The “C” Word: What’s up with cervical exams during birth?

I don’t mean the “C” word you’re probably thinking of.

For me, the dreaded “C” stands for the first word in “Cervical Exam”. I’m going to be completely honest and opinionated about this. I really dislike cervical exams during birth.

Watching a birthing woman get out of her rhythm and onto her back so her health practitioner can put gloved fingers inside of her to poke around at her cervix is on the very bottom of the list of things that make me happy.

And it’s not just because cervical exams are “kind of awkward”. They can cause a serious amount of discomfort in a birthing woman. Not only that, in my opinion, they seem unhelpful and counterproductive, giving little information for a birthing woman to work with and doing a lot of potential damage to her process.

I don’t know about you, but I’m  pretty picky about who I allow to put their fingers inside my vagina. I generally don’t let complete strangers do it, and I’ve NEVER let more than one person do it in one day.

If you’re birthing with a doctor, by the time you finish your stay in the hospital, you will potentially have had at least 3 people’s fingers up there at various stages: two or three nurses as shifts and breaks rotate through, and your doctor . If you’re at a teaching hospital such as BC Women’s, you can probably tack on a resident to the list as well. If you’re lucky, it will be your own doctor performing the exam at least one time. But only if he or she happens to be on call. The rest of the people putting their fingers in you will be people you have only just met, and they certainly won’t take you out to dinner first. Note: One advantage to choosing a registered midwife as your primary practitioner means she will be the only one examining you (unless she ends up consulting with an OB about your birth at some point) and you will have at least had a conversation with the woman beforehand. But even in that circumstance, I’m still not not happy.

So why do these complete strangers want to put their fingers all up in your goods in the first place?

Worrying that mom will push against a cervix that is not fully open:

Let’s explain what is going on with your brilliant cervix during birth. The cervix is the bottom portion of your uterus, which opens into the vagina.  The baby moves through the cervix, into the vagina and out into the big wide world.  Before your birthing time, your cervix is hard, long and closed. It feels like the tip of your nose. This is so the baby doesn’t just fall out before he or she is ready to live and breathe outside of mom’s body. During birth, the cervix softens, opens and shortens. It becomes as soft as your lips, and opens up from closed (0 cm diameter) to what we call “fully dilated” which is 10cm in diameter. The female body is pretty amazing.

The fear is that mom will start pushing before her cervix is fully dilated and nice and soft. Pushing against a hard cervix can cause the cervix to swell, and then one would be hooped because there would not be room for baby to come out. Or you may tear your cervix, which obviously we all are inclined to avoid. That just doesn’t sound awesome.

If we don’t do a cervical exam, how does a birth attendant know when mom is ready to push? Well, they don’t necessarily (although there a certainly some signs of dilation other than cervical exams). But mom does. Her body is pretty cool. At some point, she will slowly start to get what is called the urge to push. As her pressure waves continue to get longer, stronger and closer together, she’ll usually start to sound “pushy”, making deep throaty sounds with her waves.  The surges will start to take over her whole body as her uterus makes motions to push the baby further and further down. Eventually, mom will usually bear down a bit with each wave. She’ll do this naturally and gently, only as much as feels good to her with each wave. Ultimately, her body’s sensations will be so wonderfully intense that she will work with them. It will feel good to push, and she may not even realize she’s doing it! Baby’s head will be able to move around the pubic bone and out the vagina. Amazing.

Of course, if mom has had an epidural, she won’t be tuned in to her sensations, and she won’t get that urge to push. In this case, cervical exams are necessary to assess dilation, so that when the cervix hits 10cm a whole crew of cheerleaders: dad, nurse, midwife, doula can gather round the bed and scream “push, come on, keep it coming, you can do it, don’t stop, breathe in push again, you got it, push push push, hurry HARD” like some kind of curling team gone mad.

