Updated: Nov 4, 2022
How do you know if you are in labor? How can we tell if labor is progressing? How do we know when it's the right time to start pushing? If your answers to any of those involved "vaginal exam" or "cervical check", you are only catching the smallest aspect of determining labor progress.
We love sharing with our clients and online audience how little vaginal exams we perform in our homebirth practice- so it's almost a bit awkward to dedicate an entire post to them since we are actually dedicated to doing as little of them as possible. However, a huge aspect of birth culture in general includes a whole lot of vaginal exams, so it's exciting to share our midwifery perspective with you today.
We hope you are challenged to think about the variations of normal birth, and the empowering choices therein.
Here's the line-up of what's been packed into this norm-challenging post:
Protecting the Labor Space
The call of the homebirth midwife is to believe in, champion, and promote the physiological experience of labor. We understand how natural birth unfolds best on its own, we equip our clients with the tools they needs to embrace it, and we fiercely protect these principals. Not just for the best experience for birth (although that’s incredibly important), but the safest, most holistically beneficial experience for the mother-baby pair. We know that the way a birth unfolds affects the way a woman transitions into a mother, a couple into a family, and a family into a legacy.
As the gatekeepers of this normal yet profound life event, we maintain some distinguished attitudes about respecting this sacred space:
Birth happens in the primal brain. Birth loves dark and quiet spaces. When women are able to instinctually move about their environment we find them crouched alone in dimly lit bathrooms and closet corners, swaying to an internal beat, and using low vocalizations to traverse each surge. For more on this concept, grab our Free Birth Vision Worksheet HERE.
Because the primal brain is “on” during progressive labor, we work to keep the mother in that mental space and not cause too much frontal cortex activity (the area of the brain that is for higher order thinking and problem solving). We do this by limiting questions, not presenting too many decisions at once, and keeping side conversations to a minimum.
Birth works well in familiar and comfortable surroundings. Women do best with a limited amount of people attending, that respect and understand the intimacy of the experience. The support team should be knowledgeable about normal birth, slow to disturb the laboring woman, and demonstrating trust in her innate ability to birth her baby. Listen to more on this topic in our podcast episode Who to Invite to Your Birth, HERE.
In our practice about 90% of our clients give birth without ever having an exam. 5% have just 1 exam at some point in their labor. Read How to Cope with a Long Labor HERE to get an inside look on how we view and manage lengthy births. The point of sharing this is not to put any type of labor choice on a pedestal, but to demonstrate the truth that most of the time these exams are not needed... or desired. What a contrast to the medical model where they occur 99% of the time and language such as “required” swiftly takes the place of informed consent. There are, however, times in our own practice when cervical checks are incredibly useful tools. You’ll see some of those benefits listed below.
What is a Vaginal Exam?
A vaginal exam can seem so centric to dilation of the cervix, but so much more can be measured. The cervix is the opening of the uterus. It has a "neck" that extends down into the vagina. The cervix is a very dynamic part of reproductive health- changing each day of your non-pregnant menstrual cycle, and going through the greatest transition of all during labor when it opens large enough to help your baby pass through it to be born. Check out everything that can be discovered in a vaginal exam:
The Dilation of the Cervix:
The provider makes an estimate with their gloved fingers of how open the cervix is. The opening of the cervix is located, fingers are placed inside the opening and spread apart to determine how wide the fingers become before meeting the resistance of the opening. The cervix can be measured at the inside of the cervix from 0-7 centimeters or so. After 7-8 centimeters the cervix is measured on the outside of the opening for how much of it is left in the vagina. These measurement are fairly subjective, because each provider has a slightly different assessment of how open the cervix is, but good training and practice should land us all within the same 1-2 cm or so.
Position if the Cervix:
As a mechanism of protection, the cervix tilts itself to the very back of the vagina in pregnancy and sometimes remains in this position in the beginning of labor. The cervix can begin to open when it is in the posterior (back) position, but it absolutely must move forward in the vagina to finish progressing labor. The angle of the cervix changes up to 45 degrees as it moves to the anterior (forward position) and "points" towards the vagina opening to let baby through at birth.
Softening of the Cervix:
Hormones that prepare the body for labor are responsible for softening the cervix (and so much else) so that it can more easily spread and move out of the baby's way. The cervix starts out firm and goes through a bit of a "melting" as labor progresses. The firm cervix feels like the end of your nose. A softening cervix feels like the end of your chin. A completely softened cervix feels like the middle of your cheek, sometimes it can be hard to find when it's this soft because it feels like all the other soft tissue inside the vagina.
