Episode 148 - Why do they put their fingers in your vagina?
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host, Dr. Melanie Jackson. I'm a clinical and research midwife with my PhD, and each episode I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth, and postpartum journey. Welcome everyone to the great birth rebellion podcast today we're going to talk about the clinical practice of vaginal examinations during labor and as usual we're going to have a look into the research about what difference vaginal examinations would make to the overall outcome of your labor and birth and if you're pregnant you are going to give birth that's the usual progression and if you're planning a vaginal birth your care provider is probably going to offer you a vaginal examination during your pregnancy perhaps or your birth. Not all of you of course certainly if you've hired a private midwife or if you have your own trusted midwife for a midwifery program and I'm hoping some unicorn obstetricians you are less likely to be exposed to this routine vaginal examinations, but the rest of you really need to listen up because vaginal examinations in birth have become routine. They are almost impossible to escape.
[1:28] And before we start this conversation, there is something else that you should know. You know, this online process of sharing information through the podcast is great. It makes high-quality information available and accessible, and you can listen anytime. But what we're really missing... Is gathering together. I really feel this isolation personally. I spend two or three days a week just sitting in front of my computer for the purposes of podcasting. I love it. I absolutely will always keep doing it.
[2:04] But what I really crave is seeing people in person. And I know this podcast is making a difference because I get messages every day. What I actually want to see is people in real life because there's a connection and oxytocin that happens when you actually meet people in person. You don't get that from sitting in front of screens and interacting over social media. Please don't stop interacting on social media. I do love hearing from you all. So what I want to tell you is that there is an opportunity for us all to get together to do this thing. I've planned an event and you are all invited. It's called The Convergence and it's happening in Sydney, Australia at the International Convention Centre, which is in Darling Harbour, pretty much like a holiday destination. And I ran this event last year too. We sold out the venue. There was standing room only. So this year we booked the ICC,
[3:04] which has all the room that we need to spread out. It can fit thousands of people. I hope we get thousands. I'm not expecting thousands.
[3:12] But there's so much room. We can get comfortable and settle in for a weekend of absolute replenishment. I'll be there. And I've handpicked some really high quality speakers to also come and speak with us. So you can learn from the best. Be with people that have a similar mindset and intention to you. The whole conference is centered around loving you and making sure that you have the best time ever. Now I could talk about it for ages because last year we surveyed the attendees.
[3:45] And 100% of the ones who responded to the survey said they would definitely, yes, come again, no doubt about it. In fact, I lost track of the amount of times at the conference, at the convergence, that people told me that it was the best conference they had ever been to. So this convergence is for you if you're interested in having a great birth or if you support women to have great births, if you want to expand your knowledge. The Convergence is for birth workers, midwives, doctors, women, students, their families, anyone who is interested in learning more. You will be with like-minded people.
[4:23] Part of the rebellion, but in real life. I'll be there for the whole event. I'm emceeing it, organizing it, making sure it's amazing. Early bird ticket sales end in May 2025 this year. So this conference does run every year. The Convergence will run every year. so even if you're listening to this episode in a back catalogue go to melaniethemidwife.com because all of the information will be there whether you're going to come this year in 2025 or whether you want to come another year I'll put the link for this year's bookings in the show notes anyway what I'm trying to say is I'd love to see you there in person you're invited come converge with the rebels in Sydney Darling Harbour all right let's get into it vaginal examinations during labor oh what I really really want to say straight up here is that when you look at the research on this topic and realize that collectively vaginal examinations and how they relate to outcomes have been studied only over a few studies with
[5:30] like a collective total of about 750 women across all of the studies collectively. I wish I was joking. I wish I could say that this intervention is studied heavily, that every woman gets a vaginal exams based on sound evidence.
[5:51] But it's just not true. Medical management of birth has normalized and groomed women to accept vaginal examinations when we go to have our babies we just assume that somebody probably multiple strangers are going to put their fingers in our vagina not because we need it but that's just how medical care is set up it's not evidence-based somewhere along the line they decided they need to know what how dilated every single woman was but there's no evidence to suggest that routinely giving women vaginal examinations is going to improve the outcomes of their labor and birth. In fact, through this episode, you'll see that it may actually make outcomes worse.
[6:37] Okay, that is my early rant. I'm actually declaring my position early on. In so many episodes, I kind of lay out all the research and let you make your own conclusions. But I'm feeling very strong and confident about this particular topic, vaginal examinations. I actually cannot believe that it's gotten to this point. That women have become so groomed and it's become so ingrained in the birthing culture that we expect people to put out their fingers in our vaginas while we're in labour. So all of this begs the question, are they really that important? Why is every woman being offered them and often many of them? And will it change anything if you've had vaginal exams through your labour?
[7:29] So that's what I want to talk about today because I can tell you now that midwives and doctors, If you are listening, women don't really want these vaginal examinations. We don't. If we're honest, we would rather do without them. Women will often accept them if there's a really good reason for them. And you'll hear later on in this episode that there are some times where we can get information from a vaginal exam that's really valuable and does change the strategy that you might use for your labor and birth.
