The birth preferences talk is in full swing when the midwife moves merrily on to the part re ‘checking progress in labour‘… She wants to stick her fingers in where and do what? What can she possibly gain from going in there? Why do they want to do that every 4 hours? Will it hurt? Does she have to go rummaging around in there? You dare not stop her and ask any questions because you feel like you should know all of this by now. Instead you simply sit there like a nodding dog and appear to agree. What have I just agreed too? She wrote down ‘Happy to have a VE’, am I happy? Did she ask if I was happy?…where are those chocolate biscuits?…darn it, she ate them all!
Let us unravel the mystery of the VE. For many years midwives and obstetricians have led women to believe that a Vaginal Examination (VE) is a necessary evil. They are adamant that the information gained through this intrusive examination is vital to the process of birth. But is it or can we be rid of the dreaded VE? Do women have the right to say no? It's time to start to consider your preferences for birth, not theirs.
Firstly let me assure you we all have the right to say “no” even to a midwife or doctor. They may appear disgruntled but after you explain the reasons behind your decision then they should respectfully offer understanding and look for other ways of ’knowing’. After all, there is enough strong evidence to support a shift away from this common intervention in midwifery practice and to move towards a more woman-centred holistic approach when assessing labour and its progress. There are other ways of gaining an understanding of what stage a woman may be at during her labour and these skills need to be focused on and brought to the fore.
So what exactly is a VE and how do they do it?
A Vaginal Examination is a gentle examination of the vagina and cervix by a midwife or obstetrician to try to identify (as this is done by feel and so a ‘guesstimate’) not only the position, feel, and dilation (how open) of your cervix, but can also help identify the position of your baby by feeling markers on their head or if breech they may find a tiny bum! This rather invasive examination using two fingers (gloved) may help form a picture to gauge how well a labouring woman is doing and if she may need any help. But are they 100% necessary in calm, normal birth and especially at home?
In my practice, I am a minimalist in that I offer minimally invasive procedures and observations, I prefer to use my ears, eyes, gentle touch (if needed) and knowledge of a woman and her body to help determine the events that are unfolding before me. So my answer is a firm 'no', there are other ways of knowing. What do I look for instead?
As I hope you have read from previous blogs and Twitter feeds, I am a strong advocate of women, their choices, and birth as a natural physiological process. I always look at the woman and her process of birth holistically in that I observe how mum, baby and labour interact, how the process of birth unfolds for that mum, her baby and her body. the following are a few examples of other 'ways of knowing' for you to explore further.
The purple Line
As a careful watcher of birth, I also observe the ‘Purple Line’ but that will take another blog to explain so click here and do a little research for yourself and come back if you have any questions.
In short, the reason for the Purple Line is believed to be due to the increased pressure on the veins around the sacrum. This pressure on the veins creates the dark line where the thin skin of the cleft of your bottom can show it. This pressure thought to originate from the baby's head creating the line also means that you can reasonably assess the station of the head as it moves downwards. Lower head = more pressure = higher and darker line.
Listening - Labour sounds
Listening to not only your wishes during labour but also to your 'noises' can tell us so much more. The sounds a labouring woman makes can signal to a care provider (or partner) where she is in her labour. Obviously, this will not work the same for all women. Some women are very vocal all the way through which may help them to relax and focus. Other women are quiet until the very end especially if using hypnosis techniques – also completely normal. However, there does seem to be a pattern for most women in the way they vocalise in labor.
In early labour (0 to 4cm) women can normally converse easily or with little effort during contractions. She does not feel the need to rest between them very much, and will most likely continue or pick the conversation right back up after each contraction.
In active labour (4 – 6 or 7 cm) the woman usually has to do some breathing or vocalising during her contractions, and normally stops talking to concentrate during them. She may have to rest more between them also.
In transition (7 – 9cm) women tend to really need to be more vocal and make noises – I affectionately call this the 'Mooing Cow' stage! Mooing, groaning, moaning, and sometimes repetitive mantras or singing notes.
