I decided to write this blog post after a discussion in #MatExp about the use of vaginal exams (VE’s) in labour.
There were concerns that women felt pressurised into consenting to vaginal exams in order to be admitted into birthing units in labour or to access pain relief/the use of a birthing pool etc.
It was discussed that vaginal exams can feel intrusive and be upsetting and that the evidence base for using them in labour is not strong.
Others felt that they are an essential part of labour management, needed to monitor progress and prevent harm from non-progressing labours.
People wondered if there are no other ways to assess progress?
Should vaginal exams be seen as part and parcel of normal labour care?
What are the risks/benefits to having VE’s and should women have more information antenatally about them?
My own experiences of vaginal exam in labour were not distressing to me, but as a doula I have witnessed distressing events occurring in relation to vaginal exams that include:
- A woman having 20 VE by 8 different people- her cervix swelled and she had a CS due to failure to progress at 9cm
- A woman who was asked to get out of a birth pool to check for 10cm dilation when pushing, she was told the midwife couldn’t check her in the pool, she was then not encouraged to get back in the pool
- Coercion of a woman with an abuse (sexual) history at a homebirth to consent to vaginal exams (when she had discussed not wanting them in appointments leading up to the birth) which was distressing for her
- Breaking waters during an exam without permission (I’m just breaking your waters as she did so)
- A midwife gave a vaginal exam, stated the woman’s contractions were less frequent and stated she would “Just have a little fiddle about”she then proceeded to give the most intrusive, painful and upsetting exam I have seem, which was traumatic to watch
- I have also seen good practice of very respectful care to women with abuse histories and a consultant midwife that was able to give exams when women were in pools/upright
Before we look at what vaginal exams are used for, I think it’s important to remember that for a woman having her first baby in the UK, a vaginal exam in labour might be the first time anyone has put their fingers in her vagina except during sex (which may or may not have been consensual or enjoyable)
A vaginal exam involves a health professional placing (usually two) fingers in a woman’s vagina in order to feel her cervix (the entrance to the womb) to assess her progress in labour (this can also be done as part as a membrane sweep in late pregnancy to encourage labour to start.) Vaginal exams in labour are seen as a ubiquitous part of assessing progress, and therefore diagnosing deviation from expected progress and reduce the risks associated with non-progressive labour. A vaginal exam is often one of the first routine procedures when a woman believes labour has started. A woman may have previously been offered one or more membrane sweeps in pregnancy (which is similar to a vaginal exam) to encourage labour to start.
An exam can assess if a women is in ‘active’ (also termed progressive) labour. Whether a woman is ready to go into labour is to feel her cervix, its position, thickness, texture and dilation. This can be given a bishops score (http://perinatology.com/calculators/Bishop%20Score%20Calculator.htm) which can be predictive of induction success although this seems to be more reliable in women having their first baby (nulliparous)  and is disputed as a predictor of labour outcome in women having a second of subsequent baby (multipara)Before labour a woman who has not previously had a baby will usually have a cervix which is:
- Long (thick)
Before active labour begins the cervix will more forward, soften, become thin and start to open. Sometimes this is accompanied by contractions and other signs (sometimes early or prodromal labour).
The first exam in labour is often to assess if labour has started. Early labour can potentially go on for days or stop and start again days later with no risk associated with this usually unless the bag of waters surrounding the baby breaks (which could introduce infection) although there is evidence that a long early labour can be due to a babies position and lead to a non-progressive labour and more intervention. The longer a woman spends in hospital during this early labour period the more intervention she is likely to have, also maternity units in the UK are not set up to cater for women in early labour so women are often sent home, sometimes repeatedly.
Active labour is considered to have started after 3-4cm dilation (opening) and will then usually continue with regular strong uterine contractions (which become stronger, last longer and get closer together until the baby is born). It had been thought for many years that labour is a linear process, but recent reviews of the evidence have suggested that dilation and labour length is less predictable, with the early first stage of labour (4-6cm dilation) taking longer (in the US, ACOG in part of a attempt to reduce the cesarean section rate have changed national guidelines to have active labour starting at 6cm instead of 4cm[4 5]).