Effacement/Shortening of the Cervix:
The neck of the cervix is long and closed during pregnancy to protect the growing baby inside. Towards the end of pregnancy and the beginning of labor, the cervix shortens 3-4 centimeters before it begins to dilate and open. One way to visualize this is thinking about the shape and size of a glass beer bottle neck (as the starting point), and then a wide mouth pickle jar neck (as the ending point). When we measure this during a vaginal exam we note effacement as a percentage. 0% would indicate about 3cm of length, and 100% would indicate a very thin cervix, something we call "paper thin" that is akin to the skin webbing between your fingers.
Baby’s Depth in the Pelvis:
As contractions work to open the cervix (squeezing the muscle fibers of the uterus up to make an opening), the strength of them also push baby down to assist in progressing the cervix during labor. The baby's head moves through the pelvis in what we call "stations", -5 to +5. We feel the top of the baby's head in relation to the pelvic landmark. -5 is floating above the pelvic brim. 0 station is at mid-pelvis or ischial spines. +5 is at the sit bones, or essentially crowning. The station can be felt with a dilated or closed cervix- it's the only hard round thing to feel in the pelvis.
Baby’s Position and Presentation
As we feel the baby's head depth and station, if the cervix is forward and open enough (6cm+) and baby is at 0 station or lower, we are also able to notice the degree and position of the baby's head. The soft skull bones of the baby mold and overlap to be accommodated in the birth canal. A provider's fingers can often map out certain landmarks (fontanelles and suture lines) to make a guess about how baby is coming into the pelvis. We can also feel caput, or the normal temporary swelling that happens when baby's head has sustained pressure in the birth canal for many hours- also known as newborn cone head. This can alert us to positional issues with the baby and give us some insight into why labor may be extra challenging.
Effect of Contraction on Cervical Tissue + Pelvic Floor
If a provider has permission to continue the exam while a contraction happens, the effect of the surge can provide information about the labor as well. We can feel how the cervix stretches and opens with the force of the surge, how much pressure comes down with the head and how baby is moving under the force, and any certain tensions or anatomical obstacles to continued opening. This type of exam can be helpful for some women during the pushing phase if she desires coaching for effectual pushing efforts.
Presentation of Bag of Water
With enough dilation present (4cm+) we can feel if the amniotic sac is still intact and how it is presenting through the cervix. If the bag get's tight during a contraction it can give us an idea of the strength of the surges. A bulging bag lets us know that amniotic fluid in the sac is the dilating part on the cervix instead of the baby's head, and when the water breaks it may cause the cervix to slightly close if the head does not come down right after.
Pros + Cons of a Vaginal Exam
If so much (see above) can be determined with a vaginal exam, why wouldn't women want this information throughout their entire labor? Like all things midwifery, we apply informed consent to every procedure. We present the options to our clients with the known benefits, risks, and alternatives beforehand - providing privacy and time to discuss, and then make a decision. Get a sneak peek into that conversation with us right here:
Pros of a Vaginal Exam
Can be useful to collect a lot of information about what is happening inside the woman's body in the current moment
Can help to make an important decision about a labor intervention, or determine the effectiveness of an already-applied intervention
Can assist in assessing labor progress in one objective and measurable way
Can be empowering for the woman to ask for one when she wants it
Can temper expectations or provide encouragement for the labor left to accomplish
Cons of a Vaginal Exam
Can take women out of their primal brain where the most labor progress usually happens, and causes her to process with her logic and analytic brain
Is an invasive and internal procedure that can cause a disruption physically and emotionally
There is an increased risk of infection and accidental rupture of membranes
It is only one way of measuring labor progress
It relies on someone outside the woman to communicate information about what she is experiencing
Can cause overwhelming disappointment in not being further along in labor
Informed Consent for Choosing a Vaginal Exam
There are some important questions to ask yourself and communicate with your team when you are facing the decision for a vaginal exam. It may not always be presented to you as a choice, but you are *always* in charge of what happens in and to you during birth, and the type of help you desire from your provider. Sometimes we have clients who ask for an exam, and while she will *always* get what she wants, we ask a few key questions to help her decide if the information is what she really needs, or potentially some other kind of reassurance and encouragement. Consider the following thoughts as you navigate the option yourself:
What information will the exam give you? Has your provider shared the benefits and possible limitations of the exam?
What do you plan to do with the information?
Do you want to know the results of the exam, or ask for it to be phrased in less objective terms (i.e.- "there is more work to do", "you are close to the end" etc.), or would you prefer someone else (partner or doula) to know the results for you and adjust the support plan accordingly (i.e.- more rest or activity) ?
How will you react if you aren’t as far as you were hoping? How can you adjust expectation if you are disappointed?
