The Myth of the Vaginal Exam in Pregnancy

By Robin Elise Weiss, ICCE-CPE, CLC, CD(DONA), LCCE, FACCE
Read more from Weiss at About.com
posted with permission

Vaginal exams. I don't know a single woman who likes them.

However, there is a myth perpetuated in our society that vaginal exams at the end of pregnancy are beneficial. The common belief is that by doing a vaginal exam one can tell that labor will begin soon. This is not the case.

Most practitioners will do an initial vaginal exam at the beginning of pregnancy to do a pap smear, and other testing. Then they don't do any until about the 36 week mark, unless complications arise that call for further testing or to assess the cervix. If your practitioner wants to do a vaginal exam at every visit, you should question them as to why.

Vaginal exams can measure certain things:

Dilation: How far your cervix has opened. 10 centimeters being the widest.

Ripeness: The consistency of your cervix. It starts out being firm like the tip of your nose, softening to what your ear lobe feels like and eventually feeling like the inside of your cheek.

Effacement: This is how thin your cervix is. If you think of your cervix as funnel-like, and measuring about 2 inches, you will see that 50% effaced means that your cervix is now about 1 inch in length. As the cervix softens and dilates the length decreases as well.


Station: This is the position of the baby in relation to your pelvis, measured in pluses and minuses. Station addresses how far the baby is "down" in the pelvis, measured by the relationship of the fetal head to the ischial spines (sit bones). Measured in negative and positive numbers. -5 is a floating baby, 0 station is said to be engaged in the pelvis, and +5 is crowning. The positive numbers are the way out!

Position of the baby: By feeling the suture lines on the skull of the baby, where the four plates of bone haven't fused yet, one can tell you which direction the baby is facing because the anterior and posterior fontanels (soft spots) are shaped differently.

Position of the cervix: The cervix will move from being more posterior to anterior. Many women can tell when the cervix begins to move around because when a vaginal exam is performed it no longer feels like the cervix is located near her tonsils.

What this equation leaves to be desired is something that is not always tangible. Many people try to use the information that is gathered from a vaginal exam to predict things like when labor will begin, or if the baby will fit through the pelvis. A vaginal exam simply cannot measure these things.

Labor is not simply about a cervix that has dilated, softened, or anything else. A woman can be very dilated and not have her baby before her due date or even near her due date. I've personally had women who were 6 centimeters dilated for weeks before labor began. Then there is the sad woman who calls me to say that her cervix is high and tight, she's been told that this baby isn't coming for awhile, only to be at her side as she gives birth within 24 hours.

Vaginal exams are just not good predictors of when labor will start.

Using a vaginal exam to predict advisability for a vaginal birth is usually not very accurate, for several reasons. First of all it leaves out the factor of labor and positioning. During labor it's natural for the baby's head to mold and the mother's pelvis to move. If done in early pregnancy it also removes the knowledge of what hormones like relaxin will do to help make the pelvis, a moveable structure, be flexible. The only real exception to this is in the case of a very oddly structured pelvis. For example, a mother who was in a car accident and suffered a shattered pelvis or someone who might have a specific bone problem, which is more commonly seen where there is improper nutrition during the growing years.

During labor vaginal exams can't tell you exactly how close you are either, so keeping them to a minimum then is also a good idea, particularly if your membranes have ruptured.

So there's not really a great reason to have a vaginal in exam done routinely for most women. Are there any reasons not to have vaginal exams? There sure are.

Vaginal exams can increase the risks of infection, even when done carefully and with sterile gloves, etc. It pushes the normal bacteria found in the vagina upwards towards the cervix. There is also increased risk of rupturing the membranes. Some practitioners routinely do what is called stripping the membranes, which separates the bag of waters from the cervix. The thought behind this is that it will stimulate the production of prostaglandins to help labor begin by irritating the cervix, causing it to contract. This has not been shown to be effective for everyone and does have the aforementioned risks.

In the end only you can decide what is right for your care in pregnancy. Some women refuse vaginal exams altogether, some request to have them done only after 40 weeks, or every other week, or whatever she feels comfortable with.