[7:58] Either way, we really don't want them. We'll tolerate them, but only because we've been led to believe that we actually need them and that they're important. So women out there, if you're getting ready for your birth and if you support people, your care providers, today we're talking about vaginal examinations and I'm going to start right from the beginning. What is a vaginal examination? What's your care provider looking for?
[8:24] Why have you been offered them in the first place? is there any research that supports their use considering that they're so routine and I will let you know sometimes that a vaginal examination might be beneficial not throwing these out completely I'm just saying routine vaginal examinations where just everybody gets them as usual care is really inappropriate because there's not a lot of evidence but there are times where they.
[8:52] Might be useful and where you might want one you know that is another really good reason to have a vaginal exam if you think I really want one I really want to know what's going on in there that's completely up to you so what is a vaginal examination so your care provider will call it any number of things and you might not even realize what they're saying until the next minute there are fingers inside your vagina so a vaginal examination will always require your care provider put two fingers deep in your vagina so that they can find assess and measure your cervix but that's not always how it will be described to you so you can consent to this and allow it yes it's absolutely your choice or you can say no so you can always say no sometimes it's hard to say no because the way that your care provider is pitching it to you and explaining it to you or not really explaining it to you kind of hoodwinks you and for you out there if you're thinking oh man actually I really do not want vaginal exams unless I need them.
[9:57] If that's something you want to do you want to say no to vaginal examinations I would strongly encourage you to listen to episode 143 of the great birth rebellion it's about declining medical recommendations and that will give you some strategies on how you can hold your ground on this because there will be strong pushback if you decide you're going to decline vaginal examinations. So here are the ways that I've heard vaginal examination described to women in the context of, you know, can we do this? So I've seen midwives and clinicians and doctors say, I'm just going to check you. Just open up your legs for me. And they're just, they've arrived with gloves on, with lubricant on their fingers, assuming that the woman is going to accept
[10:40] this. I'm just going to check you. What does check you mean? I mean, your care provider knows, but they didn't tell you that. They just assumed that you know what check you meant. So if someone says, I just would like to check you, they're probably saying, I would like to give you a vaginal examination. So you want to clarify that, then say to them, are you wanting to give me a vaginal examination? Or the other way they say is, let's just do a quick check to see where you're up to. What does that mean?
[11:13] That doesn't mean anything to a woman, a quick check. It only means something to the care provider. Or they might use the abbreviation VE. So we'd like to do a VE. Okay, VE, Vaginal Examination. Again, what is a VE to women in labor? It's just medical jargon. Not all women know what VE stands for. You've got to explain it properly because just because you know what it means as a care provider, it doesn't mean the woman knows. It doesn't even mean she knows what the procedure involves. So what they're trying to say when they want to check you, check where you're up to, see what your cervix is doing, all these terms that they'll use, what they're trying to say is I would like to put two fingers inside your vagina to discover your cervix, what's happening around it, behind it, in front of it, where your baby's positioned in your pelvis, and what your dilation, your cervical dilation could be. And... Let's not assume here that babies come through a cervix that's 10 centimetres. Let's also not assume that 10 centimetres is fully dilated. You might have a 13 centimetre dilated cervix. Who knows? So to the care providers who are just tall shreds off, if you're listening, this is just a gentle reminder that although this is a regular daily occurrence for you as a clinician, it's not a regular daily occurrence for women.
[12:35] It's a medical procedure. It requires full and informed consent. Use terms that are common language.
[12:43] You have to ask properly and give all the information before you put your gloves on and lube up your fingers. So use details and explain what you're going to do. You're going to put your fingers in their vagina and you're going to feel a number of things. So a vaginal examination is actually a cervical and pelvic examination where the practitioner tries to determine the dilation of your cervix. Now, your cervix is part of your uterus. So your baby's in your uterus, surrounded by the amniotic sac and the fluid. And if you imagine your uterus a little bit like a balloon, and there's an end to the balloon that usually you would tie to keep the air in.
[13:26] Your cervix is kind of like that end of the balloon that's tied. It's part of the balloon. It's part of your uterus. Your cervix is part of it. And that's what they're feeling when they go in. They're feeling your cervix. So they're looking for that to assess it for position, dilation, so how open it is, how well applied the baby's head is to it, how low the baby is in your pelvis, which way the baby's facing, so they can feel the bones on the top of the baby's head and what they're feeling will tell them which way the baby's facing and that can be important if, for example, your labour has slowed or delayed or you can't get, you're not able to push your baby out. Sometimes the position of the baby can be a reason. So they can feel that by feeling the bones on the top of the baby's head and they'll also feel where the baby is in relation to the bony parts of your pelvis.
[14:23] And some care providers will also check the tension of your pelvic floor muscles while they're in there. So they're looking for quite a lot. And the procedure can take a minute or two depending on what they're looking for. And occasionally, well more often than I'd like to think, care providers might say something like, I'm just going to leave my fingers in here while you have this next contraction. So now, not only are you in labor with somebody's fingers inside you, but now you're going to do a contraction with someone's fingers inside you. And this is usually done with you lying on the bed. So that's how the procedure is done.
[15:06] And they might want to keep their fingers in there to see how the baby behaves under the impact of a contraction or when you're pushing at the end of labor. Yeah.
