The ValuE of the VE (vaginal exam)

If you are reading this, maybe you are already pregnant or have given birth and you're very familiar with this. Excuse me a sec, while I describe it for those who don't know yet.

This is the process of feeling the cervix to feel for changes - how much it is softening and opening for example. It's usually offered during labour to help determine how far in to the process a woman is. In some places, it is also offered antenatally. It may be done by a midwife, or a dr, or yourself. It may be expressed on your notes as "VE" - vaginal exam. It is offered before some types of induction, to help the mother and her healthcare team decide on the best way to procedd with the induction.

I am going to preface this by saying I bloody loathe the term "vaginal exam". For many reasons! So I often use the term interchangeably with "cervical check" - it means the same thing. Or I abbreviate it to "VE".

I am also going to reiterate my usual reminder that I am a layperson. I am a mother, a service user, and a birth support person. I am not medical. These are things I have picked up from having my own children, reading extensively, and speaking with experienced midwives.

What is your midwife looking for

I am sure when your friends tell their own stories about their births, they almost always include "how many centimetres". Maybe you've given birth yourself - it's likely this is an integral part of your story when you tell it. "When I got to hospital I was already 8cm dilated," or, "...and then the midwife checked me at midnight and I was 6cm..." This little number is highly esteemed. It tends to be the bit we focus on. But many people don't realise that the midwife or doctor is looking for much more than "how many centimetres" when she checks a cervix.

She is looking for several things:

• yes, OK, dilation - how open the cervix is ("how many centimetres")
• effacement - ie. how thin it is (you might see this expressed as a percentage, for example, 50% effaced)
• position - in pregnancy the cervix is usually high up, and posterior. It's angled this way to help prevent anything getting in. Towards the end of pregnancy, or during the labour process, it changes position. It moves lower and levels out
• consistency - the cervix becomes softer and squishier. During pregnancy, if you feel your own cervix, it might feel quite firm, like your chin. At the end, or in early labour, it might feel more pliant, like the end of your nose. Later still, it might feel very smooshy - make a soft kissy face with your mouth and press your forefinger against it. Like that. (NB. I recommend avoiding trying this if you know or suspect your waters have released due to the increased infection risk.) This always reminds me of Gordon Ramsay testing a steak.
• baby's position - is that a head, or a bottom? Or a foot? (It's usually a head.) The midwife may also be able to determine which way round the baby is facing (because of the feel of the bones in the baby's head), and whether the baby is "flexed" (chin tucked to chest. This is ideal, because it applies the most pressure to the cervix to help it to open, and presents the narrowest part of the baby's head to be born first).
• baby's station - it also helps them asses how low in your pelvis your baby is. This is usually expressed by a "+" or "-" symbol followed by a number, or just a "0". -5 means the baby is still high up in your pelvis, +5 means they are very low in your pelvis.

Choice

It's your choice whether to have one when offered. It's your choice whether to have one at all.

Key things to remember about the VE:

Consent - It should only ever be done with the express consent of the mother. That is, she must say YES while knowing the pros and cons, and being fully aware that she can say "no" instead. She can withdraw consent at any time. The doctor or midwife must stop immediately if the mother says so. The rules are really no different that any other time something is entering her vagina from the outside, and the resulting trauma can be just as devastating if her wishes regarding her own body are trampled on. If she does not know that she can say no; if she has been pressured into consenting; if she does not know the pros and cons; if she does not know that she can withdraw consent - then she has not given informed consent. I cannot overstate this. Informed consent means nothing without the right to informed refusal. You have the right to decline. If I had a penny for every time a woman said to me, "I didn't know I could say no," I would have a very heavy sock full of pennies to hit people with.

Not the same as a sweep (aka a stretch and sweep, sweeping the membranes) - A sweep is entirely different and separate. It should not be done "while I was in there" unless the mother has also consented to that beforehand. Before the gloves went on! Otherwise, that is assault and battery. If that has happened to you, please consider filing a complaint if you feel able.

Dilation is not linear. The first 5cm can take ages, most especially if the cervix has not opened to accommodate a full term baby before. The last 5 can spring open easy peasy. If it took you __ hours to get to 5, don't assume it will take that long to dilate the rest of the way! It is possible to go from 4cms to holding a baby in a couple of hours; it is possible to stay at 8cms for a few hours. It's possible to undilate.

NICE guidelines - The National Institute for Clinical Excellence states that a VE should be offered every four hours. This gives your midwives a baseline of progress, which can be useful. The key word is offered. If you decline, this must be recorded on your notes, and then they should offer again in four hours.

The value of the VE

The VE helps midwives and doctors to establish a baseline of progress. If progress is just not happening, no mum and baby can be expected to keep going indefinitely.

Any midwife or doctor working with birthing women should be able to assess labour based on external signs. Sometimes when things are not progressing as expected, the VE may be valuable in addition to those external signs, to help them get a clearer a picture.

