The case for and against vaginal examination in labour

[verylittlecarrot]

I'm considering declining VEs in labour, as it seems to me that the information they provide (2cm? 5cm?) is of no benefit to ME as the labouring mother. In fact, last time they were extremely demoralising and pretty much precipitated a big meltdown to be told I wasn't progressing, where previously I'd been coping quite well. My MW has only really managed to articulate the benefit to her, as in, "I'll know whether you're really in labour or not" (aka as I can justify buggering off for a while).

From what I've read, the 'purple line' is quite a good indication of dilatation, and there are various other signs of progression of labour.

Besides, what can one DO with the info? 2cm to 10 cm can take 2 hours in one woman, but 3 days in another, so how can any meaningful decisions be reached on that basis alone?

The only thing that concerns me is the whole 'pushing too early' scenario, when there may still be a cervical lip. (check out the MN official useful info on this topic!) Does this happen often? Are our bodies so badly designed that we feel the natural urge to push before it is safe, and need to resist our own instincts? My common sense questions this idea that women need some external third party to tell them when they can and can't push, and give them permission. I'd have thought that evolution kinda took care of that instinct properly.

But I'm open-minded, and want to hear the case for and against VEs. Do you reckon they are yet another intervention that, actually, are rather unnecessary, or do they provide vital info that we can't do without?

I didn't have one. Your body knows when it's ready to push, you feel like you want to shit a house brick. There's no need IME.

due to "issues" I had at the time I requested minimal VE's during labour with DS3. I was examined when I first got there - but not again.

I felt ready to push, and the MW could apparently tell I was ready as well (never did establish how). However I had no pain relief other than G&A with it.

I suspect if you have an epidural then there may be more need for it as I think (stand to be corrected) that it reduces your ability to feel when to push as well.

i was totally exhausted and they kept telling me i wasn't in established labour. in the end (after walking the hospital for 14 hours) i asked if they could give me something to help me rest, so that i could save my strength for 'later' in labour. eventually they said, ok, yeah, but then said, 'oh, we'd better check how far along you are before we give you this'. i was 9 cms. just because i'm not screaming, and am still walking, doesn't mean i'm not in established labour, people...

so, i'd say, depends how you labour, really. sometimes it's worth it just to get them to believe you are actually going to have a baby, like, imminently... suddenly they took me a whole lot more seriously. gah.

i would also add with dd2 (above instance from ds1) that the ve literally saved her life. the midwife did a final check to establish i was fully dilated, and realised that dd2's head was cool to the touch, so she immediately crashed the paeds, and shouted for the supervisor to prep the ventouse and help her get the baby out asap.

dd2 spent 5 weeks in scbu, and i have no doubt that the midwife saved her life.

Interested - what is the purple line?

I believe it's a red/purple line that starts at your anus and creeps up the bottom's crack (natal cleft?) steadily as you dilate, and that it corresponds very well to how dilated you are, but is of course external and therfore easily checked. My doula last time told me I had a lovely purple line when I was fully dilated! But by then I had transferred into hospital and had every intervention going, including an epidural, so had no idea what a natural progression felt like any more.

madwoman, that must have been terrifying with your dd. What happened to cause her to be poorly?

verylittlecarrot, does this purple line thing mean they check your arse regularly?
(This potentially scares me as much as a vag exam, so any clarifcation would be helpful for me!) Thanks.x

I was sure I did not want any. I was worried sick about them. However the midwife I had at the start was very kind and I let her do it. She then came back later to check on me and do another one and she said I was getting on fine but something did not feel right.

I went to the delivery suite and they scanned me after hearing this info and discovered ds was breech and decided to get him out asap.

I dont know what would have happened if I had left it.

belle that is simply not true. Many women get the urge to push before they reach 10 cms, which can make the cervix swollen and therefore not dilate fully to 10cm (either with a lip or just stuck at whatever cm).

My recent horrendous labour, I was feeling the urge to push at 5cms. My cervix did become swollen and I didnt dilate further although this was not as a result of pushing.