How is labour progress assessed?
In order to assess labour progress, observations are made by the health professionals involved in a woman’s care. In the UK this is usually a midwife.
In NICE guidance (Intrapartum care for healthy women and babies [CG190] Published date: December 2014)
The National Institute for Health and Care Excellence (NICE) provides national guidance and advice to improve health and social care.It has since acquired a high reputation internationally as a role model for the development of clinical guidelines.
A Partogram provides a graphic overview of the progress of labour and records information about maternal and foetal condition during labour. The World Health Organization has designated management of labour with the Partograph as one of the essential elements of obstetric care at the first referral level.
In 1991 in Asia, the WHO examined over 35,000 births in the largest trial of the Partograph ever done . The study found evidence that prolonged labour, postpartum sepsis, and stillbirth were significantly reduced when the Partograph was used. Augmentation rates and caesarean rates were also reduced. Another study looked at the effect of partogram on the frequency of prolonged labour, augmented labour, operative deliveries and whether appropriate interventions based on the partogram reduced maternal and perinatal complications introduction of partogram showed significant impact on duration of labour (p<0.001) as well as on mode of delivery (p<0.01) Results also showed significant reduction in number of augmented labour (p<0.001) and vaginal examinations (p<0.001). The authors concluded by using partogram, frequency of prolonged and augmented labour, postpartum haemorrhage, ruptured uterus, puerperal sepsis and perinatal morbidity and mortality was reduced.
But findings can be contradictory, another recent study looking at the role of partogram in the management of labouring mothers with high risk pregnancies at a tertiary care centre found that partogram use had no significant impact on duration of labour, rate of operative interventions and perinatal outcome. A Cochrane review on the effect of partogram use on outcomes for women in spontaneous labour at term found no evidence of any difference between partogram and no partogram in caesarean section (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.24 to 1.70); instrumental vaginal delivery (RR 1.00, 95% CI 0.85 to 1.17) or Apgar score less than seven at five minutes (RR 0.77, 95% CI 0.29 to 2.06). The authors stated ‘On the basis of the findings of this review, we cannot recommend routine use of the partogram as part of standard labour management and care’
There have been several versions of the partograph. The WHO version from 2000 starts active labour at 4cm dilation. There have also been recent studies looking at a ‘physiological partograph’ with a slower rate of expected progress in earlier active labour.
Partographs have an ‘action line’ (most also have an ‘alert’ line) which signify identification of slow progress and the point at which intervention is advised to prevent harm to the mother and baby. Many studies were done to assess the predictive value of these lines, one study found that the mean duration of active phase of labour increased as the partographic curve fell to the right of alert and action line. Increased rates of instrumental deliveries, LSCS, babies with lower APGAR score at 5 min, and NICU admissions were observed in group III (to the right of the action line) compared with groups I and II.(within normal curve or to the right of the alert line)another study found crossing the alert line in mothers who had normal vaginal delivery, with normal fetal heart rate, and with no oxytocin administration or amniotomy was predictive with high sensitivity for the need for neonatal resuscitation after birth.
How long should labour take and what are the risks of labour taking too long?
“The sun should not rise twice on a labouring woman.”(an old saying in tropical obstetrics)
Friedman’s curve has been used to assess the expected length of labour (usually 1cm per hour in active labour. With full dilation at 10cm and the pushing stage lasting approximately an hour) although other studies have suggested (especially the first time a woman gives birth) that labour takes longer, and in some places (for example the All Wales normal birth pathway) this is reflected in guidelines where women are expected to dilate 0.5cm per hour in active labour and take up to 3 hours in the second stage(pushing).
In many areas of the world, women give birth at home, without attendance by a trained health professional and only access care if they feel there is a problem with the labour. There are also cultural reasons that may discourage women from seeking help in labour as often failure to birth easily is thought to be due to actions of women during pregnancy.
In these countries, there is high maternal and neonatal mortality and morbidity relating to obstructed labour, (one of the five most common causes of maternal mortality) with many women (usually first time mothers) developing an obstetric fistula. Where the tissues that normally separate the vagina from the bladder and/or rectum are destroyed by the prolonged impaction of the presenting fetal part (usually the fetal head) against the soft maternal tissues that are trapped between the fetal head and the woman’s bony pelvis. The World Health Organization (WHO) estimates that more than 2 million women live with the condition and up to 100,000 new cases occur each year.
