Internal cervical exams….a rant. Okay, so I know I’m about to get a whole slew of doctors upset at me – but you know what? I’m big…I can take it.
Lets start at the beginning…not the beginning of the pregnancy, but the beginning of the debate over internal exams which starts at around 36-38 weeks of pregnancy. Usually I will have a client of mine ask me sometime between 36 and 38 weeks if we’re going to check her cervix to see what it’s doing.
My response is always – WHY?
That’s a bigger question than you
probably think. I’m not just asking why she wants to check as in, “what do you want to find out”….but I’m also asking why she wants to check as in, “why do you feel the need to know?”
What do you want to find out? How far dilated you are? You’re 38 weeks…what does it matter? Oooohhhh… you hoping that someone (me) could tell you how much longer you will be pregnant? I BET YOU ARE!! That is the million dollar question, and one that I wish I could find out the answer to – because I would be one rich midwife if I could!! If I had been the Divine creator and designed our bodies, I would have put that belly button to use and make it glow bright green 24 hours before labor was going to begin! When will labor begin…yes, that’s an excellent question. How very unfortunate for all concerned that that is impossible to answer. I have seen women be not dilated or effaced at all and slip into labor and have their baby hours later. I have also seen women be 7cm dilated and not in labor!! That’s more of an extreme (in 15 years I’ve only seen 3 women do that), but it does go to show that where your cervix is TODAY has absolutely no bearing on what it’s going to do tomorrow.
Okay, so it won’t tell you when you will go into labor…but surely it will tell you how your labor will go! The further dilated you are now surely means that you will have a faster and easier birth? Again, how I wish that were the case…but, again, it sadly is not. Checking your cervix now does not tell us what it is going to do, it only tells us what it has done! You might get to 4cm with absolutely no extra pressure and feeling no vita mutari (if you don’t know what that means, please see my blog post titled “vita mutari”) – and then you might feel enormous vita mutari in order to birth your baby, and it might take many many hours!
Now lets address the reason you WON’T tell me when I ask you why you want an internal exam – but the reason that is almost always universally there….the need for reassurance that your body “works”. If you are dilated, then it’s proof positive that your body knows what to do and is functional. As you probably have gathered by now, that’s just not the case.
So checking your cervix does not tell us: when you will go into labor, how fast your labor will be, or how easy or challenging your labor will be.
Ah, but checking your cervix prenatally DOES do SOMETHING!! It ruins the end of your pregnancy.
If you are not dilated yet, then that means you will begin doubting your body, feeling broken, doubting that this baby will “ever be born”. Please be reassured, the longest human pregnancy ever recorded was not “forever”. These moms who find out that they aren’t dilated leave my office discouraged, often looking beaten down and sad. What a terrible thing to feel when you are right on the cusp of having your baby! (Sometimes you’re only hours away from labor!) Your body has known how to conceive this baby, it has (without our assistance) been able to grow from a teeny tiny egg mixed with an even teenier sperm into an entire person!! A full grown baby with toes and hair and the cutest butt cheeks you’ll ever see!! It’s done this miraculous thing…and now, based on a stupid cervical check, you will lose a huge amount of faith in its ability to finish the job it started so perfectly? SHAME ON YOU! Your body is amazing, incredible, creating life! It deserves our utmost adoration…now is not the time to start doubting it! What has it done to deserve your skepticism of its perfection? Nothing…absolutely nothing!
If she is dilating…then celebration and feelings of accomplishment and she will then often run home and tell everyone that the baby is going to come at any moment! She quickly puts all of her affairs in order making sure everything is ready for the baby…and then she waits….
…..
…..
And she waits…
And I see her at the office a week later…and she’s smiling….sort of. Why isn’t the baby here? And another week goes by (that’s a long time to hold your breath) and she’s still pregnant. It is only her estimated due date (which is a whole other blog post rant for me to tackle) and yet she FEELS 2 weeks late because she thought the baby was going to come 2 weeks ago when we did an internal exam on her. This is the mom that usually wants to start talking about inducing at home because her cervix is “favorable” and because she feels 2 weeks late.