[15:19] So that's a bit of a description of what you're in for. And in case it's not obvious, they're looking for all of this with their fingers. This is not a visual thing. They can't see what they're doing. It's purely tactile. Sometimes they will try and use those fingers to open up your vagina to see what they can see inside and maybe try and push and manipulate your pelvic floor muscles or your perineum at the same time. That's an additional thing on top of a vaginal examination and certainly if that's their plan they should have told you in the first place so you can decide whether or not you want that.
[15:57] If this is all feeling too much for you so let's hypothetically say you have agreed to a vaginal examination and you're on board with the idea that you need and want this but then part way through you think well actually this is way too uncomfortable I'm no longer interested in vaginal exam you can tell them to stop at that point you don't have to commit to the whole procedure because it's your body and you can decide who is going to be inside it now this obsession with checking your cervix during labor it comes because when you're in hospital usually this is a lot less likely if you're in midwifery run settings or if you have your own midwife who's caring for you not in a hospital some some hospital midwives are excellent hashtag not all midwives I know I know there's MGP midwives who are out there and who are doing things to enhance physiological birth and women's experiences just know I know that I get messages all the time not all midwives I know not all midwives but women who are listening to this podcast very few of them are going to have access to the type of midwife that you are. So they need to know what they could be up against. I hope I'm giving the worst case scenario, but from the messages that I get about the experiences that women are having, I'm going to suggest that this is way more common than you think.
[17:26] So in pregnancy, your cervix should be long and closed, anywhere from sort of three to seven centimeters, and it's held together muscularly. So during labor, the muscularity of your uterus is activated and your uterus and your cervix is held together by these muscular structures. And inside your cervix is where
[17:50] the show sits, that little mucousy show or plug they sometimes call it.
[17:54] So when you get contractions and your uterus starts to contract under the impact of oxytocin and melatonin and all the hormones of labor, your cervix gets kind of sucked into becomes part of your uterus so it pulls up and over the baby's head and gets incorporated into the uterus so it gets shorter and it opens and this is what your care provider wants to discover what is your cervix doing because in their mind they're thinking right the shorter the cervix gets and the more open it gets that means the further along this woman is in labor and that's important to them because often in the hospital you've got a time limit on your labor it's an arbitrary time limit it doesn't it doesn't necessarily mean that once you get over the time limit you're suddenly in danger and your baby's in danger but the hospital has particular boundaries around how long they're going to allow you to labor without any intervention it's a whole other story I'm just telling you how it is I'm not going to tell you why I mean it's crazy but anyway Okay.
[18:59] They want to know, where are you along in this process? That's why they're doing it. The tricky thing is, is that when you check your cervix, it's only told you where you've come from. It has no predictive value about where you're going. So they can tell you, oh yeah, you're five centimeters and your cervix is halfway effaced, we call it. It's shortened halfway, whatever that means. I mean, what's a 50% effaced cervix? a whole other story again but it can tell you that that's where you're up to but it can't tell you how many more hours you have left are you about to have your baby how long are you going to stay there what it just has no predictive value so just know that well however you are now does not tell you how you're going to progress later so knowing your dilation can do one of two things make you really excited because maybe you've got really great news and you're coming to the end.
[19:58] Or it can completely deflate you and then you lose the mental capacity to keep going. So if you've already been laboring, let's say 10 hours overnight, it happens. It's not unusual. That's not a long time, but it's been overnight. You're tired. You've been working hard. And somebody tells you that you're three centimeters dilated and you're thinking oh my gosh I just did 10 hours and got to three centimeters so that must mean I've got at least another 10 or 20 hours to go that's not how it works it is not how it works your cervix can go from three to 10 in seconds if it wants to that's not how the cervix works it's not like whatever happened before the vaginal exam is going to continue along the same trajectory as what happened is what's going to happen for the rest of your labor so be really cautious about seeking information about your dilation because it can really throw your mental game off but even if you get really great news they say wow you're 10 centimeters this means you're ready to push that's not true either because 10 centimeters doesn't equal ready to push so you've got to ask yourself why do I want this information what's it going to do to my mental state if I know how dilated my cervix is?
[21:17] If you and your baby are not in danger and you're feeling well and can keep going, what does it matter how dilated you are? Does it matter to you or does it matter to your care provider because they want to know because you're on their imaginary clock? So you've got to know that hospitals seem fixated on the behavior of your cervix and one paper, you'll find it in the resource folder if you're on the mailing list, It describes it as a cervix-centric cervix.
[21:45] Care plan. The care hovers around and hinges on the behavior of your cervix.
[21:51] So that's what they're doing. That's why they want to do it. And again, we're talking about two fingers in your vagina, sterile gloves, and some lubricant, and they're going to try and find your cervix. So as you can imagine, this can be quite uncomfortable because it's not your lover acting gently. It's a clinical medical procedure often done by a complete stranger who you may or may not like you might meet them that minute when they're putting their gloves on and putting their fingers inside you you might not even like them and then they might be particularly aggressive or careless with their actions so they're not particularly comfortable you will need to mentally prepare yourself and breathe through this experience if you don't know your care provider now it's a completely different story if you have a trusted care provider that you know or if the person who just came in has been very gentle and loving with you and who explained it very well and you're feeling trusting that you will be happy for them to do the vaginal examination the experience is very very different depending on how you feel about the care provider but I'm just going to stop here for a second and offer some suggestions to care providers and if you're listening here and you think I'm about to potentially receive a vaginal examination this is for your support people or your doula or your care providers to know.