37 comments:

  1. Thanks for posting this. Luckily I never had a vaginal exam during pregnancy, but I did when I was in labor. It was the worst thing...I had a long labor resulting in an emergency c-section. Being examined while in labor was so painful - it seemed to intensify contractions to an unbearable point and I really don't think it achieved anything, apart from making me feel disheartened every time I was told I was still ripening or only 1cm dilated. It wasn't until after my daughter was delivered they discovered she was asynclitic. Is that something they could have picked up on during the internal exams? I don't know. I do remember a couple of times the midwife taking FOREVER to work out the position of my baby, just to guess that it was 'ok'. So I think next time round I wont be so quick to accept internal exams as in my experience they didn't help things at all.

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    1. Your story sounds exactly like mine. Every detail, right down to the nurses for my birth not knowing what position the baby was in.

      A few things I've learned:

      One, normal posterior babies are kind of a freak occurrence, and unlikely to be repeated in subsequent births - but an asynclitic baby can be an indicator of things not being properly aligned in the mother, and if that's not addressed, there's a possibility future babies will be asynclitic, as well. I'm pregnant now with my second (with high hopes for a better birth) and will be seeing a chiropractor; I'll report back with results in October.

      Two, in a normal birth, where baby is in a normal position, being vertical and having gravity pulling baby down can help speed things up - but with a posterior baby, and especially an asynclitic baby, all that does is get baby feeling more and more stuck, and cause labor itself to become painful, inconsistent, and inefficient. The positions that generally work best for an asynclitic baby & exhausted mom are a) hands and knees, with bum up and head down, b) sitting/squatting on a birthing ball (or squatting with support from a bed or partner or rail or whatever) while leaning forward & rocking hips in whatever way feels comfortable, and c) lying down. Sounds counter-intuitive to labor lying down, but an asynclitic baby slows things right down, all the way through, and if mom is tired, lying down or reclining somewhere might just be the best position to labor in while she regains some energy.

      Three, vaginal exams are so painful for some women that they stall labor, because they trigger a fear/fight or flight response. I found, for example, that after the first few hours, I would actually shrink away from the nurses in fear as they walked in The women were sweet as can be & doing everything they thought would help, but my body thought they were a threat, an assault on its birthing space. I'm certain I would've progressed more quickly if they had just altogether left me alone.

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    2. Thank you so much for pointing out that vaginal exams are downright PAINFUL for some women - and trigger a fear response. I don't know if it is because I was sexually traumatized as a young teenager, or if there are other physiological reasons, but I most certainly experience real pain when examined internally, and when it was forced on me by an OB because I was "post dates" it was just the most awful, violating, painful experience of my life - even more so than being abused when I was young because this time I was supposed to praise the OB and be thankful she was treating me medically. I was not allowed to cry or express how violating it felt to me. And she stripped my membranes without my knowledge or permission while doing the exam. All around just bad. I am just glad there is at least one other person out there who knows some women feel this way.

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  2. I hate VEs. My cervix stays waaaay posterior until I'm almost fully dilated, so I feel like they are going in up to their shoulder to find it. Ouch. I don't allow them until I am showing signs of labor, and even then, I only do a few at the insistence of my midwife.

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  3. I was so lucky to NEVER have a vaginal exam for my entire pregnancy AND delivery! It was lovely! I had a home birth and everything progressed smoothly so no one insisted on a vaginal exam. I had no idea how nice that could be. :)

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  4. I was stuck at 7.5 cm dilation. I had a vaginal exam at the birth center, right before I was told I needed a c/s. Right or wrong, I know I do NOT want another one.

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  5. Good to know... I always thought vaginal exams were necessary. I never knew that I had much of a choice. Having them near the end of pregnancy SUCKED! For me they were always painful and caused spotting, nausea and cramping for days afterwards. I dreaded those weekly doctor's appointments at the end. I'll keep this in mind for the future :)

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  6. I'm hitting the 36 week mark this week and was thinking about saying no to VE's....my gut just told me they really didn't make any sense. This is baby #4 and we are having a home birth, the VE's have never told me anything useful in the past and have always been uncomfortable and caused spotting. One doctor even separated my membranes without my permission! So thanks for the info!

