Birth Preferences (Part 2): Vaginal Exams
Photo by John Looy
(Originally posted on October 5, 2016)
Most people know that on the journey to having a baby, vaginal exams will be part of the equation. But do you know the purpose of these exams? What they're checking for? Possible risks? What your options are in this area? If not, read on.
Why Vaginal Exams are Performed
In most cases with a healthy pregnancy, a pelvic exam is done to perform a Pap smear and other tests early in the pregnancy, and not again until about 36 weeks. During the last few weeks of pregnancy it is somewhat common for practitioners to do vaginal exams, to check for changes with the cervix as labor approaches.
What Can Be Determined by a Vaginal Exam
In this excellent blog post, Certified Nurse Midwife Karin Marshall explains what your practitioner is looking for. Here are the highlights:
Effacement. As you get closer to the end of your pregnancy the cervix can start to thin out, or efface. If a cervix starts out at 4cm and is now 2cm that is called 50% effaced. When the cervix is completely thinned out, then it is 100% effaced.
Position. The cervix can be posterior (meaning far back in the vagina), mid position or anterior (easy to reach, close). Most women tend to be posterior or mid during pregnancy. As the cervix effaces and gets more ready for labor it will ordinarily be easier to reach or more anterior than it had been.
Consistency. During pregnancy, the cervix feels somewhat like touching the end of your nose. As pregnancy/labor advances the cervix usually becomes softer, sometimes almost mushy feeling.
Station. If the baby is engaged in the pelvis that is a 0 station, its head is at the ischial spines of your pelvis, which is the narrowest part of your pelvic structure. Above the spines means the head is not engaged in the pelvis and is measured in centimeters, with a negative sign in front of it. If the fetal head is 2cm above the spines, then the station would be -2. As you move closer to the pushing stage of labor the fetal head advances past the ischial spines and it is again measured in centimeters but with positive numbers. At a +5 or +6 station you can see the head at the entrance of the vagina.
Dilation. During pregnancy the cervix is normally closed. The last few weeks of pregnancy, the cervix can start to open or dilate. This is not necessarily an indication that you will labor early. Some women are dilated several centimeters weeks before they go into labor.
All of these assessments make up what is called a Bishop score. Each one of the above parameters is scored and the final score is used to determine how ripe or ready your cervix is for labor. The more ready your cervix is considered to be, the higher the score. If you are a first time mom a ripe cervix is a score of 8 or above. For moms who have had a baby before it is 6 or above.
This Bishop score can become important if induction becomes necessary, as induction success has been linked to greater Bishop scores. If the score is low, and induction becomes necessary, you may want to discuss methods for cervical ripening with your provider in order to increase your chances for success. Besides its usefulness as a tool to prepare for an induction however, this score doesn't tell us as much as many wish it would.
What Can't Be Determined by a Vaginal Exam
Unfortunately, the cervix is not a crystal ball for predicting when you'll go into labor. A woman could have a ripe cervix and remain pregnant for several weeks, and a woman with an unripe cervix could go into labor hours after the exam.
So, why would you even get routine vaginal exams during a healthy pregnancy, expected to end in a spontaneous vaginal delivery? Great question.
There may be valid reasons vaginal exams are medically indicated for a given patient, such as suspicion of cervical problems like scarring, or pre-term labor. But often times, women simply want to know. They would like to be aware of what is going on with their body, and may feel more information is always better.
Since it seems to be a routine practice, many women accept this intervention without looking into it or thinking much about it. But it is in fact an intervention, and therefore it is wise to consider the risks along with the benefits before making a decision about your vaginal exam preferences.
Possible Risks
Anytime anything enters the vagina, there is an increased risk of infection. Even though vaginal exams are performed with gloves, there is a chance that bacteria could be pushed up into the cervix. This could lead to infection of the membranes of the amniotic sac, which is a rare, but very serious complication.
In addition, vaginal exams in late pregnancy are associated with PROM-premature rupture of membranes, or your water breaking early. This can also lead to infection, or could result in additional interventions if your body was not ready to go into labor.
Then there is the emotional component. With the determination of how ready your cervix is for labor, often comes an emotional reaction. A woman may be very excited to learn that she is already a couple of centimeters dilated, and 70% effaced, only to be let down by still being pregnant a week later. The emotional letdown of learning that your cervix is not showing signs of ripeness could also be very deflating, at at time when staying positive and relaxed is very important.
While there are risks involved with vaginal exams, it is up to every person to decide if the benefits outweigh the risks for them personally. It is important not only to examine your preferences, but also to discuss them with your provider to ensure you receive the best care for you.
Your Choices Around Receiving Vaginal Exams While Waiting for Baby
While preparing to discuss your preferences on vaginal exams during pregnancy with your provider, you may want to look into the following options:
Requesting no vaginal exams until labor begins
Asking your provider to obtain permission before stripping your membranes during a vaginal exam
Requesting only one vaginal exam on or around your due date
Requesting minimal vaginal exams or at your request
Requesting the exams be done by your provider when possible
It is completely within your rights as a patient to discuss your preferences and concerns with your provider. It is not high maintenance to ask questions about interventions before you give consent. You deserve to be given information about risks and benefits, and why they may feel a given intervention is a necessary part of your care at every step along the way.
Disclaimer: The content found on this blog is meant only to provide general information and is not a substitute for professional medical advice.
See additional posts in this series: Birth Preferences (Part 1): The Importance of Informed Consent and the "Overdue" Baby, and stay tuned for upcoming posts in this series: Birth Preferences (Part 3): Birthing Environment and Choosing a Care Provider, Birth Preferences (Part 4): Labor Coping Strategies, Birth Preferences (Part 5): Fetal Monitoring