class you will leave either disappointed or excited based on what you hear, and either of those can quickly change to the opposite. I have also witnessed and had told to me of care providers doing an exam at prenatal appointments and doing a membrane sweep during the exam. If you haven’t experienced or heard of it, a membrane sweep is a minor procedure done to help induce labor, done by the care provider during an exam; this can trigger a release of hormones that can start labor. But it can be very painful and can increase the chances of a membrane rupture/water breaking before labor starts, which can lead to many interventions because the body and baby aren’t ready for labor. A membrane sweep is a medical procedure, and the risks and benefits should be clear and consent given before the exam, but that often does not happen.
Those prenatal vaginal exams can be skipped, and if you would want to skip them, make that known to your medical provider. Remember that there’s no reason to take off any clothing at an appointment if you don’t want to! If the nurse looks confused when you say you don’t want to change into a gown, let them be confused; you are under no obligation to do everything on their wish list of checks and exams.
However, what about vaginal exams during labor or when you want to be admitted to the hospital for labor? Many hospitals require a vaginal exam in order to admit a laboring mother, to be sure that labor is far enough progressed that birth will happen relatively soon. Nobody wants the mother to be at the hospital for hours or days, only for labor to stall out. What you may not know is that there are many other signposts of labor, and midwives and doulas are trained to look for them. In fact, I have attended numerous home births where not one vaginal exam was done, but laboring people observed for the signs of labor.
As a doula I have never done a vaginal exam but can usually tell where in labor a client is by watching and listening. Doulas are trained about what to look for, and home birth midwives tell me this is what they do as well. When I talk to OBs and hospital midwives, they need the numbers to enter into the computer and don’t seem to feel the signposts of labor are important, or in some cases have no idea what they are. Some tell me they need to know where the person is in labor so they can apply the Friedman’s curve The Friedman’s curve says a woman should dilate about 1 centimeter an hour consistently until birth, otherwise a care provider considers interceding. The study the Friedman’s curve was based on was in 1955 with only 500 first time mothers, yet many care providers still base what they expect on this. I’m here to tell you cervixes were not told about the curve and do not always perform as expected! But babies still come.
All of this is important, but I have an even more poignant reason for opposing unnecessary vaginal exams. I attended a doula educator’s training entitled ‘When Survivors Give Birth’, about women who have suffered abuse, and their particular needs and struggles during pregnancy and childbirth. It had not occurred to me that vaginal exams might not only be unnecessary and potentially painful, but it might add additional trauma or be triggering to a woman that has been abused. I immediately wanted to do more and be more aware for women such as these.
So what changes can be made and how? It is very unlikely that hospitals will stop requiring a vaginal exam in order to admit a laboring mother. However, that still leaves many other exams, at both prenatal appointments and during labor, that can be at least lessened, if not eliminated.
I have started talking in my classes and to my clients more about the exams; we discuss how to refuse them and when they might be necessary. If appropriate, we talk about trigger words and trauma. Then when meeting privately with clients, we discuss and come up with plans that will lessen the trauma and potential pain. Some helpful ideas are waiting awhile once at the hospital before an exam is done and the person is given the freedom to say when they are ready. Different positions for exams can also be helpful. I had a client who had this discussion and a care provider who listened made all the difference. The mother decided when we got to the hospital that she wanted to be checked while standing. Later in labor, the midwife stood by with words of encouragement and only put her hands out when the baby started crowning instead of doing constant checking.
We need to put the control with the person being examined, not the person doing the exam. Clear communication about expectations and desires also goes a long way in avoiding unnecessary problems. Come up with ways that help you feel in control. That could look like skipping the prenatal vaginal exams, asking to wait until you feel settled when first getting to the birth place, refusing routine checks during labor, or asking the provider to be hands off during pushing. If your care provider is resistant to these ideas when discussing them at prenatal appointments, maybe finding a different provider or birth place is needed.
I think the most important thing is that open communication between pregnant people, care providers and support people is vital! Sometimes these discussions are difficult, but in the end, well worth the time to help you have a pregnancy, labor and birth that is not traumatizing. The pregnant person is the one that gets the final say in how they handle their body and their baby.
I’ve attached a link below about the evidence and necessity of vaginal exams. I would love to hear your thoughts, as a pregnant person, care provider or support person. We are all in this together!