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  7. I had a vaginal exam while in labor and it was the most painful thing I remember ever experiencing. I screamed and tried to get the doctor to stop, even tried to kick him I wanted him to stop so bad. But the nurse held me down as he continued, with no expression on his face. I have never felt so violated in my life. When he left she told me he was infamous for his big hands, and she seemed distressed about the whole thing. Later, I filed a complaint with the state medical board on him, but by the time it came around I had moved to another state and couldn't get back for it. What he did was SOOO not right and has got to stop.

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  8. I am so lucky i guess that i didn't have a VE during labor with either of my children and i gave birth before my 37 wk checkup so the docs didnt even have a chance. not like i would allow it, bc to me it doesn't make sense.

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  9. Lucy's story is why I often equate them to rape. If a person feels they don't have the ability to say no, by the law, that's rape. And I know I was flat out told I couldn't say no :(

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    1. I agree...I've never had a VE because I don't want any medical tools and other stuff in there. I feel that it would be like rape..don't want a dr. ever giving me a VE

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    2. I also agree. I had one recently due to having some early contractions at 28 weeks, and I felt so violated afterwards - blood pouring out, feeling like razors had been inside me - that I couldn't even control myself and started crying. Although I've never been raped, I did feel that that was a similar type of experience. I had no say in the matter and felt pressured into just "taking it", despite the doctor seeing how in pain I was. Overall, a terrible experience, and I am now frightened of these last stages of pregnancy not because of childbirth itself, which does seem like a natural type of pain to me, but because of these horrific exams. I will definitely be refusing them...I don't know what I'll do if my doctor insists. Thanks everyone for posting here, because it makes such a difference to know I'm not alone in this!

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  10. Excellent post. I wish this could be distributed to every pregnant woman in her first trimester! I'm an OB nurse, and I work with nurses who get a VE at every visit from around 30 weeks on! It makes me ill. Sigh...

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  11. I never had a vaginal exam with any of my three pregnancies. The doctor never once mentioned it - thankfully.

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  12. Would it be reasonable to expect that too many vaginal exams too early in pregnancy could cause premature labor?I had a vaginal weeks at 30 wks.They found me 1cm. dilated so... they checked two more times.By the end of the apt.I was at almost 2cm.I was sent home told to come back one week later and was examined at the beginning of the appointment(there was no change in my cervix).About 45 minutes later they did another V.E and remarked that I had dilated 1/2 a centimeter.I was told I had preterm labor(stressing me out and scaring me) and sent home on bed rest.At 33 wks they had me back in the office for another V.E.No change.My water broke at home at 34wks on the dot.I took my time getting to the hospital.They checked me once remarked that my water had only partially broken and that there was no change in my cervix.2 hrs. later they checked me again and said my water was still partially intact and no change.
    I asked to please be allowed to wait as long as possible to induce.I was reluctantly told I had 48 hrs.When they induced with pitocin they turned up the iv to the full amount within 2 hrs.I was examined multiple times.When one of the Dr.s was trying to re-break my water he remarked how difficult it was.I labored with no epidural,squatting on a birth ball.I had a fetal monitor an I.V an later on an internal fetal moitor.I was examined several times during labor an told to get on the bed when I wanted to push.She was born vaginally after five hours on the pitocin and about twenty minutes of pushing.The baby at no point showed signs of distress.I am a healthy,active 23(at the time 22 year old).Prematurity does not run in my family.I am grateful for my now very healthy 15mo.girl but I still can't wrap my head around what happened.I naively thought that since I didn't get a midwife for my dreamed of home birth because we moved that I would be ok at the local hospital.Is it reasonable tho think that all those vaginal exams induced me early?And is there really a medical reason that I could not have waited for labor to occur naturally assuming The baby and I showed no signs of infection or distress?

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  13. Wow.My apologies for that being so long and typo riddled.

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  14. When I was pregnant with my first baby, my OB did way too many vaginal exams - at appointments and during labor. I always wondered about their necessity, but had never heard anyone address the issue.

    I switched to a midwife at a birth center for baby #2 and only had 1 vaginal exam the entire time - a super quick one when I checked into the center on the night I had my baby.