So if we hadn’t checked these women’s cervix prenatally, the not dilated mother would have gone into labor and had her baby on her baby’s good time, and the dilated mother would have gone into labor and had her baby on her baby’s good time. What did we accomplish here?
So why do so many care providers do routine internal exams on every mother late in their pregnancy? I think that’s an excellent question for you to ask your care provider…and if there is an answer, I am very curious to hear it – because I can’t think of a good reason at all!
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What about in labor?
I get the call.,…vita mutari has begin and is growing, we’re ready for you to come. I head over to the family’s home and she wants her cervix checked. And again I wonder…why? Is it to prove to me that she’s in labor? I believe her…and I doubt that’s the main reason. The main reason women want their cervix checked in labor is to prove to THEM they are in labor! They can’t just let it be what it needs to be…and my question would be this – what does it matter? What you are feeling is valid and real, and what is going to be is what is going to be…
I don’t care where your cervix is when I arrive! I’m not going anywhere,…I’m here until this stops or we have a baby. The only time I can see the value in an internal exam is if labor doesn’t seem to be progressing in a way that we would expect, and I may want to check to see if there is an answer I can find (such as a baby’s head being crooked in there, for example). It is not to see how fast your progressing, really…as long as you are moving forward, I do NOT care how fast it is going! Take your time, have your baby in your own time…so long as everything is healthy. But for a normal labor, I don’t care how long it’s taking, I don’t care what your cervix is doing…I accept your labor is what it is and will take as long as it needs.
What about to see how much longer you will be in labor? I’ve seen women go from 4cm dilated to birth in an hour! I’ve also seen them take 12 hours to go from 8cm to birth. Okay, so that doesn’t help.
What about when you feel the need to push? Here is where I’m going to get the biggest chair-squirming from nurses and OB’s (and even a bunch of midwives). When you begin pushing your baby out, do I need to check your cervix to make sure it’s “okay” to push because we’ve made sure you’re fully dilated? (you know, to make sure you don’t ‘swell your cervix’) No, I don’t. Usually women don’t start pushing by all of a sudden full-on full body pushing…usually you hear a catch in their voice during the contraction, a grunt, a tightening. Rarely does this happen when she is fully dilated, it’s almost always in transition…and I’ve never seen little grunty pushes swell a cervix. What about when she does those full-body pushes? For the first 15 minutes or so my response is “YOU GO GIRL!” After that I look (externally…but LOOKING at the mother) for signs that the baby has moved down and therefore she’s fully dilated. Yes…you can actually see signs on the outside without touching mom! If she’s pushed for a while with no external signs, then and ONLY THEN will I ask if I may slip ONE finger in and see where the head is and if there is cervix I can find.
This past year I did 8 births in a row…with a total of 1 internal exam (because the mother said that with her previous babies she was “stuck at 8cm” for hours until her water was broken artificially and she felt for the last couple of hours that she was again “stuck”. This being her forth baby, I believed her…checked her cervix, she was, indeed, 8cm and we broken her water and she had her baby 15 minutes later. Did I mention that I have a HUGE amount of respect for the wisdom of mothers?? I’m always humbled by it..) I actually feel sorry for my apprentices – because cervical checks is going to be the LAST skill they master with me…because I just don’t do them very often.
Sometimes I will see a woman that loses all confidence in her body and the process for no reason other than societal anxieties and fears that everyone has given her that birth is scary and doesn’t work 32% of the time (our current cesarean rate). Sometimes that mother needs to regain her confidence and that can sometimes be accomplished with an internal exam that shows that her cervix is blossoming open. It’s wonderful to be able to help a woman regain the trust in her body! (also runs the risk of finding out she’s not as open as she hoped and having her completely give up…even though her cervix could blossom open quickly and at any moment!)
So let me summarize my position on this subject:
REASONS NOT TO DO AN INTERNAL WHILE PREGNANT: it won’t tell you when you will go into labor, or how your labor will be.
