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Cervical Exams in Pregnancy

care providers prenatal care risks and benefits of interventions Jan 20, 2023

 

Prenatal cervical exams are commonly offered by health care providers in the third trimester of pregnancy as the birth window opens or nears. A cervical exam is a procedure in which a care provider uses a sterile glove, and inserts two fingers into the vagina. Once the provider locates the cervix at the top of the vaginal canal, they will examine it with both fingers to determine the dilation and consistency, as well as fetal station and positioning, if they’re able (further illustrated below). 

If the cervix is open enough for both fingers to enter, the provider will insert their fingers into the cervical opening, then separate the fingers to measure the distance in between. This is how cervical dilation is normally identified. Though cervical exams have the potential to reveal a significant amount of information in regards to cervical changes and infant positioning, it appears western birth culture has hyper focused on one element of the cervical exam - dilation. Though dilation is an important function necessary for the physiological unfoldment of labor, fetal positioning, adequate application of the fetal head to the cervix, fetal station and cervical effacement are equally important, and can all be identified with a cervical exam. 

Cervical exams in pregnancy are intended to identify the following:

  • Dilation (expanding of the cervical opening from 1-10cm).
  • Effacement (thinning or reduction of the cervical length from 0-100%).
  • Fetal station or engagement in the pelvis (-4 to +4).
  • Fetal positioning by feeling the suture line on the fetal head.

 

Cervical Exams and Informed Consent 

Cervical exams in pregnancy have the potential to offer helpful information when performed on a case by case basis. However, just as exams have the potential to be a supportive tool for one’s birth preparation journey, they also have the potential to cause harm to those who receive them without informed consent. This is one of the many reasons why the routine use of cervical exams is so harmful. 

When a client chooses to opt out of a routine procedure, the care provider may perceive them to be a difficult client, which may reduce the quality of care that client receives. In addition, it is less likely for a care provider to truly illustrate the risks and benefits of the procedure, as well as inform the client of their right to decline, if the routine use of the procedure is normalized within the care setting. Developing a relationship with a care provider who exercises informed consent is vital to actualizing a safe, autonomous prenatal care experience. Informed consent is intact when the care provider illustrates non bias, evidence based risks and benefits in regards to the procedure, including the risk and benefit of not performing the procedure. 

 

Routine Exams vs Case by Case Exams in Pregnancy

There is a drastic difference between the routine use of cervical exams (receiving an exam at every appointment) compared to exams performed on a case by case basis. Depending on the care provider and facility in which they are operating, the philosophy and guidelines surrounding vaginal exams varies. The more extreme routine use of exams in pregnancy begins as the birth window opens or nears, around thirty six weeks gestation. In this case, exams are performed at each weekly prenatal appointment, and in some cases, the client is unaware of their right to refuse the exams. The routine use of exams are old, outdated medical interventions currently practiced more out of tradition and less out of evidence. 

The unpredictable window of birth challenges western culture, as we’re used to instant gratification, reliability and scheduling. The inability to plan such an event may stimulate a desire to resist and control, rather than surrender. If you were to go back over a century in history to the roots of modern birth culture, you may find that the foundation was paved by those who prefer to exercise control over women and birthing people. This influence manifests today as a projection and need for predictability onto pregnant people, through cervical exams and otherwise. 

When the pressure of routine exams diminishes, exams become a helpful tool for women and pregnant people to utilize if needed. Cervical exams can offer helpful information that may aid in various elements of the birth preparation process. Interested in induction? A cervical exam may help inform which induction method you choose. Curious about your infant’s position? A cervical exam may be able to identify it. On a case by case basis, exams can be offered when the client is looking for further information to help make an informed choice regarding their pregnancy or birth, or to simply satisfy their curiosity. If a client has no interest in what an exam will reveal to them, why offer it? 

 

Do Cervical Exams in Pregnancy Predict When Labor Will Start? 

A common misconception among clients and care providers is that the presence of dilation in pregnancy will help predict when labor will start. Sure, if an exam revealed that you’re five centimeters dilated, you’re more likely to go into labor sooner than someone who is barely dilated at all. However, as cervical changes are unpredictable and offer little insight into the timeline of pregnancy, checking a pregnant person’s cervix routinely for insight into when they’ll go into labor is not an evidence based practice. 

First time parents often efface, then dilate. Second time parents and beyond typically efface and dilate simultaneously. Knowing this, if you’re a first time parent hopeful for labor to start soon, and a care provider finds no presence of dilation from a cervical exam, yet ample effacement, this means that your body is making labor preparation cervical changes just as it should. 

Birth culture has granted too much weight to the dilation aspect of cervical changes, while the position of the baby in relation to the pelvis, and the application of the fetal head against the cervix may offer more insight into the “when am I going into labor?” guessing game. If you’re curious to play this game (many are, it's okay to be curious!) weighing in all elements of the cervical exam may be more informative than simply dilation itself. If your baby is well applied to the cervix, well engaged in the pelvis, and your cervix is dilating and effacing, you’re more likely to go into labor sooner than someone who’s baby is high in the pelvis. Then again, it’s birth. Anything is possible. 

 

Benefits of Cervical Exams in Pregnancy 

For those interested in induction, understanding the cervical changes your body has already undergone will allow for some induction methods to become available to you. Certain methods, such as mechanical methods or membrane sweeps, require a small amount of cervical opening to be performed. In addition, one may prefer to be dilating naturally before opting into pitocin augmentation, as pitocin stimulates the longitudinal smooth muscles of the uterus, but does not encourage cervical changes. If the baby is in a good position, the pressure of the fetal head pushing against the cervix during pitocin augmented contractions will likely support dilation.