    My second pregnancy/birth experience was a thousand times better than my first - for a variety of reasons. I highly recommend midwives and birthing centers to all moms-to-be. Now that I've had that experience, I'll NEVER go back to an OB (if I can help it).

    Thanks for this informative post!

    stephanie@metropolitanmama.net

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  15. I was one of those women who was 6cm dilated well before going into labour - at least a week before; a week before that, I was 5cm, and a week before that, 4cm. Next pregnancy I think I won't be so quick to agree to a VE at 37 weeks, since I then agonized for the next 2 weeks about why I hadn't had my baby yet.

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  16. I had long discussions with my mom about why I wasn't having vaginal exams at the end of my pregnancy. She had 2 twin pregnancies and one ended with the death of both twins, so to her she would want to know everything she could to put her mind at ease. I had to explain to her that the exams really wouldn't mean anything, even if the doctors thought they did.

    I had no vaginal exams other than the group B strep test, and by the time I got to the hospital in labor my daughter was crowning, so I never did get one after that! I'm trying to talk my friend into not getting them as she is 37 weeks this week...but in the end we have to make our own decisions. I loved it, because labor was such a surprise and as a private person it was better not to be examined..

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  17. I've been a midwife for 33 1/2 years and rarely do vaginal exams anymore. I can tell by the way she moves & the sounds she makes where she is in labor. Occasionaly I have to hold the cervical lip up, but women don't complain about that. The thing is my students don't learn how to do vaginal exams either, but they learn how to read women in labor! How exciting is that ladies!

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  18. I'm a student midwife and we just learned how to do vaginal exams (and practiced them on each other - I tell you, for a nulliparous woman like me, 7 vaginal exams in a row was very, very interesting!). There is one other reason to do a VE on a pregnant woman towards the end of her pregnancy, but it's only useful really as an FYI, it doesn't change your care of the woman. Using your hands, you can measure the locations of the ischial spines, observe the angle of the pelvic arch, and find the diagonal conjugate. This, along with the basic feel of the pelvis, tells you what shape the pelvis is (there are 4 basic shapes in human females). Unfortunately, doctors can use pelvimetry to scare women, not taking into account the fact that the pelvic actually stretches and changes shape during labor. A skilled midwife can use her pelvic measurements to inform position changes and identify labor patterns. For example, if a woman seems to stall at some point, it doesn't necessarily mean that her labor isn't progressing. Sometimes it means that the baby is working to find the right angle to get through a narrow section of the pelvis, and you can use various positions tactically to help that process out. It's just one more piece of information that a midwife can use to help a difficult labor and avoid unnecessary interventions.

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  19. I recommend that you read a book called: "Confessions Of A Medical Heretic" by Robert S. Mendelsohn. Yo may also want to read another book called: "Male Practice: How Doctors Manipulate Women."

    You will be shocked to discover how much of these exams are unnecessary and how doctors will use scare tactics on women. You will learn about the agenda's the medical industry has and how they like to keep their patients ignorant. It makes me angry how much women, and also men, are being deceived by doctors. Read the books and see for yourselves.

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  20. The books Stephen mentioned are excellent. Thank you for the reminder.

    Confessions of a Medical Heretic - http://astore.amazon.com/peacefparent-20/detail/0809241315

    Male Practice: How Doctors Manipulate Women - http://astore.amazon.com/peacefparent-20/detail/0809259745

    Women's Bodies: A Social History of Women's Encounters with Health, Ill-Health and Medicine - http://astore.amazon.com/peacefparent-20/detail/0887388485

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  21. My doctor gave me the option to do them or not to do them, I chose not to do them. He did an ultrasound each time so that he could tell the position of the baby. I knew he dropped at 36 weeks. I had a very fast labor, got to the hospital fully dilated and effaced which was my only vaginal exam. I'm glad I didn't get them, because I think it could cause stress if you aren't or if you are and aren't having the baby. I just relaxed and expected to be late and have a long labor. I was 38 weeks and had a five and a half hour labor lol.