The formation of an obstetric fistula is a problem that originates during prolonged labor when that labor is obstructed. The critical problem in the first phase of delay is recognizing that labor is prolonged. By WHO standards, labor is prolonged if it lasts more than 24 hours.
Length of labour does not always predict fistula formation, it is strong, frequent contractions where the baby is impacted against the pelvis and does not descend. In women having second or subsequent births this more frequently results in uterine rupture.
Relatively short labours less than 12 hours in length may result in a fistula if the conditions for “a perfect storm” are present. In practical terms, this means that all cases of obstructed labor should be regarded as emergencies and treated promptly to avoid the development of serious complications.[15 16]
There are arguments about the slowest ‘normal’ rate of progress that does not result in increased risk  Quite a large number (approx. 37% in one study)of low risk women do develop dystocia, but we don’t know how to predict who will reliably. Some studies have also found that slow progress during a VBAC increases the risk of uterine rupture
Although labor dystocia (slow or difficult labor or birth) is the most frequently documented indication for primary cesarean birth, there is no universally accepted definition.” Failure to define dystocia in evidence-based, well-described, clinically meaningful terms that are widely acceptable to and reproducible among clinicians and researchers is concerning at both national and global levels.”
The frequency and reasons for vaginal examinations in labour
Even though NICE guidance states that women should be offered vaginal exams 4 hourly, a recent study found that almost 70% of women had more VEs than expected when the criteria of 4 hourly VEs was applied. The most common reason given by midwives for performing a VE was to assess labour progress and to assess the commencement of labour. 
Other reasons to do a VE include:
Ultrasound assessment of the fetal head position in labor is feasible in a busy labor ward. Digital examination is less accurate than ultrasound, in particular in cases of obstructed labor when medical intervention is more likely to be needed. Ultrasound assessment may prove useful in the prediction and diagnosis of difficult and prolonged labor
Second stage of labour
Vaginal exams are often given to diagnose the start of the second stage. Sometimes women feel an urge to push before their cervix is fully dilated (usually due to fetal malposition) and it is thought that pushing on an undilated cervix can cause swelling. There can also be a ‘lip’ of cervix remaining which can be due to asyncliticism (tilted head)
To help women push better?
In one study (Titled: “You’ll Feel Me Touching You, Sweetie”: Vaginal Examinations During the Second Stage of Labor) to determine how caregivers performed sterile vaginal examinations researchers examined videotapes of women during the second stage of labor. Results showed that the examinations were performed in a ritualistic manner by all caregivers, and the way the ritual was enacted repeatedly demonstrated the power of the caregivers over the women. The most common reason for performing the procedure, to help the woman push better, seems to be specific to the second stage of labor and is not described in the literature.
Other possible reasons include:
- Detecting baby position (especially if breech position or cord prolapse is suspected)
- Concern over babies’ heartrate and possible rapid labour progress
- Abnormal bleeding
- Making decisions about pain relief/transfer/intervention
- Deciding when to get in a birth pool
Evidence for and against vaginal exams in labour
Even though routine vaginal exams are now seen as part and parcel of intrapartum care the lack of evidence for their use is highlighted by some, with a Cochrane review concluding: “Women prefer vaginal exams to rectal exams. No other evidence was found to support or reject the use of vaginal exams. More research needed to find other ways to assess progress of labour [25 26]
What can the experience of vaginal exams in labour be like?
There have been few studies looking at women’s experiences of vaginal exams in labour, but those that have been done found that women find VEs in labour to be unpleasant, invasive, embarrassing and sometimes painful and that women felt powerless to control when and how the VE was conducted[21 27] The VE has been described as a type of health care ritual with the labouring women playing a generally passive role with no active part and the healthcare provider demonstrating that they are in control of both the woman and the process of labour itself Women have reported that they have to tolerate the pain and discomfort of the VE as it is an integral part of labour.
