This post is about routine vaginal examinations (VEs) during physiological birth (i.e., an uncomplicated birth without any medical intervention). A VE is a useful assessment in some circumstances, but its routine use in an attempt to determine labour progress is questionable. As birth knowledge evolves, and research challenges the current misdirected approach to labour progress, there is an opportunity to shift practice. I hope this post will inspire readers to reconsider their beliefs and practices regarding cervixes and VEs.

We need to look at history to understand why we are so fixated on what one small area of the body is doing during birth. The following is based on content from my book Reclaiming Childbirth, where I explore history in more depth. Here is a quick overview:

98 AD to 1900s
Vaginal examinations were only carried out during complicated births, for example, to assess if the baby was malpositioned. They were not used to determine the progress of labour. Early midwifery textbooks warned against routine vaginal examinations. For example, in the 1700s French midwife, Madame du Coudray wrote: Too much vaginal meddling is bad too: the best thing is to wait patiently, alert to all cues.

1900 to 1970s
Social and cultural changes resulted in childbirth moving from the domestic domain of the home into the medical domain. Influenced by the development of industry and technology, the body was conceptualised as a machine, with distinct parts that could be studied and understood separately. The birthing woman was 'broken' into physical parts – uterus, cervix, baby – and a systematic, linear understanding of labour progress developed. This is still evident in modern textbooks. The woman has disappeared in favour of diagrams depicting her 'parts' (and the fetal skull) alongside precise measurements. This simplified and incorrect understanding has underpinned education about birth and practice during birth.

In the 1950s, an American obstetrician named Emanuel Friedman plotted onto a graph the cervical dilatation of 500 women having their first baby in a hospital [1]. The study population included women who were sedated and had medication (Pitocin) to induce or speed up their labour, and 55% had forceps. The study found that most women had birthed within 12 hours, and when averaged out, cervixes dilated 1 cm per hour. However, individual women's cervixes did not do this in a linear way. Instead, some women dilated faster, then slower or vice versa. However, the averaged-out, neat and linear graph became established.

In the 1970s, based on this reductionist and linear approach, the partogram became established within medicalised maternity systems. In his 1978 textbook Labour: clinical evaluation and management Friedman describes labour assessment: The phase of maximum slope is a good measure of the overall efficiency of the “machine” with which we are dealing. The aim of the partogram was/is to measure and control labour progress by plotting cervical dilatation onto a graph, along with descent of the baby's head. If the cervix does not open along the prescribed timeframe (1 cm per hour or 0.5 cm per hour depending on the hospital), labour will be augmented, i.e., speeded up with an ARM or synthetic oxytocin.

Research
In recent years, new knowledge about birth physiology and research has challenged the cervical-centric approach to labour progress assessment. A previous article/post discusses the research regarding labour patterns and partograms. In summary, the research shows that women's labour patterns do not fit the timeframes prescribed by partograms. A Cochrane review on the use of partograms in normal labour concluded that [2]: On the basis of the findings of this review, we cannot be certain of the effects of routine use of the partograph as part of standard labour management and care, or which design, if any, are most effective. Further trial evidence is required to establish the efficacy of partograph use per se and its optimum design. The findings of a large study also challenged the accuracy of partograms concluding that [3]: Averaged labour curves may not truly reflect the variability associated with labour progression, and their use for decision-making in labour management should be de-emphasized.

Partograms and VEs go hand in hand. Filling out a partogram requires regular vaginal examinations to 'plot' along the graph. However, there is no evidence that routine VEs in labour improve outcomes for mothers or babies. A Cochrane review concluded that...

Continue reading this article on Dr. Rachel Reed's website here.