REASONS TO DO AN INTERNAL WHILE PREGNANT: because you want to become frustrated with your body or want to wait with baited breath at the end. (note: the one GOOD reason to do an internal is if you are looking to induce labor – that is the only medically indicated reason to do an internal exam)
REASONS NOT TO DO AN INTERNAL WHILE IN LABOR: to make sure you’re really in labor, to see how much longer it will be before the baby is born, to make sure it’s “okay” for your to push.
REASONS TO DO AN INTERNAL WHILE IN LABOR: to make sure (after given ample time) that things are progressing (no matter how slowly) and that there aren’t issues that need to be addressed.
And my question to you is: Why do you need external validation that your body is perfect? And why is it that I respect the phenomenal perfection that is your body more than you do?
40 Comments
I have to say that until we looked into having a home birth and met you I never knew that so many medically endorsed things were optional and/or unneccesary. This whole birth process with Lena (4 kids later…) has been very eye opening and wonderful!!
Love this! I forwarded the link to my pregnant sister in law.
I also added you to my blog list.
Great post!!! Thank you!
I think part of the reason women want them done is the inherent competition between pregnant women. You hear from your mom, sister, best friend, perfect stranger, that they were dilated to a 4 at 38 weeks. And now they feel like they have something to prove.
This birth was the first time I had no internal checks during labor and it was by far my quickest and easiest. I even slept for 3 hours at the end of labor. Would I have done that if I had been checked and “known” that I was in labor? Probably not.
Fantastic post! I agree with every sentiment except the checking prior to full-blown pushing. I did squirm a little at that :p
Been there done this got the t-shirt
Excellent article. However in the Hospital setting this is a required bit of information!
Thank you, my darling friend, for you perfect and complete confidence in the women you care for. And thank you for these words, to them and to the members of The Washington Birth Network (I posted a link!) that remind us that that confidence is well placed. We are amazing. Let us never doubt it.
Hmmm…so does this apply to possible pre-term labor? It sounds like your cervix doesn’t tell you much usually, huh
I was one of those women who thought something was wrong with me because I never felt the urge to push and that I needed a doctor or midwife to tell me when I could. Imagine my surprise when I had my 4th baby (after one hospital birth with an OB, one with a midwife and a homebirth with a midwife) when I actually felt like pushing on my own without being told to by the midwife!! I’ve had 2 babies without anyone telling me how my cervix was doing and it just happened! I’ve got about a month or so before I have my 6th and am looking forward to just going with the flow, once again.
Rebecca:
No no no….this absolutely does NOT apply to someone who is preterm!! Before doing any test – ANY test – I always ask the question, “What are we going to do with the information?” If you are worried about preterm labor, there is LOADS we could do with that information!! I see total value in checking the cervix if a woman is preterm with threatened labor….that is something we need to know before it’s too late!! This post was only in reference to those women who are full term.
Great post, I agree wholeheartedly. We need to bring back the trust in our bodies and we do that by allowing our bodies to do what they are designed to do without messing with it.
I’m right there with you, Stephanie. Cervical exams of full term moms are by and large unnecessary, invasive, and dare I say for many women downright humiliating. Unless something isn’t right with the labor, I do not do cervical exams.
Yep- been the one who goes from 4cm straight into transition and then pushing 15 minutes later. I had one cervical check, and all it did was piss me off!
Loved the butt reference! Great info! My dd managed to only have 1 cervical check and only because her water had broken10 hrs ago!
I never understood this either. My most recent child, born at home, unassisted, and I didn’t have one single check my entire pregnancy.
You should have seen the look on the Medwife’s face at the clinic I was going to for prenatal care when she asked to do a cervical check at 30ish weeks. I looked at her and said ‘we just met, and I don’t feel comfortable with your hands inside my vagina. But thanks.’
Great post! I’ve been thinking a lot lately about these routines that are a part of mother and infant “wellness” care. Seemingly benign at first glance, but I think they insidiously contribute to building in women a mistrust of their bodies and a feeling of being unqualified as an authority about themselves and their babies.