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  22. I think my midwife asked to perform a vaginal exam maybe... twice during my labor. I requested one before labor and one during. She's a great lady. :)

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  23. With babies 4 and 5 I was 8cm days before labor set in. I defiantly agree that V/E are not good predictors of when labor will start! But, I did know that when I did do into labor I would be in transition =)

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  24. Is it an American thing to do all these exams in pregnancy? I live in the UK and with 4 children I never had an internal exam during pregnancy, I've never heard of anyone else having it done either. During labour yes - in fact my first baby 18 years ago I lost count of the number I had, but I only had a couple in my second and third labour, and none in the fourth. Is it because UK women are mainly looked after by midwives in pregnancy and labour? Most women will not see a doctor at all.

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  25. It is NOT routine here in New Zealand to perform a pelvic exam in early pregnancy, nor a pap smear. Mothers can expect to be asked questions about STDs and whether they're up to date with paps (recommended every three years here for most women) and tests for HIV and syphilis are part of 'routine' antenatal bloods - but can be declined.

    In fact, paps are NOT recommended in pregnancy at all here - if you're not up to date, you're likely to be told to wait until baby is around four months old so that there's no hormonal interference affecting the results. Women need to be aware that they ALWAYS have the right to deny a pelvic exam, ALWAYS. Non-consensual pelvic exams are rape. If women are made to feel that they don't have a choice, it's rape by coercion.

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  26. All about no vaginal exams unless Mom requests one!! For me - no thanks!!!

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  27. What about for confirming the baby is head down? Sometimes, especially for a first time mom, the provider can be mistaken about the baby being head down and a VE can help to clarify/confirm position.

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  28. I went into my last pregnancy thinking I wasn't going to get any vaginal exams until I went into the hospital in labor. However, my 38 week appointment came and I was so curious. Thankfully, my midwives didn't push them on me and I got to decide. I was also backed with the knowledge that regardless of what they SAID, they didn't KNOW when I would go into labor. During my vaginal exam at my 39 week appointment, my midwife suggested that I was in early labor and to head to labor and delivery (I was 5cm, having contractions while she was doing the exam and about 80% effaced) and offered to strip my membranes (to "get things moving along"). I declined BOTH and ended up going into labor about 16 hours later. I'm personally glad that I got to get the information that I wanted at my request (I'm always curious.) and didn't have to feel pressured to do what the midwives suggested.

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  29. Sometimes the provider can be mistaken about the presentation even with a vaginal examination. I took over care of a lady in labour, whose baby was confirmed by VE as head down by the previous midwife, and on "crowning" it turned out to be a bottom!

    I'm seriously shocked at some of the stories above. I wrote a paper in 2004 on assault in labour. I am shocked to hear that the things I reported on then are still happening nearly a decade later.

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  30. I'm from the UK and moved to the US 2 years ago. I've been rather shocked at how liberally pelvic exams are performed in this country. I'm now pregnant with my second child. My first was born in the UK and I did not receive a single VE throughout my pregnancy and labour. None are done routinely in pregnancy and the head was crowning when I got to the birth centre. At 13 weeks I have already had to refuse a pelvic exam in the US, I even said to the OB "..unless you think there's a good reason for one" to which she said "not really". Which begs the question - why do them if there's no good reason?? I plan on refusing as many as I need to and plan on seeking out a midwive-led birth centre for the birth. It makes me really angry that so many women feel like they have to undergo this type of examination unnecessarily. Why? Is it just because more money can be charged to the insurance companies for VEs?

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  31. I work in OB clinic and you would be SHOCKED at how many women come in for there 36,37,38 week check ups BEGGING for a VE................Go figure!

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  32. My son was breech and i cant count how many VEs i had. this time im refusing all!

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  33. During my second son's birth I went through birth trauma due to the attending doctor's (a doctor I had never met) unnecessary VE as I was pushing. Now that I am in my third pregnancy, I understandably don't want anyone down there unless absolutely necessary. My current doctor went with it the first time I declined, then had one lined up for me (without asking before hand) for my second appointment, and I declined again. He talked about me having one at my next appointment but with a female provider. Without being downright argumentative, I'm not sure how to get it through his head that I am not going to consent. We are a military family (so this is a military establishment), but are moving before this baby is born and planning to deliver at home with a midwife. VE will be a hot topic as I'm interviewing midwives!

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