Studies exploring the qualitative experiences of midwives and women in relation to vaginal examination in labour have also described midwives using abbreviations or euphemisms as a means to distance themselves from the realities of the procedure. ‘Some midwives were observed washing women’s genitals in a highly ritualized manner prior to vaginal examination, apparently as a strategy for establishing power differentials. ’The authors conclude ‘It is also important to carry out vaginal examination in a way that is not demeaning and does not reinforce notions that women’s bodies are dirty.’
Previous trauma and abuse
Many women have experienced rape, abuse or other sexual offenses in their lifetime.
Based on aggregated data from the ‘Crime Survey for England and Wales’ in 2009/10, 2010/11 and 2011/12 around one in twenty females (aged 16 to 59) reported being a victim of a most serious sexual offence (rape) since the age of 16. Extending this to include other sexual offences such as sexual threats, unwanted touching or indecent exposure, this increased to one in five females reporting being a victim since the age of 16.
Many women do not disclose their experiences but the experiences during pregnancy and labour can trigger unwanted memories and fear. Worry about physical exams can stop women from accessing healthcare (for example cervical smears) and if women feel coerced or disembodied during childbirth they can be retraumatised. It is not always intimate procedures themselves that can be triggering for women, but how they are conducted, ‘re-enactment’ of abuse occurs as a result of crossing a woman’s body boundaries (and this can be a subjective internal sense) it is suggested that:
“As staff may not know of a woman’s history, they must be alert to unspoken messages and employ ‘universal precautions’ to mitigate hidden trauma. Demonstrating respect and enabling women to retain control is crucial. Getting to know women is important in the building of trusting relationships that will facilitate the delivery of sensitive care and enable women to feel safe so that the re-enactment of abuse in maternity care is minimised.”
Prior trauma is the most predictive factor of Post-traumatic stress disorder (PTSD) after birth. 
Consent to vaginal exams is necessary but women may not always understand the procedure or may feel coerced into having examinations done, as this is part of routine care, which can be traumatic, both for the woman, her birth partner/s or students, as described in this reflective piece-
It wasn’t supposed to be like this (c) S. Wallis
You thought, you would open up beautifully-like a flower does
air spreading your petals, slowly.
You thought, you would open up gently like an anemone,
red fronds unfurling with smooth salty ripples.
Not submit to this, four hourly ritual,
Spreading your legs wide, for relentless gloved fingers to press, into, you.
Assessing your readiness; your worthiness-
Like that boy at your fourteenth birthday party, after spinning the bottle.
You could taste your Mothers stolen vodka in your throat when he fingered you-
Biting your lip, trying not to cry out so the others would hear.
You thought the Universe would be moving through you,
Youe Man kneeling in worship at your feet-
With you birthing the world anew
Not strapped down,
With them crowding round and shouting that you are useless, that you aren’t trying
-that your baby is going to die if you don’t push harder.
And the student midwife is cutting you, and the senior midwife is cutting you again
And the surgeons are hovering, and your Man’s eyes are looking on with horror,
And your baby is limp and grey and quiet…
Even after she starts to cry, her eyes are screwed tightly shut,
And she is over with the medics, not on your belly like you thought
And they are stitching you up, and you are crying, and he is crying,
And you didn’t think it would be like this.
Are there other ways to assess progress in labour?
Several alternative ways to assess labour progress have been suggested, including:
Contraction shapes (fall to rise ratio is higher when labour is nonprogressive)
Changes in behaviour have been described by experienced midwives that signify active labour and progress in labour. These include:
- Breathing patterns
- Skin changes and body temperature
- Pain perception
There is good association between non-invasive ultrasound-based determination of fetal head station and clinically assessed cervical dilatation. When women were asked to compare the experience of vaginal exams and translabial ultrasound the majority (70.5%) considered VE worse than translabial ultrasound (TLUS) as compared to only 4% who felt the opposite.and has been found to be considerably less painful and may be useful to help predict which women will have vaginal births with prolonged second stage and which need assistance.