If you do not consent to the exam now, what options for future exams are possible?
Assessing Labor Progress without a Vaginal Exam
Ok ladies, you made it to my favorite part of this post! If we do such minimal vaginal exams as homebirth midwives, and are certain they are not needed in the majority of labors, how do we know what kind of progress is happening for a laboring woman without them?! There are SO many variations of labor progress. Learn more about this in particular in our post What to Do During Early Labor HERE. Although even we have been wrong about what we think we are noticing at times, spend some time around undisturbed birth and you will pick up on some nearly-universal hallmarks of the process. (Always exceptions to these concepts, but they are true enough for the huge majority of laboring women).
Contractions get closer together in frequency, longer in length and stronger. An active labor pattern is typically 60 second long surges, coming every 3-4 minutes, regularly for 2-3 hours.
As the strength of the contraction increases, so does a woman's coping capacity. She responds to the intensity with increased breathing patterns and more vocalizations, like moaning or humming.
The emotional signposts of labor are often the most reliable signs of progress.
In active labor the woman is not able to walk or talk through her surges anymore, as she concentrates hard on the work of each one. When the contraction is over she can move and chat more freely again.
Nearing transition, the woman is concentrating seriously on both her work and her rest. She may not want to move or talk in between her surges anymore, but require concentration during her breaks to gather strength for the next one. (Ps. This is a great stage for reviewing positive affirmations- you can get some ideas from some of our favorites HERE, in our Free Birth + Postpartum Affirmation Cards.)
Other signs of transitional labor are the experience of being suddenly hot or cold- asking for a fan with a sudden hot flash or a blanket around the shoulders with chills. Women may start to share their doubt and uncertainty in their ability to finish the work and need new reassurances and reminders she can do it, and she is safe.
Water breaking is another sign of progress, especially when all the above is happening or in the works. 85-90% of women's amniotic sac break at the end of labor. (Check out THIS post on all the deets surrounding water breaking).
An increase in pressure is announced by the woman as her baby moves down and onto her pelvic floor. Often the woman is certain she has to have a bowel movement, only to discover it's just the pressure of baby's head pressing on the rectum (which is a good thing!). The pressure may start out at the peak of each contraction, and continue to increase until it's felt all the way through surges and their breaks.
The woman begins bearing down as she works with the pressure, or it can happen involuntarily as an automatic reflex. We can hear her breath catching during the peak of a surge, and an increase in grunting and straining noises as she works to push her baby down.
During the pushing stage we can notice the perineum getting round and full from the outside as the baby comes down, then labia parting and bulging as the head moves the tissue. Women often report a burning when the tissue near the vaginal entrance is stretching taut.
Pre-pushing Dilation Checks
"But midwives," you may be wondering, "what about checking the cervix before pushing to make sure it's completely out of the way?" This is included in our previous statements that vaginal exams are not necessary to assure there is a certain type of progress happening. The vast majority of women who are free to labor without interventions and disturbances are going to progress seamlessly from finishing cervical dilation to pushing their baby down.
Here is something that may blow your mind- not all physiological pushing phases begin right as the cervix is fully open. Many first time moms dilate completely to 10cm and then take a few more hours before baby is low enough to trigger the desire to begin pushing. Many second + time moms begin pushing before the cervix is fully open and it dilates completely as she moved her baby down. 10 centimeters does not indicated that it is time to push!
What About Premature Urges to Push?
Pushing well before the cervix has finished opening can cause cervical swelling and damage that may complicate or delay the final stage of labor. We rely on our intuition and observance of the labor so far to determine if it is likely to be the right time for pushing. It can also be an indicator that baby's position is non-ideal and encourage more investigating. If pushing seems out of place with the other signs of labor we have observed, we may ask women to describe a bit more of their sensations. Issues with the cervix are more likely to occur when the woman is applying her own effort before complete dilation, but spontaneous bearing down is involuntary and impossible for the woman to control.
We may offer an exam at this point to collect more information to help her, women typically sense something is off and ask for one themselves. Alternatively, we may simply suggest positions that relieve the intensity of her pushing urges, like side-lying or hands and knees. You won't find us asking her to fight her body's own urges, but discovering ways to let the uterus work without her voluntary efforts being added.
What About a Cervical Lip?
A cervical lip occurs when the cervix dilates unevenly, and may be completely open in 70-80% of the cervix, but have some work to finish, usually at the front or "anterior" near the pubic bone. This is a normal variation of labor that does not always require an intervention.
