What’s the deal with vaginal exams during pregnancy?


By 40 weeks of pregnancy I’ll have to admit that I, like many women, was curious about my cervix. Was it doing anything in there? I hadn’t had any signs of cervical change (mucous, “bloody show”), but maybe it was a little dilated. Maybe it was starting to efface. Hopefully it was at least soft!

Most women cared for by obstetricians in the U.S. have got some kind of an idea about the answer to those questions by the time they are “at term”, because vaginal exams in late pregnancy are extremely common. Most women accept them as a matter of course. Their doctors do them routinely, so they must be beneficial, right? They certainly couldn’t be harmful, anyway. And who doesn’t want to know whether they’ll be going into labor soon?

If only it were that simple.

To make an educated decision about any intervention, it’s important to understand what the procedure, drug, test, etc. involves as well as its inherent benefits and risks. Let’s start with a description of what a vaginal exam involves. During pregnancy, these are examinations of the cervix, often performed weekly from 36 weeks of pregnancy up to the time of birth. During an examination, the care provider, with a sterile glove on his/her hand, places the index and middle finger into the vagina and assesses the situation. He/she will be feeling for cervical ripeness or softness, effacement (the “thinning” of the cervix), and dilation (how far open the cervix is). The position of the cervix – posterior (toward mother’s back) or anterior (toward mother’s front), station of descent – how far down into the pelvis the baby has come, and presentation – head-down or breech and which way baby is facing, may also be noted.

That seems like a lot of information! Good things to know, right? Well, what are the benefits of learning all of these things about your cervix? Does it tell you how soon labor is likely to begin? No. A mother with “nothing going on” can go into labor within a day or two, and a mother who is effaced and dilated a few centimeters can walk around that way for weeks. Does it tell you how long labor is likely to last? Not really. So why are these exams performed? What benefit do they confer in exchange for their inherent indignity and discomfort?

With the exception of the presentation of the baby, which, if it turns out to be something other than head-down, will likely affect your choices surrounding the birth and which, by the way, can usually be ascertained by external palpation of the uterus*, the information gained in a pre-labor vaginal exam isn’t particularly beneficial to you, the mother. It satisfies curiosity, sure, and it lets the care provider know a couple of things – whether your cervix is favorable for induction (I will be posting in the future about the bishop’s score and what that has to do with all of this), and, when you present in labor, whether your cervix has changed since your last exam. The second part is a little helpful but certainly not necessary, and as for the first part, well, the usefulness of that information depends on whether you are planning to consent to an induction.

OK, so there is a little bit of information to be gained from a vaginal exam. Its value is questionable, especially when the exams are done as a routine procedure rather than for a particular indication, but it’s a pretty minor, low-tech procedure, right? Yes, it’s low-tech, but it’s not without risk. First of all is the psychological effect of the exam. It’s painful (moreso than exams you received when not pregnant), which is in and of itself a consideration. Also, finding out that you are three centimeters dilated can seem pretty exciting. You’re going into labor any moment, right? Not necessarily. Or, you find out that your cervix is high, closed, posterior, and thick. Bummer! It’s going to be a while, right? Maybe not. Remember, the findings of the exam don’t have great predictive value as to when you are going to go into labor, but it’s hard not to read into the information and thus add to the emotional roller coaster of the last weeks of labor. In addition to being No Fun, this can lead to discouragement, stress (remember that stress hormones fight your labor hormones) and a higher likelihood of consenting to procedures, such as induction, that you may not have really wanted. Many women find it better to peacefully wait it out without exams, knowing that labor will start when it’s right for the baby.

How about physical risk? Yes, there are real physical risks to vaginal exams. Although the care provider dons a sterile glove, they are not inserting it into a sterile place. We all have normal “vaginal flora” in the lower part of the vagina, which, during a vaginal exam, is pushed onto the cervix. The result? A higher risk of infection of the membranes of the amniotic sac, which is a serious complication. Studies confirm a link between vaginal exams, infection, and premature rupture of membranes**.