At full dilation, I find many women really retreat within and become calm and quiet. She may not want to speak at all, even between contractions. Breathing your baby out (Pushing) has its own set of noises and can range from guttural deep growls with deep breath work, to sweet ranges of almost singing with the out breath. And just a note on noises – low and open noises seem to help women dilate. Keeping the jaw loose and not clenching helps the pelvic area to open and your baby to move downwards
This is a documented way of measuring dilation from the outside. When not in labour and full term (37-42 weeks) the fundal height is normally 5 finger-breadths between the fundus (top of the uterus) to the bottom of the breast bone. As labour progresses, the uterus pulls up on the bottom of the uterus (which is the cervical opening) and this is what creates dilation. Think of it as the uterus “bunching up” at the top in order to pull the bottom up and open. As dilation progresses, the finger-breadths between the fundus and the breast bone becomes smaller and smaller – at full dilation, you can normally no longer find the gap between the two. Unfortunately, this measurement must be done at the height of the contraction, whilst the mum-to-be is lying on her back. This makes it another uncomfortable way of assessing progress – but it does work and is surely better than unwanted fingers?
Mexican Hot Legs - Coldness of the leg during dilation
One of the more obscure named 'ways of knowing'. As the labouring woman's body works harder and harder, blood is withdrawn from the extremities to be utilised by the uterus. This causes the woman's legs get progressively colder from the ankle to the knee as labour progresses. At the start of labour, the whole leg will be warm. At around 5cm, the leg will be colder from the ankle to around mid-calf than it is above the calf. Once the whole leg feels cold up to the knee, then the urge to push should shortly follow.
This technique is less reliable if the woman is having an epidural, as the drugs will also affect the temperature of the hands and legs. If a woman is birthing in water then she'd need to be on dry land for around 20 minutes to allow the temperature in her legs to be measured accurately
(A. Frye, 2004).
The above are just some of the observations midwives can use to detect subtle clues as to what is happening in there. Other methods explored include smell (of the birth room and of the labouring women), emotional changes, and of the presence of a bloody show in advanced labour.
In essence, simply listening to a mother (sounds or words), the tone of her voice, her body language, her whole demeanour and/or the use of gentle touch (externally), can tell us so much more about an individual birth journey than sticking fingers where they are undoubtedly not wanted! As midwives we need to empower you as women to be the experts in your own birth experience, we should be guided by you.
If you have decided to challenge your midwife over the offer of a VE then you may like to have some evidence at hand and currently your biggest advocate comes in the form of our own UK midwifery guidelines for care. Trusts use the current National Institute for Health and Care Excellence (NICE) Guidelines for care in labour(Click here for link) to help form local guides for excellent care. This short women's version of the document clearly expresses that a VE will be offered…note the word OFFERED every 4 hours, this clearly means that it is not Law, it is not a rule, you are allowed to say "No thank you". The RCM (Royal College of Midwives) also reflect this by suggesting VE’s may be offered but that there is also little evidence to suggest that these should be carried out frequently and there are other ways to observe labour progress (Click here).However if your midwife feels that a VE is needed as there is some concern about your labour progress or your baby, then it may well become that true ‘necessary evil’ but again any VE mentioned should be ‘Offered’ and discussed gently and only justified if ‘clinically necessary’ for the health and welfare of you or your baby.
So go research that Purple Line, marvel at those 'Mexican hot legs', and look at other ways of 'knowing'. Talk to others about their experiences, go forth and enlighten yourselves and your midwives with the evidence you uncover. Birth can and does happen without the need for this invasive procedure and it is safe to avoid during normal and natural birthing.
In essence be kind to your Vagina, don’t let it be poked and prodded during this delicate time unless ‘Clinically necessary‘! A baby, your baby, will be passing through there soon enough. Keep that jaw loose, pelvis wide, legs open and let's see what you can achieve! Be amazed, our birthing bodies are awesome!
A. Frye (2004) Holistic Midwifery: A Comprehensive Textbook for Midwives in Homebirth Practice, Vol. 2: Care of the Mother and Baby from the Onset of Labor Through the First Hours After Birth 2nd Edition