Another example of this is baby weigh-ins and plotting on the growth charts. I’ve seen women doubt their milk production and/or their ability to know their baby is growing and developing well based on nothing else but this static data point. These little things really do mean a lot!
I agree with most everything you said. I am a L&D nurse and feel that we do way to many exams in the hospital. But I was wondering how you check to make sure the baby is vertex. I see a lot of people do Leopold’s maneuver but some have been wrong. Do you have another way to tell the position of the head?
Bethany:
Since I am a midwife (as opposed to an L&D nurse), I have the ability to be seeing these moms throughout their pregnancy (as opposed to seeing them for the first time in labor, which is what you have to do)…so I’ve been palpating (doing Leopolds) for MONTHS, checking position of the baby…seeing the stability of the position, engagement of the head can be felt externally…is it possible for me to be wrong? Sure. But the odds of the baby being breech is small, the odds of me not being able to tell is even smaller…so the risk of not checking internally, IMO, is worth it to avoid the risks…
This is great, Stephanie! Aww…I just love u! I was not checked prenatally, BUT I was checked during labor. When u checked me I was fully effaced and 4 cm dilated. I had worked sooooo hard up until that point and I was crushed to learn I was only 4 cm. I will not be checked next time! It’s just a mind game and I’m not playing!
Thanks for this post. I’m both a word junkie and a birth junkie, so between this and “vita mutari,” you have a new fan!
I was at 38 weeks a week before Christmas (2008), and I asked my midwife to check my cervix because I had family coming into town and apparently I thought my cervix was a crystal ball.
Not really, but I was anxious for some idea whether I should shuttle my family off to a hotel room! Well, my cervix “admitted a fingertip,” which of course resulted in about a day of bleeding. Every time I went to the bathroom and saw blood, I cried, thinking things like “I asked for that check, and now I’ve probably lost my mucous plug, and what if I have this baby before it’s ready because I wasn’t patient…”
Thankfully, my baby waited another two weeks to be born on his own schedule, and needless to say, I am not going to stress myself out with pre-labor checks in the future!
During labor, I only twice sat still long enough to let my midwife check me. Both times the result was reassuring and gave me renewed strength, but “less positive” results could easily have had the opposite effect! Having gone over my records and talked with friends who are apprenticing, I realize now that the paperwork required by the state is a huge part of why otherwise non-interventive midwives do regular cervical checks. Thanks, nanny state, for yet another interference in what should be a private and personal relationship! (Oops, I forgot to mention that I’m also a liberty junkie.
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Great article!
With my first I was 4 cm dilated for 3 weeks before my 16 hour labour.
With my second I was not dilated at all until I hit labour. That labour was 3 hours.
Thanks for sharing from the HCP point of view! I blogged about this last year, from the doula and CBE point of view, (and coincidentally used the same picture!) Thought I would share the link here, to read how an exam at 33 weeks almost turned out bad!
http://www.newmoonbirth.com/2009/06/keep-your-pants-on/
I LOVE this post. When I “grow up” and get to be a midwife…I plan tio have this attitude.
I totally agree. My OB hospital birth w- my 1st was completely different than my midwife homebirth w- my 2nd. I was strongly encouraged to be induced w- the 1sst b/c at me EDD I was barely 1cm and -3, so I was induced at 40wk5d and it was horriblew, the back to back forced contractions and 12 hours of labor. I wanted to go natural but kept being urged to get an epi. when I was checked after 9 hours and crying b/c of the pain, i was at 40 on my epi, I was told i was 8cm and it could be at least 2 more hours. I didn’t know I was going to handle 2 more hours so I agreed to the epi, but over an hour later when the anest got there he placed the epi wrong so it was pulled and i didn’t allow them to replace it. by this time I was beginning to have the urge to push but wasn’t allowed to until my doc got there which was over an hour later, but funally my daughter was born. i got pg again a little over a yr later and chose a different ob, only to feel everything that could go wrong did and I m/c at 8wks. thet did an internal and pap w/out asking me if i wanted one or if it was ok, then when i started spotting a few days later I went back in and internal was done, everything “felt” fine, I was sent to the hossi for an u/s adn the external showed a good h/b but then the tech wanted to do an internal b/c my ob said, which it was a newbie and she was very rough, i was her 1st internal(wasn’t told til she had started doing it), after that I lost my mucous plus and started bleeding and cramping, 2 miserable days later i m/c so when i got pg again i was determined not to use a dr and sought a CPM. i had a great pg, was only checked at 37wk b/c i was going out of town, had been having lots of BHC but i was only 1 cm and -3. well, i had 2 false alarms, the 2nd i was checked and was still 1cm -3. when labor did start i was checked and i was 3cm -1, and 4 hours later gave birth to my 2nd daughter. I’m thankful for my midwife and willnever use an ob again
Great timely article! I’m 41 weeks and have declined checks knowing that they won’t tell me anything. But I was at the point where I needed some information, even useless information, and considered a check at my next visit. Now, I will sit and be patient. Thanks!
