Vaginal Exams

48 years ago (ish), when my mum gave birth to me, it was standard procedure, on arrival at hospital when in labour, to get the birthing person to dry shave all her pubes off and have an enema (to force the bowels to empty completely). I mean, CAN YOU IMAGINE? Let’s put this in to context, during my antenatal preparation sessions with clients I often talk about the best place for a great, efficient, beautiful whopper of a contraction that will open your cervix is also the place your body and mind would choose for an orgasm. You see they run on the same hormone, oxytocin (but you probably know all that, right?!). So, I don’t know what your sexual preferences are, and there will never be any judging from me, but dry shaving my foof and shitting uncontrollably just aren’t going to get me feeling sexy. Not in the least bit.

Thankfully, all that shaving and shitting is now a thing of the past. It was based on no medical evidence and I have a sneaky suspicion (probably because I am constantly on the look out for an opportunity to smash the patriarchy) that it was some bloke doctor who wanted a better view and was frightened of a bit of girl pooh when he was doing his very important job of ‘delivering’ the babies. (Sorry, boys, I know you’re not all bad.)

So, what does this have to do with a simple old vaginal exam? And what is a vaginal exam exactly?

17 years ago (ish), when I had my first baby, a vaginal exam was almost like a mandatory entry fee to Labour Ward (sadly, in some hospitals, it still is). Literally as soon as you got into hospital you had a hand up you (along with continuous foetal monitoring and lying on your back as standard protocol for anyone arriving to give birth). And then you had a VE every 4 hours and it was assumed, as with the shaving and shitting, that this was just the way it was.

So, how have we progressed? Sadly, I have to say, sometimes it feels like not much… Just recently I had a second-time mum go to hospital in labour. She absolutely 100% did not want a VE and stated so very clearly. She knew she was in labour and her contractions were powerful and regular. The triage midwife told her she would not be admitted to labour ward without a VE. My client called me and I assured her that she didn’t have to agree to a VE if she didn’t want one and that there was no other indication that her labour wasn’t perfectly straight forward. I suggested she ask the midwife what other options there were. She was told there were none. After another discussion with me my client decided to go home. She had the baby 2 hours later in her bedroom. Thankfully she was delighted. Thankfully she didn’t feel terrified at being denied care because of her vaginal entry policy.

When you arrive at hospital/birth centre, or the midwife arrives at your home to support your birth, they might suggestthat they perform a “VE” to see how things are progressing. A vaginal exam is when a midwife or doctor places two gloved fingers inside your vagina to feel your cervix. By doing this they will be able to feel how much your cervix has changed in shape and length. The shorter (effaced) and more open (dilated) your cervix is, in theory, the further along in labour you are.

Please note (and this is SO important), you do not have to have a vaginal exam at that moment, later in the day or ever at all. If you agree to a vaginal exam it MUST be with informed consent. I am not suggesting that midwives and doctors are going to force you against your will into one. But “hop up on the bed, Dearie, and we’ll see how far along you are shall we?”, whilst said with kindness, isn’t informed consent. Neither is “well how do we know you’re in labour if I can’t examine you?” And ditto “your baby is at risk if I don’t perform a VE”. You get my gist I hope. It is YOUR choice at all times.

So, let’s look at why you might decline a VE and then we’ll look at why you might want one.

You might decline a VE because the thought of a stranger putting their hand inside your vagina whilst you’re in labour (or at any time, come to think of it) is upsetting to you. Or just not your cup of tea. You might decline THAT person because you don’t feel comfortable with them. You might decline THAT moment because you feel your labour has just stalled a bit/ramped up and you’re focussing on that instead, maybe later. You might decline because you feel like you know your own body and know where you are in labour. You might decline because you are happy to let your labour unfold in it’s own time. And then, later, you might change your mind on all of that and decide to have one afterall. That’s also okay.

What’s really important to understand is that it is your choice, always. Also:

- A VE cannot hasten your labour

- It isn’t always an accurate indicator of how your labour is progressing

- In fact, the information itself might knock you off your stride (you think you’re doing great, you’re told you’re ‘only’ 4 cm, you then feel like giving up. Or you’re told you’re 9 cm, feel like you’re almost there, only to find yourself still 9cm 4 hours later and crestfallen)

- More than 5 VE’s during labour is associated with an increased risk of infection

- They can be uncomfortable

Now let’s look at why you might either accept or request a VE (even if you have previously declined). A vaginal exam can help to inform you of the presentation of your baby (which part of their head is moving against your cervix from the inside). This can be useful if you feel your labour is taking longer or has stalled. Although what you can do about it at that point is limited so, again, is just information. It might help you to decide whether it’s time to get in the pool, choose to take some pain relief or consider other options appropriate for your circumstances. And, finally, you might just be really curious to know what your ‘number’ is. And it might offer you the encouragement you need to tell you that you ARE progressing, giving your energy levels a lift.

And I’m certainly not anti VE’s per se (even though I’ve been given the moniker ‘The Vaginal Gandalf’ by some of my doula colleagues - I even have a Gandalf key ring from one of my Mentees!) As with all things birth and breastfeeding, I’m pro-choice and anti- pressure. I have been at too many births where the birthing parent has very clearly made her wishes about vaginal exams clear on her birth information document and verbally, and is still pressured to have a VE for no good reason than ‘it’s on a list of things to be done’. I’ve seen mothers been told THEIR baby is at risk of dying without a vaginal exam (also for no good reason than it was on a list of things to do). In fact, during my second birth at home, just 3 hours before I gave birth, as I was regularly contracting every 2 minutes, moo-ing like the happiest labour cow on the planet, waters gone, my midwife said to my doula “but I HAVE to give her a vaginal exam, how else will I know she’s in labour?” My lovely doula, Belinda, smiled benevolently and just said “oh I think we can all see she’s in labour.”

And there in lies the nub. What about reading a person in labour’s breath, the sounds she makes, the spaces between contractions, is she chatty or is she lost in her birth power? Can we encourage her to do her own vaginal exams (as my beautiful second-on-the-scene midwife encouraged me to do). Can we read all the other signs of labour first, and then offer undying trust in her body so she finds it herself to carry her through to the other side? And, of course, should a labour look like it’s taking a detour, or should it become an appropriate tool in the toolbox of support, then we can offer a vaginal exam. With fully informed consent.

I’m convinced that in another 20 years VE’s will be a bit outdated, along with the shaving and the shitting. Having said that, if your preference is to go in to hospital with a Hollywood having had a good old bowel clear out then you go for it, mamma. But if you want to go full bush and a bit constipated, like many of us end our pregnancies, then that is your CHOICE. At the end of the day your cervix won’t mind either way and neither should your midwife*.

*Here’s to all the FABULOUS midwives who use informed consent at all times, know the power of patience and the wonderful art of reading a woman in labour without putting their hand inside her at the first ‘hello’. I’ve met many of them and I’m sorry I haven’t featured you as heavily within this blog. I am also in awe of midwives medical knowledge and responsibility at all times, I couldn’t do your job and I don’t ever claim to.