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.

**http://www.ncbi.nlm.nih.gov/pubmed/21090085
 http://www.ajog.org/article/S0002-9378(97)70568-4/abstract
http://www.ncbi.nlm.nih.gov/pubmed/7569588
http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.1982.tb05028.x/abstract

6 thoughts on “What’s the deal with vaginal exams during pregnancy?

  1. —-” 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.”

    Your statement is slightly true. But it doesn’t take into account using your husbands prostaglandins for cervical ripening.
    His penis isn’t sterile and that flora is going to be somewhat interrupted. I have yet to hear a doctor advise against sex in normal circumstances due to the reasons stated above.
    The real issue is that doctors offices are dirty and not all doctors wash their hands before and after visiting with us. Like they are supposed to.
    There is no reason why women can’t check their own cervix. It is fairly easy to do. You may not be able to differentiate 4-10 cm but you can easily feel effacement softening and up to 4cm dilated. Google the information, youtube it….and wash your hands!

  2. First of all, WOW! A comment! Thank you for stopping by my little old blog!

    Now on to the matter at hand: Many of us in childbirth-related professions like to say that for the most part, things are designed to come *out* of the vagina. The one thing that is meant to go *in* comes equipped with its own antimicrobial properties! That’s right – semen is antimicrobial. I’m not sure how much doctors have this on their minds when they say intercourse is ok in pregnancy, but it’s a good reason why it is, and why it’s different from a vaginal exam. I am aware that a woman can perform an exam on herself, but for all the reasons I mention in my post, really, what’s the point? Do the benefits of this actually outweigh the risks? http://www.ncbi.nlm.nih.gov/pubmed/814615

  3. Thanks for posting this. When I was pregnant with my first child, I had a stressful uphill battle against the attitude that vaginal exams were a normal and necessary part of pregnancy. My intuiton said no, but I had nothing else to back it up with for a long time (I had the I but not the B, R, A or N!). Plus, I live in France where the cultural attitude is that doctors are always right and you should never question or disagree with them.

    I had an especially nasty encounter with a gynaecologist who, after asking me only the date of my last period, told me to strip and sit in the chair for an exam. When I asked him why he thought it was necessary, he just looked at me with impatience and irritation and said ‘We must always do this.’ When I politely said that I did not want an exam if there was no specific reason for it, he told me that he refused to have responsibility for me and my baby if I was going to refuse proper care, sat back in his chair and waited for me to leave. I was shaking with stress and anger afterwards, as I was nearly 8 months pregnant and had no idea who would now be helping me through the birth.

    Articles like this one are what can give women ammo and inner strength when facing less than caring healthcare professionals. I’m sure there are times when a doctor is right and an intervention is for the best, but a patient always has the right to information, and to make their own choice.

    I’m pregnant again, and I will definitely be keeping ‘BRAIN’ in mind for this pregnancy!

    [WORDPRESS HASHCASH] The poster sent us ‘983707387 which is not a hashcash value.

    • Congratulations on your current pregnancy, and on being strong and exercising your right to informed choice! That shaking with stress feeling is one I am familiar with. I hope you were able to find a supportive care provider quickly!

      I’m so glad you enjoyed this post, and thank you for your comment.

      I’m sorry I delayed in approving it. Somehow I didn’t get the e-mail. Heading off to check my settings. 🙂

  4. If a nurse has told me that I cannot refuse a pelvic exam, EVEN THOUGH I specifically stated that I have had several sexual abuse traumas and can be set into a panic attack easily, would I still be able to talk to my OB/GYN about maybe waiting until I’m 36 weeks? Surely here in Indiana, I have some legal rights to refuse if it can be detrimental to my psychological health?

    • Actually throughout the US you have the right to informed consent or refusal, so the nurse was entirely incorrect in stating that you cannot refuse a pelvic exam. You can refuse them during pregnancy and you can refuse them during labor, if that’s your choice. Are you able to speak with a doula in your area? A doula might be a big help to in understanding your rights, helping you advocate for those rights, and even finding a practice that will be respectful of your rights if need be.

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