Great article (sadly 9 years too late for me). With my first, I was induced with Pitocin at a very high level at 41 wks, and cervical checks told the nurses/doc that “I wasn’t progressing”. I was not given the freedom to move around much with the Pitocin drip… duh! 8 hours into the induction, I was checked and was going to decide from there whether to accept a half-dose of pain med. Though I’d desperately wanted a natural birth, so much was being taken out of my hands & the Pitocin level was giving me unbelievable pain that no natural methods were helping me with. Again, “little progression”, so I accepted a half-dose of oral pain med. Unfortunately, the cervical check introduced bacteria into my amniotic fluid and I developed an infection in the fluid. My temperature rocketed up to 103, and I was told that my daughter was in fetal distress. Terrified and devastated, we agreed to the emergency cesarean. I was in the hospital for 15 days with fever before I was medically okayed for discharge (I’m allergic to most antibiotics)…& developed a wound infection too. I was in counseling for months, diagnosed with PTSD for the trauma of that experience. After 2 years, I felt healed enough emotionally that I was ready to give my daughter a sibling. Much better educated the second time around, we hired a doula to help us at our hospital birth. Unfortunately I was strep B positive and not in labor at 42 weeks, so again they induced, but thankfully at a more manageable level of Pitocin. We walked for miles around the maternity ward, but each time they did a cervical check (& of course I hadn’t progressed), my confidence would be shot. The impatient OB suggested a cesarean late that evening due to my lack of progression, but we told him we were not in a hurry and were committed to a VBAC. The next morning, I ecstatically delivered my son (26.5 hrs of labor), as happy about the VBAC as I was for his birth, I’ll admit! I felt such a sense of victory! But I’ll never forget how those cervical checks made me feel during both birth experiences, not only physically, but eroded my confidence in my body, my confidence as a woman. I so wish I had seen your post 10 years ago… thank you so much for sharing with those who are pregnant today!
After laboring all day on no sleep, being told was 5cm at the hopital was devastating. I cried, I considered drugs, cried again believing I’d surely beg for drugs I did not truely want before I finished dialating, and worked myself into a panic calculating the hours it had taken to dialate halfway to predict when my work would be done. All that mental/emotional drama and I birthed my son less than 30min after that cervical check. Yeah, its funny now…
I have 8 dc, 6 born at home. I believed I was broken for the longest time. It wasn’t till I read Power Birth that I realized what my body was doing was absolutely RIGHT. Great article. thank you for sharing it so articulately.
I think I’ve already commented on this article, but I LOVE IT and have cross-posted it with my own comments. Thanks for talking on this subject!
http://birthingathome.blogspot.com/2010/02/sacred-cow-of-modern-pregnancy-care.html
I loved this post because I really believe it. My ob’s office routinely started doing internal exams at 36 weeks, which I declined, much to my mother’s dismay. I had a great pregnancy- never felt any contractions until I went into labor on my due date, much to my surprise. She was born 5 hours later- the only cervical check I had was upon my arrival at the hospital which really was just a glance confirming that I was pushing her out! The surprise was so much better than trying to guess how much longer I would be pregnant
You rock! This is one of the most awesome things I have ever read! I’ll be sure to come back and read it again once I get antsy about baby getting here and doubt my decision to refuse internal exams (I’m 30 weeks right now).