[23:19] About how to make you comfortable before all of this starts. So it doesn't have to happen quickly. Usually vaginal examinations, when they're done routinely, they just come around every two to four hours, depending on your scenario. So we've got time to do some preparation. It's not an emergency circumstance. So if the care provider just first acknowledges that this might be uncomfortable and that most women don't want vaginal examinations if they don't have to. So here are a few tips for care providers to increase the sensitivity around this so firstly, you know you'll be lying down most care providers will need you to lie down on the bed there are some very skilled care providers who can do vaginal examinations if you're sitting on the toilet or upright on a birth stool or if your hands and knees but typically most commonly you're going to be lying down flat so there's no harm in offering a sheet over the top to enhance privacy See, we're not looking with our eyes. We actually only need to feel with our fingers. And so when the woman's having this procedure done, she can feel a little bit more comfortable, a little bit more relaxed if she's covered and not everybody in the whole room is seeing her vagina with your fingers inside.
[24:32] So again, before we've even done anything, explain the procedure carefully to the woman in detail, just using normal language. Don't use medical jargon, midwife words. There's no rush. You've got time to explain it. If she says no, just accept this without question. After you've given a full explanation and why you want to do it, accept it without question. You can't coerce someone into letting them put your fingers inside them. If she says yes, then it's time to... Activate comfort measures. So you can do that by putting a rolled towel or a pillow under her lower back to help tilt her pelvis upwards and make access easier and more comfortable. So if you're a care provider and you're a sadist, you know, some care providers get the woman to hold their own pelvis up with their hands or put their fists under their back. But this is actually hard enough for someone who's not pregnant and not in labor to lie in this really awkward position with their fists under their pelvis like we just never would do that in real life and all of a sudden we're getting this woman to do it so just put something soft under there instead so that she can fully relax her body and not have to hold herself up.
[25:50] So then you'll be asking her to open her legs and let her knees fall out to the side and for women listening you know the midwife might describe sort of putting the bottom of your feet together and letting your legs butterfly out the way that the people around you can help with this feel more comfortable is maybe prop the sides of your legs up with some pillows or towels or you can rest on someone because if you're trying to hold your legs up and you've partially opened them that creates a lot of muscular tension in your pelvic bowl and your pelvic floor and within your pelvic muscular structures and that can make it harder to do the vaginal examination and potentially more painful. So if your legs are actually relaxed and floppy because they're resting on something that will make things easier for you but also for the clinician doing it so it can shorten the length of time that they'll actually be in there looking for information and ideally this would be done between contractions so they're not doing it while you're having a contraction depending on why they're doing it so sometimes a vaginal exam will be done because they've been seeing you push for a long time maybe over two hours, And they're not seeing any progress. The baby's not dropping down and coming out after two hours or depending on what time they're looking at or working with.
[27:12] And so your clinician might say, okay, I'm going to leave my fingers in here while you have this contraction because I want to see how far the baby moves down when you do have a push or when you do have a contraction. And it can be a sign for them if you're having good strong contractions and then you they ask you to push and you do that and they're not feeling the baby move at all there could be some signs that the baby is not coming through the bony pelvis for example or it's been held up some other way sometimes if the cord's really tight it can give them some information but that's not usual practice that's sort of used as a diagnostic tool and again it would have to be with your full consent so you being comfortable and getting comfortable is the first step in this in vaginal examination comfort and etiquette and just creating emotional safety it's a sensitive procedure are there other people just standing.
[28:08] Around watching this process has it been a total stranger maybe you could ask the woman to select which one of their care team would you like to do the vaginal examination that can help make it less bad for the woman remember just assume they don't want them and that they're uncomfortable so what can you do as a care provider to make this more comfortable now this idea of comfort being attached to trust and the feeling of safety it's it's in the research certainly what we know from the research about vaginal examinations and women's experience of vaginal examinations is that when they're in a continuity of care model so there's a relationship built with their care provider who they trust and who's with them and gentle with them that they're less likely to have negative experiences around vaginal examinations and they won't hurt as much certainly on the rare occasions that I do vaginal examinations I mean, I'm talking years between vaginal examinations sometimes, is that because I don't do them routinely, I only use them, I reserve them from when I think there's actually a problem that needs investigating and.
[29:23] And I know all of my clients very intimately and they're in their own homes. And obviously I do all those steps that I just mentioned and they're fully aware of why I'm doing it and what it's for. They rarely describe them as painful. And I don't really want the woman to feel that it's uncomfortable. So I'm a bit of an overchecker in the child exams. I'm just constantly asking them, does this feel okay? Are you feeling uncomfortable? If you need me to stop, just let me know. I'm really kind of overcautious and I do try and be as gentle as I can to get the information that I want. You know, I've seen care providers just like really ram their hand in there and be super aggressive and, you know, just be gentle, go slow. There's no need for this aggression that I, for some reason, witness with vaginal examinations.
