Safe, never expires
Safe, never expires
This is something that brought me a great amount of fear when I was pregnant and there is a great amount of conflicting information out there. When a friend of mine approached me and asked me about it. I decided to pore over all the information out there to bring to you a primer if I may say so about this much dreaded topic. I will try and cite scientific papers so that it is evidence backed.
I have divided this post into three sections. I hope to cover the following topics.
What is it?
Vaginal/internal examination are physical examinations conducted by the doctor/caregiver to determine cervical changes and progress of labour.
Typically these exams are conducted in three times during your pregnancy:
What does one hope to learn from an internal exam?
When is it indicated before onset of labour?
In a healthy pregnancy, the main reason given by doctors is to see if the cervix is favourable and progressing towards labour.
Is an internal exam needed before labour?
It is surprising that there is such a widespread use of this intervention without good evidence of effectiveness, particularly considering the sensitivity of the procedure for the women receiving it, and the potential for adverse consequences in some settings. (Cochrane Review) ⁸
Although there are reasons why a vaginal examination might be necessary during pregnancy, it’s still an intervention, and every woman should know the risks and benefits before having one. These exams have become such a normalised part of prenatal care that nobody questions them anymore or even feel that they have to understand such an invasive and uncomfortable procedure. There are definitely cases where vaginal exams can be helpful prior to labour, in a healthy term pregnancy they don’t usually provide any necessary information.
Dahlen is one of the authors of a recent review on the routine use of vaginal examinations in labour. The review found no evidence to support or refute the routine use of vaginal exams to improve outcomes for babies or their mothers in labour, and recommended urgent research be carried out on the benefits and possible harms of this practice.¹
In a study published by NCBI suggests that pelvic examinations before term may be a significant contributing factor to the incidence of premature rupture of membranes (PROM). ²
Can an internal exam or vaginal exam predict onset of labour?
Further study has shown that contrary to the mechanistic ideal of a steady curve, cervical opening in natural labour is unpredictable and non-linear (Ferrazzi et al., 2015) ⁹
One of the things an assessment of the cervix cannot do is determine the day and time someone will go into labour. Labour is unique to each person and the gestation is typically 42 weeks and that the due date is an indicator and not a hard and fast date when the baby arrives. No woman is pregnant forever and the baby will arrive on its birthday. Even if you are a few cms dilated during your vaginal exam, that is not an indicator of when the labour will actually kick in. It could be hours or days or even weeks.
A cervix that is soft and dilated today doesn’t suggest that tomorrow or the next day it will ripen or dilate more. One of the things an assessment of your cervix cannot do is determine the day and time of onset of labour. In fact, research has discovered there’s a substance called surfactant, secreted by your baby’s lungs, which triggers an inflammatory reaction in the uterus resulting in labour ³. So the cervix is definitely not a good indicator of what might happen in the future.
Often pregnant women can be slightly dilated (1-2 cms) for weeks before labour actually begins and in other cases, women are well into labour before any dilation begins. Cervical dilation is dependent on factors that are beyond our control.
What actually happens is that instead of telling women that they should relax and go with labour, the underlying message is that labour needs to conform to a particular expected timeframe, rather than accepting all women labour in their unique way. A woman who is 4 cms may dilate completely in less than an hour, when others may dilate very slowly until 7 cms, then complete dilation in a hurry. Measurements do not indicate how labour will unfold. Also, cervical dilation does not occur in a round, uniform circle fashion. WHO’s recommendations recognize that the previous benchmark for cervical dilation rate at 1 cm/hr during the active first stage of labour may not apply to all women and is inaccurate in identifying those at risk of adverse birth outcomes. A slower cervical dilation rate than this benchmark should not be seen as a routine indication for interventions to accelerate labour or expedite birth.
Why is the vaginal exam/internal exam performed during labour?
What are the key risks involved?
In a randomised controlled trial of routine cervical examinations in pregnancy published in The Lancet, it concluded that its findings do not support routine use of cervical examinations during pregnancy ⁶
Why do women find internal exams uncomfortable and undesirable?
What questions to ask the doctor before consenting to the procedure?
If your care provider insists on a vaginal/internal exam, it is important to know why, what, how, when of it.
If you aren’t convinced there’s a good reason for the exam, then you are within your rights to decline it, or to request a second opinion.
If you decide to go ahead with the exam, make sure your bladder is empty, and that you are warm, comfortable and properly covered. Your privacy must be ensured and no extra staff should be present unless you wish. Breathe deeply and relax your pelvic floor muscles to limit discomfort.
Having an internal examination during pregnancy should be something you decide only after having all the facts. The procedure must be explained to you and your informed consent must be obtained every single time before the procedure.
Your doctor/caregiver should give you the following details:
For instance, women are asked if the doctor/midwife can do a vaginal examination to check how far long in labour they are. This is not asking for informed consent.
This brings us to an end on all things internal exam during pregnancy and labour. Let us know if you had an internal exam? When? And if you had a say in the matter and if informed consent was taken.