Thank you for posting this phenomenal article! In my case, EVERY single unwanted intervention that ultimately led to one very unwanted, unnecessary cesarean, was precipitated by cervical checks for dilation. I have written a blog about it and plan on editing it to include a link to yours. http://www.mybestbirth.com/profiles/blogs/avoid-the-cascade-of
My midwife checked me twice during my labor and never prenatally. The first time it was because I felt “stuck” for a couple hours, and apparently I was as I had gone from 6 cm back to 4 cm. Then later when I was involuntarily pushing, I didn’t believe it could be time for the baby to come so I asked her to check. The baby’s head was in the birth canal.
When those two checks were done, I was not ashamed or uncomfortable as I have been in the past during OB checks at the doctor’s office. I had transferred to my midwife’s care at 20 weeks and fully anticipated internal exams, until she told me they weren’t necessary and I researched them better.
It’s amazing what women think is necessary for them to have a baby!
I thought nobody would ever say this.
The first time they told us in Lamaze class that you must never push before the doctor checks you and tells you you are 10 cms, I wondered, how did babies get born when women just had them at home? Wouldn’t the woman know when to push them out? I also wondered how everyone could dilate to exactly ten when people and babies and babies heads were different sizes.
I wound up having my fourth through my eighth with nary a cervical check in labor…and my ninth with one just because I felt something when I went to the bathroom and wanted to know what it was so I asked the nurse midwife (yes I finally got a CNM, but she had been a direct entry midwife before that)
to check me and I was at 7 and it was the bag of water bulging. I was relieved chiefly because I was afraid until then that she didn’t believe I was in labor.
What a crazy tyranny of numbers!
I think that much more must be going on than a circle opening getting larger in a mechanical way.
Tissues are softening. Babies are moving down and wiggling their heads into better position. Probably a midwife could think of a slew of others. The cervical dilation numbers involve imposing a very simplified mechanical model of birth on a much more complex natural process. The doctors even have charts and rules; you have to dilate so many cms per hour, or else!
Your baby will be born. You need never, EVER, know how many centimeters your cervix is dilated!
Hooray! Thank you again.
Susan Peterson
So glad i read this one…thanks for being so empowering!
I am a midwife for the past 33 1/2 years & I rarely do vaginal exams anymore. I can tell by the way she moves & the sounds she makes where she is in labor. I occasionally have to hold up a cervical lip, but women don’t complain about that. The thing is my students are not learning how to do vaginal exams either, but they learn how to read women too. How exciting is that ladies!
Great article! It is so refreshing to see a health professional advocating that women should trust their bodies. Childbirth is such a natural and wonderful experience and I feel it is diminished by unnecessary medical interventions. Thank you, I now feel so much more confident with the choices I have made.
“I’ve never seen little grunty pushes swell a cervix.”
I *have* seen this happen, where a woman is pushing gently, gruntlingly, and then I check her and she is swollen up like a donut where before she was paper thin. It has always (so far) ended in c-section. I do wonder, though, when it happens, if the swelling is not a result of the little pushes, but of the underlying problem that is preventing birth.
Thanks for your information. This article is very useful for my wife because she is pregnant. But if you ask me, women do not need to do a cervical exam unless there is something wrong in her body.
I’m so glad I surfed and found your site. Thanks for the inspiration, you’ve helped me out a lot.
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[...] midwife’s blog post Cervical Exams: Who Needs Them? rants in more detail on the [...]
[...] and barely 50% effaced. She was disappointed, I know…but (and this makes me laugh) had read my blog post on internal examinations and knew that she shouldn’t put too much stock into [...]
[...] appointment with Carina, her midwife. Carina checked her cervix. (Oh, I am getting mighty tired of unnecessary prelabor cervical checks.) She was still 0 cm dilated, but had effaced a lot, and her cervix was farther down — which [...]
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