[30:13] So if the woman is experiencing pain through a vaginal examination it's probably because you're either being too rough or because they don't feel safe and comfortable with you so just a bit of preparation to maybe try and prevent and mitigate that there is some brilliant research that I read in preparation for this episode the full paper is in the resource folder for those of you who are on the podcast mailing list and it's called exploring women's experiences, views and understandings of vaginal examinations during intrapartum care and it was written in 2023 and they synthesized all of the existing literature about how women experience vaginal examinations and I think this should be essential reading for anyone who is performing a vaginal examination so that you can understand what the woman is experiencing when you're doing it. But the take-home message of this research paper is that women don't want them.
[31:17] But they tolerate them and they suffer the experience of them because they believe them to be a necessary part of a childbirth. And the problem with that is that most of the time they're not necessary. As I said, I've gone years between vaginal examinations at times in my clinical practice. I do them so rarely, but the babies keep coming out nonetheless. So, you know, we will talk about the clinical reason for vaginal examinations, But just know for now that they're just so rarely actually necessary. So please know that if you do not want to have to endure or suffer through them, thinking that they're a necessary part of your labor, that you don't have to.
[32:01] And the final thing I'll offer here for care providers to remember is that consent can be revoked.
[32:08] So if you're doing a vaginal examination and the woman says, stop, if your response is, oh hang on I'm nearly finished I just want to check one more thing or hang on I just want to see what your baby does during a contraction and you continue with the examination you are assaulting women this is obstetric violence and you are the perpetrator the only acceptable response if a woman says stop is to immediately take your fingers away you can't continue and if you're listening today as a birth worker or a partner or a support person or another care provider who's in the room with this laboring woman and her care providers if you witness this behavior your only role in this scenario is to advocate for the woman and be very clear with the care provider to tell them to take out your fingers because she said no you have to defend her and protect her in this because she's only got so much power in that scenario in labor lying flat on a bed with someone's fingers inside you is a very powerless position and so if she's gathered up the strength to say no then you have to gather up the courage to say something you're in your full power because I've seen this happen too where the other people in the room are watching this happen to the woman and they will start actually trying to comfort the woman.
[33:37] And help her to get through it. I'm putting that in inverted commas. They see their role in that scenario is help the woman get through this scenario of being assaulted in the middle of her labor. I've heard people say, it's okay, take some deep breaths. It'll be over soon. Try and relax. It'll just be a few more seconds. And they don't stand up for the woman. They just try and give her strategies to relax during the assault as I say it I know you're all thinking ah shit yes this is what is happening, She is vulnerable. If you're watching this, your role is to protect her, not be complicit in it. She can say no, but she can't fight people off at this point. That is your job to stand in immediately. And use strong words. This is assault. You cannot continue. She said no, take your fingers out. And I know I'm going to get messages, oh, this doesn't happen.
[34:40] Or people will say well actually they're just trying to do the best for the woman and the baby they're just trying to keep them safe but that intentionality doesn't justify the behavior, I know I made all that sound super scary and like it happens all the time I mean it does happen all the time I'm not saying it's going to happen to you just saying be prepared for the possibility and make sure that your support team is robust and capable of defending you in these kinds of scenarios. Now the other way this consent issue can play out is that the practitioner actually does more during the vaginal examination than you actually consented to as a woman. So you might say yep happy to find out how dilated I am whatever you normally do during a vaginal exam but then say they go in there and they discover oh there's just an anterior lip the front part of your cervix is just a little bit over the baby's head and they'll take it upon themselves to wait for a contraction or not, and just push the lip of the cervix back. That's something sometimes midwives and obstetricians could do. They push the cervix back, see if it moves.
[35:50] They decide to do that while they're in there. While you consented to a vaginal examination, but you didn't consent to your cervix being pushed back over the baby's head. They didn't ask you for that. Or they might break your waters while they're in there, or maybe do a stretch and sweep or give your vagina a little bit of an internal vaginal or pelvic floor release. All of this stuff is additional clinical tasks that don't need to be done during a vaginal examination. So if you feel like they're doing more than they actually need to do.
[36:24] Ask them, excuse me, have you finished? Is there more that you're doing in there that I should know about? Again, this is kind of up for your support people to be advocating for.
[36:33] And certainly, unconsented for vaginal and cervical procedures are a number one source of birth trauma for women. It's the most likely place that you're going to experience obstetric violence during these vaginal examinations. And trauma and unwanted medical procedures are some of the main reasons that women will opt out of hospital births choose home births and choose free births certainly in my PhD research this these are the stories that I hear of the whole system becoming complicit in this obstetric violence you know women being told me that they were held down for vaginal examinations and then they wonder why women are fleeing hospital services and they're experiencing obstetric trauma you know one in three women feel traumatized after their birth and one in 10 report being assaulted by their care provider that's the reality so this is I know I'm being extreme maybe a bit in this episode but it's not talked about enough one in 10 women assaulted by their care provider. So these are the scenarios in which they're happening.
[37:49] Okay I know it's a lot to take in. We just had a look at how vaginal examinations are done and the importance of women's comfort and complicit consent.
