CERVICAL EXAMS: WHO NEEDS THEM?

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 youinternalexam 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?

8 Comments

  1. Fifi wrote:

    thanks for this post – Im 41 weeks, with baby number 2, just come back from the docs and been told nothing is happening – its very disappointing indeed, but your post cheered me up immensely!

    Thursday, May 16, 2013 at 9:14 pm | Permalink
  2. FTMOMMY wrote:

    My Dr said he wanted to do cervix checks starting at 35 weeks because if I was dialating, it would mean I need to stay off my feet, whereas if I wasn’t dialating I would need to walk around more. Doesn’t make sense to me though…baby is gonna come when baby is good and ready. Why would he tell me that?

    Wednesday, June 19, 2013 at 1:11 am | Permalink
  3. Crissie wrote:

    You say you have had women devastated after hearing the results of pelvic exams? Don’t you discuss ahead of time that primiparous women will usually be closed longer and multiparous women may dilate sooner? Preparing the woman for the correct expectation of what happens commonly helps her accept the lack of dilation or the early dilation that usually is found on exam. Most HCPs will explain to primiparous women not to expect much, and when examined and found to be closed or 1 cm, no one is devastated. So have you not prepared women for appropriate expectations that you blog how women you have cared for in the past? It is an easy fix. Just talk to your clients ahead of your exam and the won’t be let down. And you won’t miss any breeches either. Too many patients arrive in labor at hospitals after laboring with no exams done and are found to be breech. Oops.

    Wednesday, July 10, 2013 at 11:43 pm | Permalink
  4. Janel wrote:

    Thank you! I was checked today and I didn’t feel right about it for some reason. I really do feel violated, I bled and had cramps after and the Dr. said I’m 1 cm and he touched the top of my babies head. I hope it doesn’t affect my baby! I’m only 35 weeks and I won’t have it done again thanks to you!
    Sincerely,
    Irritated

    Friday, August 9, 2013 at 1:54 am | Permalink
  5. Tamara wrote:

    I agree with Chrissie. I feel like there is generally some need for cervical exams(preterm labor patients, incase baby turns breech at the end, determine pelvic bone structure) Also, people really do have different pain thresholds and it would seem almost impossible to determine what each individuals actually is. I know that I didn’t know that I would be able to handle contractions as well as I did. Mine were not bad. I didn’t have the jerk reactions and facial grimaces and grunting that lots of women have(that mid-wives may look for). I agree that many times it works, but not always. Isn’t it smarter to err on the side of caution when there is relatively little risk involved in the exams? Unless the patient personally feels uncomfortable, then that is another story all together. Educating the patient beforehand about how dilation and effacement may or may not play into the onset of labor is key. That is what I think the main issue with this situation is, not the exams themselves. I know I preferred to know with the kind of profession I had (standing/walking ALL day) if it was affecting my cervix too early. For some women active jobs like that can put stress on the body and pull them into pre-term labor category. I wanted to know if I was subject to that as to avoid pre-term labor, thus avoiding a higher chance of CS. In my case, having the exam made me feel safe to know I could still continue working at the level that I was used to working. Listening to your body is important, yes, but sometimes the mind has a way of tricking us into thinking we can do anything we did pre-pregnancy. I think that there is something to be said about trusting your physician or mid-wife. If you trust them, then let them do what they feel is best for you and baby…whether than be cervical exam or no exam. I think the same fear you are placing on the exam you are now placing on women who still want the exam. There is no scientific evidence that points to the exam being dangerous for mom and baby. It’s truly a personal choice. I feel like making a negative connection between the two is not necessary. It’s good that you feel so strongly about something that is very important to pregnant women everywhere, but women who come across this site are going to doubt physicians they entirely trusted beforehand. This will make their visits more stressful for both doctor and patient. It’s better to have an open mind about this particular matter. I think a much better way to approach this sensitive subject is to tell your patients why you don’t personally do them, but keep that information between you and your patient. Let them decide based on your history and education if you’re the right fit for them instead of blasting all physicians who still deem the exams very useful. I feel like if they caused more harm than good that the majority of physicians would no longer implement them. This is just my opinion.

    Monday, August 19, 2013 at 11:00 pm | Permalink
  6. Joan wrote:

    My midwives arrived after I started pushing. I wish I had put in my birth plan not to be internally checked because it was very obvious the baby was coming and it was very painful to lie down and have her check me. It took 8 cycles of pushing to lie down and get back up when I could have been in the pool. That is my only regret from my birth.

    Friday, October 18, 2013 at 11:02 pm | Permalink
  7. Annette wrote:

    This is a great article. Thank you! I don’t understand why a digital cervical exam that is painful and can stall labor is the standard procedure. Studies like these shown that visual exam is as accurate and would not be painful. Why has this information not made it into clinical practice when it would save so many women from a painful procedure? http://www.ncbi.nlm.nih.gov/pubmed/16147828
    http://www.ncbi.nlm.nih.gov/pubmed/8423953

    Monday, February 16, 2015 at 11:42 am | Permalink
  8. Sarah s wrote:

    Just stumbled upon this.
    It was important i had internal cervical assessments during my pregnancy as i was high risk for preterm birth due to an incompetent cervix. I had some painful contractions at 29 weeks and my cervix was regularly checked for dilation then. I made it up to 4cm until the dilation was stopped with medical intervention. My ob happened to suspect cervical issues during my pregnancy from an internal exam, which prompted him to order an endovaginal ultrasound to confirm his suspicions. Internal exams are absolutely useful during pregnancy, but i agree not totally necessary when you are full term.

    Tuesday, January 12, 2016 at 4:01 pm | Permalink

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