It’s up to you to weigh the benefits and risks of any intervention proposed during your pregnancy and birth (and really for all of your life and your child’s life for the first 18 years). When it comes to vaginal exams during pregnancy and other procedures, remember the “BRAIN” acronym: What are the Benefits, what are the Risks, what Alternatives do I have, what does my Intuition tell me, and what happens if we just do Nothing and let nature take its course?

So then, what’s the deal with vaginal exams during pregnancy? The nutshell version is that they sometimes can provide some useful information, but if there is no indication and the exam is simply being performed as a routine procedure, it may be that the benefits do not outweigh the very real risks in your individual case. If the exam is being proposed due to a particular indication, you still (and always) want to ask the BRAIN questions in order to make an informed decision.

*If external palpation leads the care provider to suspect that your baby is not head down, he or she will likely want to confirm the baby’s position via a vaginal exam or ultrasound.


Babies Want to be Born

Babies Want to be Born…

This idea has been rattling around in my mind a lot lately, and I thought my first “real” blog post was a great place to let it out.

It seems like an odd thing to say, doesn’t it – “Babies want to be born.” Do fetuses have wants? Doesn’t it call to mind the sweet female relatives saying, “Oh that baby is so cozy in there he doesn’t want to come out?” Doesn’t a lot of our verbiage around a woman’s due date revolve around the idea that baby’s going to have to leave his snug warm abode and that mama’s going to ‘kick him out?” Of course it’s always said in jest and with the most well-meaning sentiments. But doesn’t it kind of reflect the way we often look at the baby’s journey – as one forced upon him and against his wishes?

I have a feeling that it’s not quite like that.

One thing I try to instill in mothers and in couples in my childbirth classes is that mothers and babies (and fathers too!) are a team when it comes to birth. That baby is working to be born just as mother is working to give birth – and father to support and protect his family. Maybe it’s obvious to you and to others, but for me, it was the sprout of an idea that has been forming as I talk to students about this topic… Babies want to be born.

We know that instinctively, babies use the stepping reflex to push off as mother’s fundus pushes down, piston-like, during the second stage of labor. We know that unhindered by narcotic medications, a healthy, alert fetus will perform a series of “cardinal motions,” rotating his head and shoulders, extending his neck, to be born. These are normal responses to the actions of the mother’s body during labor. Babies work hard to be born as mother is working to give birth.

But what about before labor begins? Is labor “kicking baby out” of his cozy environs? Well, it’s theorized that structures in the hypothalamus of the fetus monitor his maturation and help trigger labor when the time is right. So presumably, the fetus is at least subconsciously partially responsible for the onset of labor.

Another thing that got me thinking recently was a video I watched, produced to increase awareness about late preterm birth. A mother in the video talked about the end of pregnancy – how even though women know that labor is not going to be a cakewalk, they look forward to it – they long for it to begin. She said that the end of pregnancy seems to be designed to make women want it to end.

I think it may be the same way for the baby. Cramped and getting cramped-er in the snug warm womb, even though labor must be a difficult journey for the baby, the baby instinctually knows that it’s time to be born. Time to make his entrance into the world of humanity, time to meet the mother face-to-face that he has known always. I am not talking about a cognitive, conscious awareness of this, but of an innate, instinctual urge.

So how can this idea, this concept of babies wanting to be born be translated into something real and meaningful? I think that remembering this can help us to remember to respect the baby. Respect that the baby wants to be born. Let him choose when the time is right. Don’t rob the baby of his ability to be an active participant in his birth by needlessly cutting him out of his mother’s body or by interfering with his labor – by starting it artificially, speeding it up artificially, inhibiting his ability to work with the labor by drugging him (via mother’s medications) or inhibiting his mother’s ability to move and work with the labor and facilitate his movements. Let him find his way – don’t twist and turn a baby’s head who was doing the job very well on his own, thank you very much. And of course, reward baby’s hard work by greeting him with love, sensitivity, respect, consciousness, and by immediately allowing him to go right to the place he was working so hard to get to – his mother’s arms, between her breasts.

I know there are times when intervention is warranted, but really, as Christiane Northrup states in Giving Birth by Suzanne Arms, ‘When birth is done on an eight-hour workshift, we miss the magic. And I think we do more harm than we know.’