[38:01] I'm going to take a little breath because I feel like I'm getting worked up in this episode. So now let's have a look at some of the reasons that vaginal exams would be done. So we'll start with a hospital setting. That's where most of you listening are going to be giving birth. So when you arrive at the hospital, it's pretty universal practice that you'll be getting a vaginal examination if you're getting contractions and you're full term. So the vaginal examination becomes like a gatekeeper.
[38:32] For a method of women to get access to the hospital and to midwifery care and then if depending on what your cervix is doing that determines whether or not you can stay at the hospital whether or not you can go to the birth unit whether they put you in the antenatal unit with four other women in your room so this all hinges on the behavior of your cervix and the wellness of you and your baby of course, but it's not reliant upon your emotional care and your need for early labor care. So what often happens is women will arrive at hospital, maybe they've had a long early labor and they're tired and they actually want midwifery care.
[39:14] And a vaginal exam will be done and they say, you're not in labor, you can't stay here. So this is like the gatekeeping process for whether or not you are allowed to access the birth unit. So they're not thinking, what are the needs of this woman in labor? It's clear that she needs a sleep or she needs comfort or she needs another assessment or she needs reassurance. They're just thinking, we can't look after you here until you are past four or five centimeters. So that'll be your first exposure to a vaginal examination. Again, you can completely decline that. Now, please know that this admissions process, this gatekeeping process of doing vaginal examinations to get into the birth unit is in no way although it's embedded in maternity care culture and routine and policy it is in no way on any planet I can't even work out a good reason to do it supported in any research they're a non-evidence-based tool.
[40:17] It's a triage tool, really. It's not a clinical tool. And these vaginal examinations that are done routinely will cause more harm than good. They're helpful for diagnosing labour dystocia or malposition.
[40:34] Cord prolapse, potentially, because you can see those even without a full cervical check.
[40:40] Sometimes it helps with the diagnosis of dystocia or malposition, but it doesn't change things. What we also know, you know, when we do these things, the midwife or the clinician will be so confident. Okay, yep, you're six centimeters and 50% are faced or whatever positions they're talking about. What we actually know about vaginal examinations is they're only ever accurate, and the research varies a little bit, But 48% to 56% of the time they're accurate. So only half of the vaginal exams that are going to be done at any one time are actually deemed to be accurate. So if you're out there as a student, you're thinking, how do they know? Half the time they don't know. They're just potentially making it up. So just putting it out there, it's a flawed assessment system. And also, if anyone's read anything on Ina May Gaskin, who, by the way, is a speaker at the Convergence this year, she talks about the cervix as a sphincter. You won't read that anywhere else. This is Ina May's idea. She talks about it. I mean, it's supported by observation. The cervix as a sphincter, a little bit like how your rectum is. So she believes, and it's muscular, so why not? She believes that your cervix can open and close at will. So in stressful situations, for example, people can get constipated and they can't poo because their sphincters won't relax.
[42:09] So it is with the cervix that it's able to open in a safe place and an ideal environment where women feel safe and they think, yep, ready to let my baby out in this scenario. This feels safe and appropriate. Ina May is saying in situations, for example, where women don't feel safe or where they don't feel like they're supported to give birth safely, their cervix will either not open or it can open and close. So if you're thinking, it's not like a linear opening, you know, medical textbooks and today's language around the behavior of the cervix is that it will go from closed to open. There's no backing and forthing. I don't know that that's completely true. Anna Mae believes that it acts more like a sphincter. And there is no evidence to support the use of routine vaginal examination. And there's a Cochrane database systematic review on this. It's been recently updated in 2020. Again, this research is in the folder. It's not just me rubbing on about unnecessary vaginal examinations. The highest level research that we possibly have access to.
[43:22] Systematic reviews, the Cochrane Database Systematic Reviews tells us that routine vaginal examinations have so little evidence that we can't even make conclusions about the appropriateness of their use. But in addition to that, in addition to it not being evidence-based, there are some risks to vaginal exams. The most common is distress, pain and discomfort from the woman, bleeding from your cervix. You're more likely to get an infection in your uterus, especially if your waters have broken, and the more vaginal exams you have, your risk of infection exponentially increases. In fact, some hospital policies have that if you have over five vaginal examinations, they'll give you antibiotics, prophylactic antibiotics, because of the number of vaginal exams you've had. So you can absolutely say no to a vaginal exam. You can decline those. You can start by getting the information first. You know, why do you need to do this vaginal exam you can ask questions like that have you got concerns for my baby and if they say well no we don't have concerns but this is a routine check so we can see where you're up to if you don't let us do a vagina exam we can't see where you're up to now the reason they need to see where you're up to what they mean is how dilated cervix is is they want to know how much longer is this woman going to be here in labor having her baby because we have and.
[44:50] A mental time limit on how long we're going to allow in inverted commas allow her to labor here so they need it for their own workflow but you don't need it for your labor your labor is going to progress how it's going to progress whether you have a vagina exam or not so most of the time you're being offered a dilation check a cervix check because they want to check how you're progressing are you getting closer to having your baby or not there's not actually anything wrong with you it's just vaginal exams are system-centric they focus around the needs of the system they don't focus around the needs of the woman there are some reasons why a vaginal exam would benefit you so if I think of the times that I've used them at home uh there was a baby oh ages ago now probably 12 years ago this is how far back I'm going to remember the handful of vaginal examinations.