I agree that when you get to 10cm that 'urge' to push is different but I do think VE's are important.
However I was examined about 20 times prior to my labour actually staring which didnt help.

I do find this mentality that any medical intervention is a bad thing and that our bodies do things 'naturally' , yes sometimes they do (I had two normal deliveries no intervention) and sometimes they dont (3rd birth was long, painful, epidural and emcs).
Im sure there are many women on here who can testify that if it hadnt been for monitoring or intervention then they wouldnt have their babies with them today and I am sort of along that line of thinking

My first labour I managed with just G&A and had regular VE's - I had a cervical lip at 10cms and remember it being nigh on impossible not to push by then, but I did manage to wait til it had gone, really didnt want to end up with anymore intervention than Id had already because Id made my cervix swell by pushing on it. Second time, I had an epidural, the only VE I had was at 5cm when I requested it to make sure I was far enough along. I then promptly fell asleep and midwife woke me up when my daughters hair was visible, a couple of pushes later, she was born, much better but every labour is different I guess and it depends on what assistance you want or will need.

Necessary with me, I didn't get the urge to push. I clearly remember lying on the bed and saying to the midwife 'would you mind just checking that I'm at 10cm before I start to push this baby out'!!

I agree it's demoralising though when after several hours of pain and contractions you are still at the same amount of dilation.

carrot - the jury is still out on that... we know she suffered from hypoxia during labour, (from the mri scan results) but not what caused it. presumably somewhere along the line the cord was squashed resulting in poor flow. she did have the cord round her neck, but it looped off v easily (in the middle of the panic) and a short period of shoulder dystocia (one push long lol, between us we did manage to break her clavicle, which wasn't discovered for 3 days because they were understandably prioritising her other needs (oxygen, suctioning and anti-sz meds lol) but there is (according to the lengthy list of medical professionals) no definitive explanation as to what caused the hypoxia...

but i do beleive the midwife's actions at that point saved her life. which is a bit weird, as i suspect that with a bit more (ie some) monitoring, they might have noticed her deterioration earlier, and she might not be currently going through 'mummy, i wish i wasn't disabled'. but all that not entirely relevant to this thread (sorry!)

am def proponent of ve but for obvious reasons probably tend towards more medicalisation of labour than usual on mn lol.

verylittlecarrot, if you're worried about being demoralised by being told you're not progressing you could ask them not to tell you the result of their VE. Just put it on your birth plan that you only want to hear the amount of dilation when you're close or ready to push - they can still make the checks and you would have the advantages of them possibly finding early problems without the negative mind game of trying to deal with hours passing and only hearing 1cm progression has been made?

ahhh - that purple line must be how the MW knew - I spent the last part of my labour on my knees leaning over the back of the bed - arse in air.........I posted a photo on MN (of DS3 being born) of my arse and some of the doula's and MW's got very excited about "the line",

Some really interesting replies here, thanks! Mosschops, I followed some of your recent horrendous experiences, I do hope things are getting better for you. I'm not against all interventions - only 'unnecessary interventions' of which I believe there are truly quite a lot, but it is very hard to establish the difference between the two, I admit. I think in most cases, but not all, nature does kind of get it right, and the remainder definitely benefit from medical intervention, but I genuinely believe that intervention happens when it isn't needed, and actually causes the problems which it then takes credit for resolving, IYSWIM?

On this thread there have been a couple of examples which have intrigued (and scared!) me, but I wonder whether the VE was in fact a secondary check which picked up a problem which should have been diagnosed earlier in the labour by a primary, less intrusive method; ie, competent and early palpation to diagnose breech presentation, or as madwoman suggests, more (some) monitoring to detect FHR deterioration? What would an experienced midwife conclude? I don't know.

As for your experience of wanting to push too early, as I mentioned, this is something that bothers me. It clearly happens that nature sometimes stuffs up and hands you an urge which is completely unhelpful. I want (for my own selfish sake) to believe that you were an exception, and incredibly unlucky, but I don't have the evidence to back that up! I wonder how common your experience is?