So, what about that fear that mom will push before her cervix is open fully? My personal belief is that mom, if left alone, will NOT push until her body is ready. Just like we don’t go sit on the toilet for 8 hours and push before our bodies tell us we will soon be having a bowel movement, and no one has to tell us to push when the time comes. Our bodies are made for this, and they know what they are doing. But if mom’s not confident in her body and wants some reassurance once she starts finding herself bearing down with her pressure waves, she certainly has the right to gently ease her own fingers inside herself and feel how open and soft she is. In the end, you’ll know she became fully dilated because a baby will come out.

But at the very, very least, if mom WANTS a medical professional to asses her dilation, why not wait until she starts to feel pushy? If mom is worried about pushing too soon, I can’t understand why you would want to start assessing her dilation hours before she even begins having the urge to push.

Why do they start doing cervical exams so early in the birth process?

Because hospitals are all about efficiency and management. They want a birth to progress at a certain rate. Once a woman is in the active phase of birthing (5cm of dilation and onward), they want to see her dilate at a rate of 1cm per hour. They perform vaginal exams so they can diagnose if birth is progressing too slowly for their standards, and if it is, they will recommend augmenting progress through an induction method such as rupturing her membranes or administering artificial oxytocin with an I.V.

It’s important to note that women are not baby factories, and giving birth is not simply about being efficient. Every woman’s body is different, and every birth will progress at a different rate. In fact, generally speaking, a slow birth can be a much more gentle experience on mom’s body.

The risks of cervical exams:

They interfere with mom’s rhythm

Women kind of go away during birth. They go into an altered state, becoming very inwardly focused, and this altered state allows the normal progression of birth to take place. Interrupting her, asking her to get onto her back (the most uncomfortable position to be in while birthing) and allow you to perform a vaginal exam while she is having pressure waves every 30 seconds interrupts this altered state, and it is difficult to get back into it.

They are uncomfortable and stressful

Vaginal exams are uncomfortable at the best of times, even when a non-pregnant woman simply has one done in her annual medical physical. During birth, women are very sensitive, and extremely uncomfortable being on their backs. The often extreme discomfort of a cervical exam can cause stress, and as I always say, stress is the enemy of birth. Stress hormones get released, and they actually physiologically inhibit the progression of birth. This has an evolutionary explanation: if a mammal in the wild was suddenly in danger, she would need to stop birthing so she could run away to safety.

They can throw off mom’s confidence somethin’ awful

This again relates to the huge role stress plays in inhibiting and slowing down birth. For example, one of my first hospital births turned quickly into a medical procedure when mom was given artificial oxytocin to bring on pressure waves after hers stopped completely. Why did they stop? Because after a cervical exam, the midwife sighed and said “It’s been two hours, and you’ve only progressed another half centimeter”.  Mom became scared she was going to be given artificial oxytocin, and through her prenatal education had learned how much more intense pressure waves are with that intervention. Her pressure waves stopped instantly because she became stressed, discouraged and disappointed to hear her body wasn’t performing up to par. It was amazing. Nothing highlights the truth about mind-body one-ness like birth. I really liked a recent article that explores this, called How Cervical Dilation Checks Undermine the Imaginal Power of Birthing Women.

Ultimately, what we are doing with vaginal exams is trying to make sure birth is progressing “fast enough”, while the very act of the vaginal exam has huge potential for slowing down birth! Not only that, it has the added risk of introducing bacteria with the potential of causing an infection with every single exam. It seems ridiculous to me.

Your rights when it comes to cervical exams

As with anything in our medical system, you always have the right to decline diagnostic techniques or medical treatments. It is very important that you give consent to a vaginal exam before it is performed. It is also important to know that if you make an informed choice to decline an exam or being examined by any particular person, it is absolutely your right to do so. That being said, care providers have their own philosophy and reasons for wanting to do cervical exams.  If you feel more comfortable and confident having your medical professional assess your cervical dilation regularly, that’s fine too.

But just know it’s your choice.  This should go with out saying, but it is always up to you to decide who you let put what in your vagina, whether they are wearing scrubs and a white lab coat or not.

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