It helps health care providers and birthing women to make an informed decision about what to do next, based on an educated estimate of what is likely to unfold in the coming hours. We can't know for sure, obviously, as every woman, every baby, and every birth is different. After labouring a long time and feeling exhausted, I am sure any woman would not want to trundle off to theatre not knowing she was 9-10cm! Many women will agree it is just logical to check and see. Yet, knowing that she is 9cm, she might still choose that caesarean birth if she knew she had already been at 9 cm for several hours and wasn't progressing. See? Value.

Sometimes the value of doing one outweighs the associated risks, and sometimes it doesn't. There is no one-size-fits-all. It's ultimately up to the woman.

The Bishops Score

A VE can be helpful prior to induction. There really is no point inducing contractions if your cervix is not soft enough to make changes and start to open.

The cervix is assessed and each attributed (how open it is, how soft etc) is given a number. These are added together and the result is your bishops score. The higher the score, the more chance there is you will either go into labour soon by yourself, or that induction is likely to begin working quickly. If the score is very low, it indicates that spontaneous labour is not likely to happen soon, and induction is likely to take longer. Essentially: a high score means your body is showing many signs it is getting ready to go into labour, and a low one means it probably isn't ready at all. (Source.)

The Limits of the VE

It can only tell you the changes on the cervix on the outside. It can't tell you what is happening behind the scenes - what your cervix is like from the baby's side, what your fundus is doing, or how much work your body has done to shift the baby into a better position, or help them to rotate. It happens - we've all heard stories of women who were told they were only 2 or 3cm, who had their babies just a short time later! Perhaps, at times - if baby isn't positioned in the usual way, for example - those changes that can be observed by feeling the cervix do not correlate with what's going on inside in the same way. Maybe that is why sometimes, babies can take doctors and midwives by surprise!

Midwife Rachel Reed says the cervix can be pulled up and over the baby very quickly (in celebration of the OP baby). This makes total sense to me!

Keep in mind, the VE is only a snapshot - it only tells you and your health care team what one part of your body is doing for one moment in time. It is not, as many women wiser than me have asserted, a crystal ball. Although, I argue that it might be a bit cooler if it was.

Labour is a dynamic process. It can be progressing beautifully, and then something upsets the mother and she can be "stuck" for ages. Or she can be labouring away, seemingly forever, and then all of a sudden the planets align, something shifts, and a baby comes whooshing out in a hurry who wasn't expected for hours yet. (My own dad missed the birth of me for this reason!)

Other disadvantages

As with anything, there are pros and cons. We've already touched on some of the benefits, and the limits. Now, let's look at the downsides:

Physically uncomfortable/Painful - The VE may be physically uncomfortable for the mum, especially if early in the process.

Emotionally difficult - It may also be difficult mentally and emotionally for many women. This element cannot be understated. Many people consider birth as only a physical, even a mechanical event. But it is just as much a mental and chemical one. Therefore, a woman's state of mind during the process is extremely important. Perhaps even supremely important. Upset must be avoided if at all possible. The VE can feel quite invasive - let's be honest, you can't get much more invasive. This is especially true if the woman has experienced prior trauma. Dear health care providers: this is your reminder that no woman is obliged to disclose a history of abuse to you. If you don't know, assume that she has and proceed accordingly - ie. with extreme care and sensitivity. If you already do this, thank you

Infection - if waters have released, there is an increased chance of infection. The vagina self-cleans downward. The insertion of anything pushes any bacteria sitting in the vagina further up. That's not what we want.

Disappointment - This is a wild understatement. To hear a low number is beyond depressing! I've seen this myself. I've seen a woman disappointed to hear a 6 when she expected to hear 8 or 9. I've seen mums devastated to hear 2 or 3 after many hours, or even days, of labouring hard. I say "disappointed" - but this really can be crushing disappointment. I've seen it sap the strength of the bravest woman, who has coped magnificently with some extremely intense contractions. Of course, on the flip side, to hear a lovely high number like "9" or "10" is wonderful and can give you a lovely boost! Just to hear confirmation that the hard work you've done over the previous hours has been doing something can be reassuring. But, it's important to remember that every contraction is working - even if you do hear a low number!

Observation changes the observed. We have dozens of ways to observe birthing women. It is done with the very best intent - to assure everyone concerned that mum and baby are doing well and everything is normal and safe. But it is not without cost. Observation increases adrenaline, which can impede progress and cause pain. (I will go into this in more detail another day).

The woman may be offered a VE if she has started to involuntarily push, and then instructed not to do that because she isn't "10" yet. This can cause doubt, anxiety, and pain.

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What's been your experience with this procedure?

Was any of this new, interesting or useful for you?

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Edits made for minor typos and to add information about the bishop score.