The cervical lip presents this way most often when women are in a position that puts pressure on their sacrum (lying back). The lip can become trapped between the pubic bone and the baby's head, preventing the baby from moving down fully into the birth canal when the mother has a strong urge to push. It may happen more often than we even realize, because we do not routinely check the cervix- but women may move instinctually into a position that allows it to self-resolve.
If we have not done a vaginal exam to diagnose this issue, the situations that need more intervention usually becomes obvious as the woman is pushing and reporting pain near her pubic bone. She will also very characteristically be trying to get up and away from her abdomen as she is pushing, arching her back and throwing her hands behind her, while appearing to be in discomfort. We are not usually at a risk of missing this, and can offer an exam when this is noted to help the cervix move. Changing positions to leaning forward usually resolved the cervical lip on its own, but we can also place pressure to it with our fingers while the mother pushes and reduce the cervix back over the pubic bone during a small handful of contractions.
What About Cervical Swelling?
Swelling of the cervix is most likely to occur when circulation to the pelvic tissue is poor, like during increased pressure with pushing too soon or very decreased maternal movement in labor. The latter is hardly ever the case in natural birth at home, since the woman will instinctually move her body quite frequently as she works with the physical sensation of labor. In addition to the norm we see in physiological birth, the swollen cervix is hardly ever noted except with premature urges to push.
Sometimes cervical swelling can be an indicator of positional problems of the baby (especially if the presenting part is putting pressure on the cervix or sacrum unevenly) and we may take time to diagnose that and offer some supportive options to influence better positioning. In other cases, we want to get the pressure off the cervix by changing positions to hands and knees or side-lying. We may begin an oral homeopathic protocol of arnica, or place arnica and evening primrose oil on the cervix. Although uncomfortable for the woman, we can also massage the fluid out of the cervix with our fingers or place an ice-packed glove directly on the swollen cervix.
Prenatal Dilation Checks:
You have picked up by now that we find very little use for vaginal exams in labor, and are adamant that they should not be used routinely. We are even stronger proponents of avoiding routine prenatal pelvic exams and are utterly boggled how they remain so commonplace in medical care. Vaginal exams have ZERO evidence in determining or supporting any type of certain positive outcome for low risk pregnant women. The only time this information may be moderately useful at the end of pregnancy is when a medical induction is indicated (no longer low risk) and the exam can help determine which course of action for medication or procedures is needed for a woman.
Beginning at 36 or 37 weeks, during the weekly prenatal check-up, the OB (or the midwife) may offer a vaginal exam. "Offer" is a generous term for the more likely communication that "this is what is happening now" reality of the how the visit is directed. The purpose of the exam is to determine if your cervix is changing in any way that may indicate labor is near. Think about it; if that was remotely possible, wouldn't we have so much more figured out about birth?
What we do know is that your cervix can not, and will not predict the future. It utterly refuses to in its very nature, and she will not be bossed around, either. Your cervix can be completely closed, long, hard and posterior and you can have a baby in your arms that evening. Your cervix can be 6 cm open, open and soft with a very low baby and not go into labor for weeks. The mechanism of labor initiation is not at all determined by what your cervix is doing. The way your cervix changes, before or during labor, is not linear.
But, what if you want one? Your curiosity is insatiable and you just gotta know what is happening in there. You can utilize the Informed Consent section above to discuss your options with your care provider. I will admit that a couple of times in our own homebirth practice we have offered them to women who have had a lot of start-and-stop contraction to determine if any of that rather frustrating work was making any cervical change- as a means to make a support plan for them to either encourage labor or encourage patience. We still would maintain the concept that labor progress is best determined by external means, and emotional support for our clients in this situation is paramount to all the other offerings.
3 Foundations to a Natural Birth Plan (Instant Download)
There are many, many ways to go about planning for a natural birth. Surely you have heard countless stories from friends, family, and online forums about the natural birth they wanted and planned for but did not get. You know your body was meant to birth, but what strategies increase your chances for the type of experience you want to have?
The main keys to a physiological labor lie in the choices, education, and communication needed to simplify your natural birth plan.
Birth is big but your body already knows what to do! Find out exactly how to support this innate ability with our midwife-vetted essentials. Download our newest (and FREE) birth resource:
3 Foundations to a Natural Birth Plan HERE. Here's what's included:
Learn what you have control over in planning for birth, and harness your decision-making power as you get ready.
Discover the best ways to prepare your body and mind for the intensity of labor so that you can work with the natural process instead of against it.
Understand how to confidently communicate your plans with your birth team to make your birthing day smooth and supported.
After supporting hundreds of births as doulas and midwives, inside all types of settings and outcomes, we learned the secrets to a personalized approach to birth. Let us help you get connected to the options that match your desires.