[45:46] But I was listening to the baby's heartbeat and it was starting to.
[45:49] Drop and I thought whoa if this is the baby's heartbeat and the woman is three centimeters dilated we've got an emergency on our hands and it's time to transfer or at that heart rate the other thing I thought is or this baby is about to be born and this is something that can naturally happen is a dip in the heart rate and that was the case we did a very quick check it occurred to me while I was doing the check whoa actually this baby is actually coming out that's why I got that heart rate and the baby did it was born beautifully fine no problems it's just a really quick labor and I wasn't expecting the baby at that time so that's one thing if you know there's changes in the baby's heart rate some people are thinking okay the baby could be distressed how close is this woman to having her baby is she about to have her baby in which case we can we've got time to wait and see if the baby comes out vaginally or is this a more sinister problem and the woman's not anywhere close to having vaginal birth that could be one reason cord prolapse if you suspect a cord prolapse very very rare if the woman's waters break on their own and the baby's head down it's a super rare circumstance this is going to be a cord prolapse certainly though that's something you can check but it wouldn't require a full vaginal examination not full fingers in the vagina That's usually you can visualize the cord in the vagina without even putting your hands in there or outside of the vagina.
[47:17] And the other reason that vaginal examinations can be helpful is if the woman seems to be experiencing labor dystocia. So I'm not going to explain dystocia too much, but basically it's some delay in the progress of the baby moving down and out. And it can be a bony issue or a positional issue with the baby. And in that case, a vaginal examination can help determine the baby's position.
[47:43] So the take-home message here is that routine vaginal examinations are not actually beneficial and can be more damaging than do good for the woman because it, as I said earlier, can change their mental headspace. So routine vaginal examinations are only beneficial to the processes and desires of the system and of your care provider and the hospital policies.
[48:05] They're not actually beneficial to you as a woman, unless of course you want one. If you need to know where your cervix is up to in order to mentally keep going in your labor or you know you're thinking about having pain relief and you think how much longer have I got if I'm nine centimeters I'm not going to have pain relief, but if I'm three centimeters maybe I'm going to consider it so it's a tool that you can use, in the context of decision making and of you know and to help enhance your experience but if you don't want one and there's nothing wrong we don't have to accept the routine vaginal examinations and the cochran review that i was just talking about about vaginal examinations again it's it's in the resource folder if you're on the mailing list specifically said that decisions shouldn't be made based on cervical dilation or on how long the labor's going it should always be made on how well the woman and baby is so this is just a clinical assessment tool that we can use to help make decisions, clinical decisions not used routinely.
[49:09] And we also need to mention that your cervix doesn't dilate in a linear progression. So, you know, at the same rate and pace. So if we're looking at the line, it doesn't just go up in a straight line. There are plateaus in cervical dilation. We've heard about that actually in episode 11. We talk about the labor process and how your cervix behaves in labour. You also don't need to be 10 centimetres dilated in order for your baby to come out. You might have a smaller baby. It needs a smaller cervix to come through but also you might have a much bigger baby and it needs 11, 12, 13 centimetres to come through in order to come through your cervix. Now here's also another reason why you might be offered a vaginal examination in labour and it's probably the one that I just hate the most is that there There will be a point in your labor where you get an urge to push your baby out. At home, that's great. For me, I just go, great, you know, probably it's going to be a baby soon.
[50:17] But if you're in hospital, there seems to be this habit of, okay, the woman is showing signs of pushing. Before she goes any further, they'll want to give you a vaginal examination to confirm that you're fully dilated as some kind of diagnosis of, oh.
[50:36] Yes, now we will allow you to push your baby out because we can confirm that you're fully dilated so that can be one reason again not necessary certainly if you've got an urge to push and you're pushing for a while and we're thinking why isn't the baby coming down that might be a reason but there's no need to diagnose full dilation when a woman starts pushing out her baby the vast majority of women who have an urge to push are going to push their baby out and if they don't that warrants vaginal examination again in the context of something unusual occurring alternatively you might not have an urge to push and you've had a vaginal examination and they go great you're fully dilated go ahead you can start pushing out your baby but if you have no urge and the vaginal examination says your cervix is fully dilated you are not ready to push your baby out there is so much more involved in the baby being ready to be born and your body being ready to push the baby out then your cervix being fully dilated there's a whole lot of other things that are needing to happen before that can occur that was my own experience in fact with my first baby I was fully dilated for at least eight hours there was obviously some other things that my body and baby needed to do before they were born it's not time just because you're fully dilated wait for the urge let it build when you're ready push your baby out.
[52:04] The activity of your cervix is almost irrelevant in fact I again I can remember a time I was with a client.