Another benefit to receiving a cervical exam in pregnancy is the ability to identify fetal positioning. When it comes to encouraging labor or promoting an easier birth, improving fetal positioning is everything. In the case of a head down presentation, some infants face forward (known as occiput posterior or OP) and some infants face backward (known as occiput anterior or OA). In each of these positions, the infant may look a little towards the right or left side, or even favor one side. 

Infants have spaces between the bones in their skull known as sutures. Sutures act as an expansion joint, allowing for increased flexibility throughout childbirth. The suture lines on the front side of the fetal head make a diamond shape. The suture lines on the back side of the fetal head made a triangle shape. With suture identification during a cervical exam, the provider is often able to identify the position of the infant, as well as if the infant is well applied to the cervix. 

Identifying positioning may help inform the woman or gestating person as to which position to adopt in order to support their infant in coming into better alignment, if needed. For example, if your baby is favoring one side, laying on the other side in a supported side lying position may encourage the baby to come into alignment. If there is more tension on one side of the musculature that surrounds the pelvis, stretching that side may also encourage more optimal fetal positioning. For those interested in learning about supporting fetal positioning in pregnancy, I encourage you to visit the Spinning Babies website. 

Summary of Benefits: 

  • Identifies the state of dilation and effacement of the cervix.
  • Satisfies curiosity.
  • Identifies fetal engagement.
  • Identifies if the infant is well applied to the cervix.
  • Identifies fetal positioning.
  • Identifies if the fetus is head down, which may benefit those who aren’t able to access ultrasound technology, or those who choose to opt out of it. 

 

Risks of Cervical Exams in Pregnancy 

The amniotic sac is a fluid filled bag that protects your baby as they grow. The amniotic sac is made up of two layers, the chorion and the amnion. The amnion is the layer that surrounds your baby and holds the amniotic fluid. The chorion is the layer surrounding the amnion, acting as a protective barrier as your baby develops. Most of the time, the amniotic sac will rupture sometime near or throughout labor, known as the breaking or releasing of waters. Sometimes the sac stays intact throughout birth, known as en caul. Though the risk is unlikely, the pressure or stimulation from a provider's fingers against the amniotic sac during a cervical exam could cause the sac to break prematurely, known as premature rupture of membranes or PROM. 

Though the chances of premature rupture of membranes to occur during a cervical exam isn’t high, it is a significant risk to the procedure. If someone were to experience PROM before their body is ready for labor, the open bag of water may send their labor path down a medical induction road, a path the pregnant person may have wanted to avoid. This is due to the risk of infection that becomes present once the amniotic sac ruptures. Once ruptured, most care providers prefer for the infant to be born within 24-48 hours. 

In addition to the risk of PROM, cervical exams in pregnancy may be emotionally damaging to the one receiving them. Many people have reported exams to be uncomfortable or unwanted, which may ignite feelings of violation or powerlessness. These feelings experienced among pregnant clients are influenced by the reality that many are unaware of their right to refuse exams. Aditionally, uncomfortable exams have the potential to resurface traumatic memories for those with a history of sexual abuse. 

When discussing the difference between exams in pregnancy and exams in labor, it’s important to note that cervical exams are sometimes more uncomfortable in pregnancy, as the cervix is higher up in the vaginal canal compared to someone in labor. Near the end of pregnancy, the cervix is often in a position pointing backwards, known as posterior positioning. As labor nears or begins, the cervix softens, opens and moves downward into a midline position, allowing for providers to reach it more easily. As a care provider myself, I’ve been trained to “walk” my two fingers inside the vagina of the pregnant person, as far as they can reach, to encourage the inner tissues to move forward to allow for me to reach the cervix. This process involves more pressure and prodding compared to a simple insertion of fingers. 

If a care provider were to suggest a vaginal exam, describing the process in which the exam is performed is incredibly important. I find that many care providers do not illustrate this process to clients prenatally, causing them to feel surprised if the exam is more uncomfortable than they’ve been led to believe. The result of this lack of information may be damaging to someone in labor. If a laboring person were to enter a situation where a cervical exam would be helpful, they may still avoid the exam at all costs due to the uncomfortable prenatal experience. 

Summary of Risks:

  • Increases the risk of infection by pushing bacteria from the vaginal canal into the cervix. This risk is heightened for those with an open bag of water.
  • Increases the risk of premature rupture of membranes (PROM).
  • Prenatal cervical exams may be uncomfortable and unwanted, causing the woman or pregnant person to feel violated or uncomfortable.
  • Many people report feeling exposed and uncomfortable during exams.
  • Many people are unaware of their right to refuse exams.
  • If someone has a negative experience with a prenatal cervical exam, they may experience fear regarding exams in labor. 

 

Conclusion 

In conclusion, cervical exams in pregnancy may be harmful, or they may be helpful. Your positive cervical exam experience is dependent on true informed consent, as well as your relationship with your care provider. Developing a relationship with a care provider who supports you in feeling safe and respected is vital to actualizing a safe and well supported prenatal care experience. 

Cervical exams can offer meaningful information that can change the course of action in pregnancy, such as informing induction method choices or informing optimal fetal positioning choices. Cervical exams do much more than identify the state of cervical opening, they also identify cervical thinning, fetal engagement and fetal positioning. Some people receive exams because they’re looking for information, and others are simply curious. There are no wrong choices, so long as you’re choosing for yourself, from an informed place. You never have to receive an exam unless you want to. 

Resources 

I encourage you to preview the Evidence Based Birth article on cervical exams in pregnancy, as well as the Spinning Babies website to learn more about positions to support fetal alignment. 

EBB Evidence on Cervical Checks in Pregnancy

Spinning Babies Maternal Positions for Labor

Spinning Babies Daily Activities for Pregnancy

 

Photo by @whenabellyblooms

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