Purple line[42 43] the formation of a purple line during labour, seen to rise from the anal margin and extend between the buttocks as labour progresses has been reported. This is being looked at as an alternative measure of labour progress but may not have a high predictive value.http://www.sarawickham.com/questions-and-answers/evidence-for-the-purple-line/
What changes could we make to services to improve things?
It seems unlikely that a change of practice to stop or reduce the use of vaginal exams in labour would happen in the UK soon, so what can be done to improve things now?
In a study that looked to improve the vaginal examinations performed by midwives, suggestions included:
- Judging the necessity of vaginal examinations
- Using effective communication skills
- Informed consent
- Exploring the patient’s preferences and choices
- Providing sensitive woman-centred care
- Minimising variability during vaginal examinations
- Paying attention to the frequency of vaginal examination
- Using alternative ways to measure the progress of labour
- Managing unresolved traumatic experiences
Screening for prior experience of abuse, rape or PTSD symptoms prior to birth is also seen as key to prevent retraumatisation during birth. This screening needs to be appropriate
A thesis by Amina White ‘BEST PRACTICES FOR LIMITING RISK OF POSTTRAUMATIC STRESS RELAPSE DURING CHILDBIRTH’ outlines a three-part strategy for trauma-informed obstetrical care that calls for PTSD screening, avoiding posttraumatic stress triggers, and enhancing stress-coping resilience in order to promote the physical and mental well-being of trauma survivors during the birthing process.
‘Obstetricians have a clear duty to inquire sensitively about past trauma and to screen trauma-exposed women for PTSD’
If a woman discloses her history, a plan can be made to reduce or avoid ‘micro triggers’
Not all women will want or feel it is necessary to disclose their history, so it is important during labour to look for signs of anxiety, discomfort or distress.
Narrative accounts suggest that survivors whose clinicians ignore distressing micro-triggers are more likely to perceive those clinicians as disrespectful and as providing substandard care
In the event that the clinician and medical staff are aware of a patient’s trauma history, it becomes especially critical to avoid phrases that accentuate powerlessness such as, “Just let it happen, you can’t fight it”
I have personally seen successful birth planning of women with abuse histories with Consultant midwives in the UK that resulted in positive birth experiences, including a homebirth and a planned caesarean section.
A doula may be able to support women in labour and can concentrate of communication, comfort and emotional support.
Vaginal exams are done in labour for many reasons. The first exam is usually to assess if a woman is in active labour. Once active labour has started exams are usual every four hours in order to plot labour progress on a pictorial record (partogram). Although vaginal exams should be ‘offered’ they have very much become part of routine care and women often feel unable to opt out.
Evidence of benefit from vaginal exams is scant, and little research has been done on women’s views in relation to their experience of vaginal exams or consent.
In low and middle income countries many women and babies are damaged by obstructed labour, which leads to negative outcomes including obstetric fistula, uterine rupture and stillbirth.
There is still disagreement about how long is too long to wait for labour to progress when labour is slow in both the first and second stage without intervening.
Possible disadvantages from refusing vaginal exams are: not knowing if active labour has started (so potentially having pain relief like an epidural or diamorphine when labour has not started) not knowing if labour has stalled or for how long (with possible risks to mother and babies health)
70% of women had more VEs than expected when the criteria of 4 hourly VEs was applied
Women find VEs in labour to be unpleasant, invasive, embarrassing and sometimes painful and sometimes feel powerless to control when and how the VE was conducted
1 in 5 women have experienced rape or sexual threats, unwanted touching or indecent exposure since age 16.
Experiences during pregnancy and labour can trigger unwanted memories and fear
If women feel coerced or disembodied during childbirth they can be retraumatised
Language used is important, as being asked to tolerate pain and discomfort, or ‘just a little’ longer can be similar to phrases used during sexual abuse and coercion. Respecting women’s wishes and boundaries is key
Be alert to signs that someone is consenting under internal duress as this can be extremely distressing
NICE guidelines state VE’s should be ‘offered’ they should not be required to access pain relief, birth pools or access to a maternity unit if other signs of active labour are present
Several alternative methods can be used to assess labour progress in particular trans-labial ultrasound is a promising method to sequentially assess labour progress
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I made a Storify book summarising the twitter chat I recently hosted