[52:14] And she appeared to be in early labor and she called me to her birth which was completely fine and because she'd had a few babies before that I'd actually called the second midwife as well because I thought she's had a few babies before if she's calling me she's probably really close to having this baby as well gonna get the second midwife to arrive with me and when we arrived the contractions were fairly spaced apart she was managing really really well in my mind I thought I think she might actually be in early labor a better strategy he might just be to rest, so I proposed that to her and I said hey here's what I think might be happening.
[52:52] Would you like me to do a vaginal exam before I go? Because if you're in early labor, she didn't really seem to need me. Before I go, I could do a vaginal exam just to confirm and check that if that makes you feel more comfortable about me leaving. She said, yeah, actually that would be great. I'd be interested to know where I was up to because if it's not fully happening, I will try and just go to sleep and everybody go home.
[53:16] So I did a vaginal exam and she was two centimeters is dilated and at that point she was only getting contractions every 10 minutes so I packed up got in the car and I got a call from my husband about five minutes down the road or maybe 10 even 10 minutes down the road and he said I think you need to come back and so I did a big u-turn went straight back up the mountain and I was only 10 minutes from my house at that point and I arrived at her home and she was sitting in the hallway with her baby in her arms and the placenta in the bucket and I said well what happened and they said that the phone call that her husband made she had this huge contraction and she said I felt like my cervix fully dilated and then just prior to my arrival she had another contraction and in that contraction the baby was born completely followed soon by the placenta her body just expelled that baby and I thought oh my gosh did I get this vaginal exam completely wrong and she said no I think my cervix went from two centimeters to fully dilated in one contraction and my body pushed my baby out in the other You know.
[54:45] The cervix and our bodies can do all kinds of things. So to be so obsessed with checking the cervix and linking that to progress, it just seems so counterintuitive. Now, the other thing that we haven't really touched on here is vaginal exams during an induction.
[55:09] Now, I have an opinion about this. Of course, I've got an opinion about this. So vaginal examinations will be routinely done during an induction. And the reason they're doing that is that you're receiving artificial oxytocin. This is a manufactured labor. This labor is being completely medicalized and medically managed. We're already interfering with your body. It's the responsibility of your care provider and the person who's recommended and started this induction to ensure that this process is adequately monitored because we all acknowledge that there are risks to induction that are in addition to physiological labor. There are some risks to normal labor. And when you add an induction, we all acknowledge, there's no mistake, that there's additional risks to you and your baby. And we've got two whole episodes on the risks of induction on the Great Birth Rebellion podcast. So in that more risky scenario, it's the responsibility of your care provider to be monitoring and mitigating those risks. Having a long, drawn-out induction, it increases the risks of things going wrong because of that induction. And so if your body's not responding to the induction with your cervix dilating and the baby moving down in your pelvis and the contractions acting effectively on your body.
[56:37] Then you are increasing the risk of things going wrong and so your clinicians are really interested in understanding is your body responding to this induction is this going to be an appropriate way and a safe way to help get your baby out. So I am actually in support of vaginal examinations during induction and also during things like epidurals where the normal physiology has been interrupted. Now we need to know is this impacting on the woman's body's ability to function properly because when you interrupt physiology you interrupt normal function. So now we do have a very good reason to check is all these things that have been done, the epidural, the induction, whatever other interventions have been applied, are they affecting the woman's physiology? Because if it is, something needs to be done. We can't rely on physiology, you know, physiological labor, uninterrupted labor. You can trust most of the time that woman's body's going to work. But you can't do that when you've intervened in that process. You have to micromanage it. Even knowing that, though, you might want to decline vaginal examinations. That's completely up to you whether or not you want to have them in the same way that if you're having a physiological birth, you might want to accept all the vaginal examinations, even if you don't have any medical reason for them.
[58:04] I'm not saying accept vaginal examinations in some and not others. This is just information that you can use if you really feel like you don't need one. There's a lot of justification as to why that would be a clinically fine thing to decline and even if it's not clinically fine you are welcome to decline these things but I do think there's a place for them at times and that's where we use interventions when they're needed and don't use them when you don't need them so today I've explained to you how a vaginal examination is done some of the reasons why they'll be offered to you the fact that checking your cervix and knowing what your cervix is doing seems to be linked in the mind of your hospital clinician and hospital policy to your progress in labor. That's not necessarily true, but that's how they're thinking. And so cervical examinations are for the benefit of the system and of the care provider and for the triaging and workflow of the hospital. They're not necessarily beneficial for you unless of course there's a very good reason for checking in if there's a problem if there's been an interruption in the labor if you want one and as a diagnostic tool.
[59:23] For those listening as clinicians you must get consent and explain it properly and if you're supporting a woman in labor and birth if you're a partner doula other care providers in the space you are responsible for ensuring that consent is respected that's been today's episode of the great birth rebellion podcast and as always if you want the research papers for every episode that i make then just sign up for the mailing list for the podcast the link is in the show notes below and it'll be sent to your email and then you can read this stuff for yourself i will see you in the next episode of the Great Birth Rebellion podcast. To get access to the resources for each podcast episode, join the mailing list at melaniethemidwife.com and to support the work of this podcast, wear the rebellion in the form of clothing and other merch at thegreatbirthrebellion.com. Follow me, Mel, @MelanietheMidwife on socials and the show @TheGreatBirthRebellion. All the details are in the show notes.
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