Ladybee, it's not just the metal torture of being slow to progress I want to avoid, though. I know that many experienced MWs now believe that VEs are not just uncomfortable and even distressing physically, with an increased risk of infection, but also unneccessary and misleading, in fact even disruptive to the natural progression of labour, and so they no longer recommend them if labour appears to be progressing normally. That approach is at odds with convention at the moment, and I'd like to hear more justification I suppose, that it is safe to forgo VEs because other observations will cover possible risk situations.

Thank you for sharing your experiences!

Being Group B step positive I had no VE in my birth plan. I was fortunate enough to have a quick labour (2nd one) and my body just got on with it. Midwives were happy to be hands off, though I do remember getting pissed off with them just trying to listen to the babies heartbeat, just as well they didn't try feeling me up too.

I found that the frequent VEs in my first labour were painful and made me feel really tense and scared. After hours of painful contractions I was still at 2cm and getting seriously frustrated. After a shot of pethidine I dilated to 10cm in 5 minutes flat!

Second time round I put in my plan that I didn't want any unless absolutely necessary. My MW was fantastic - when she arrived at our house I said "I suppose I have to get out the pool so you can examine me" and she laughed out loud "Why would I do that? Anybody can see you're in labour. Just carry on!" The only time she touched me was to check the baby's heartbeat.

My personal feeling is that VEs are intrusive and pointless and they can increase the risk of premature rupture of the waters and infection. IME the amount I'd dilated was no indication of how far I was progressing so why bother?

i found VEs incredibly painful. but from what i recall it was those examinations that they realised ds wasn't going to come out without assistance.

I had one in dd's birth at a mw led birth centre at about 4cm

ds was delivered by paramedics so i had none

Nobody ever checked i was 10cm and i never asked when i could push, i just told them to come (from outside room with dd and in ambulance with ds) as i was already pushing

so imo in a strightforward birth its unecessary but if you have any probs can be very helpful, so i wouldnt have them as 'routine' but only if mw needed extra info

i am not sufficiently knowledgeable to comment on the pros and cons of VE's

I do, however, know 2 independent midwives who I greatly admire and who are both incredibly good at their jobs.
Neither of them feel that VE's are necessary and on a discussion on another online forum did talk at length on how they check progression without using them,

I would trust either of them implicitly withj mine and my baby's life.

I had ONE when I had ds2 which was when the midwife came to examine me to see how far I was (homebirth) and if she needed to call the second midwife.
she KNEW i was ready to push almost before I did simply because of my behaviour and the noise I was making, twas amazing

I was set to refuse them at all with ds3, and as it was I had none anyway because he was born before the midwives arrived lol

do you have a link to that discussion please, thisisyesterday? I'd like to be better informed about the other signs of progression.

i will see if i can find it, the forum it was on is one you need to pay a subscription to, but it might have been in the free section on there

I had no VE's with my first two, I know my midwife and she and I were happy that things were progressing. As progress was fairly rapid we didn't go down that route. With my third (six days ago!) the midwives had already been at my house for three hours and there was no sign of baby so I had a ve. He was still not born for another three hours after that. I think it is good to go with the flow, see how you feel and accept that it is sometimes a good idea to have one.

I'm a midwife myself and despite careful palpations have missed the occasional breech, sometimes it is very difficult to tell, (not that I think that is a reason on its own to do a ve unless you suspect a breech.) Also we have many women who come in thinking they are in labour who aren't, if I weren't a midwife I would have probably gone in 24 hours before I actually had my first and third thinking I was in labour cos early labour can be painful and demoralising. It is important to know that some progress is being made if things are taking a long time, however for a second time mum there is no reason why you should'nt wait a few hours before doing the initial ve, many second timers will deliver in this timescale reducing the need for a ve at all.

Another thing is that you won't be able to have an epidural without having a ve first and I would prefer to do a ve before even offering entonox, it might sound harsh but in the past I have given a woman entonox and after several hours examined her to find that nothing is happening so she then has to go home which is a horrible situation to be in.