From Issue No.97, Summer 2003
Sue Hanson
WHEN I HAD MY OWN BABIES, long before I thought about becoming a midwife, one thing I dreaded about the labour, was having to lie down for vaginal examinations (VE). When I started my midwifery training in 1993, I accepted that VEs were a necessary part of labour and I was taught to do one on admission, and then four hourly during labour, with an extra one to confirm full dilatation. This is what I continued to do once I qualified and became a hospital midwife. On my latest rotation to the labour ward, however, I considered areas where I could change my practice, and I thought about trying to cut down on the number of VEs I did. I felt that I now had more experience to recognise what a woman's behaviour meant. I also realised that there was a limited value in finding out how many centimetres dilated a multip was, as I had seen many multips go from almost nothing to fully dilated in a very short space of time.
My thoughts about VEs led me to conclude they were done for two reasons: to give information about where a woman was in her labour, and to help the midwife decide if any action needed to be taken.
I learned from some e-group discussion, that routine VEs were not considered necessary by some (independent) midwives, and I thought I would change my own practice. I started off by looking after a multiparous woman, whom I could see was in advanced labour. She was contracting strongly and frequently, and I assessed from her behaviour that:
1. She was in established labour
2. She was in late first stage.
I decided that a VE was not necessary. I could already tell that she was labouring well, and I decided to leave her alone to get on with it. She coped well, and before too long wanted to push. I decided to take a chance and let her go with what her body was telling her. I did not do a VE, but told her to push only if she felt she had to. My fall back position was that I was prepared to do a VE if there was no sign of the baby within a few pushes; however, the baby was born very soon. I was delighted that for this woman I had avoided two VEs, and it confirmed to me that this path was worth pursuing. I did the same thing again with the next multip I looked after, and there was a very similar pattern, again avoiding another two VEs. I can't emphasise enough how ground breaking this was for me.
In continuing along this path, I have considered the following issues.
The admission VE
Some midwives feel that they could not possibly not do a VE on admission. For some, the only time they would not do one would be when a woman came in in advanced labour, and the baby's head was visible. On reflection, I feel that with a primip, an admission VE is usually very useful; it gives some indication of where they are, or helps to decide whether they would be better off at home. With a multip, contracting strongly and frequently, I question the value, as multips may progress extremely fast, and a VE done just 10 minutes later might give an entirely different result.
Routine VEs during labour
Again I think that these may be useful in a first labour, to confirm that progress is being made, but it really depends on what action you are going to take. When it was routine to put up Syntocinon with progress of less than 1 cm per hour, then four-hourly VEs were needed so that the drip could be put up at the right time, as it were.
However, now we are more circumspect about the use of Syntocinon. As long as someone is progressing half a centimetre an hour, it is usually considered fine to continue to plod along. No one would want is to find out that it would have been better to put Syntocinon up several hours ago. If we cannot be confident that the woman's behaviour indicates that cervical dilatation is progressing, and this is considered important, as it is in hospital, then it is probably necessary to do a VE.
If a woman has an epidural, then I think we need to do regular VEs; we will not be able to assess progression by her behaviour. However, with an epidural in situ she will not find it painful.
I'm not sure why four-hourly assessment has become such a mantra. In some cases it would be useful to do a VE more frequently than four-hourly, and for other women, it might be better to wait longer, perhaps until pain relief is requested. Individual woman-centred care - is this possible in the hospital setting?
How good are we at recognising where a woman is in her labour? Anyone who has worked on a labour ward gets a pretty shrewd idea about this. And I don't just mean midwives! How many times has the receptionist rung the labour ward to say a woman's just about to deliver in the corridor, and is the receptionist ever wrong? We can't be correct 100% of the time, but in the walk from reception to the admission room, many midwives will have a fairly good idea of what they will find on VE.
Confirming full dilatation
Recognising full dilatation is something we all learn from the woman's behaviour. She may well say that she has to push. Or she may say she can't take any more, or that she wants to go home. Often you can tell by the change in her breathing. There are often additional clues, such as the membranes rupturing, or early decelerations. Can we be sure that if a woman wants to push she will be fully dilated? What if there's a rim of cervix - will pushing on this mean that her cervix becomes oedematous? This is a separate issue, and it is something I would like to know more about. However, I think it is important for the woman to push only if she has to. I do not go in for cheerleader type pushing, unless she has an epidural, or there is some urgency to get the baby out.
Other issues
Soon after I began cutting down on VEs, I came across an issue that is only relevant to hospital midwives, that is, the need to hand over at the end of a shift. You do not know who you will be handing over to, and the next midwife may require a more detailed handover than, "I think she's labouring well". Some midwives would find this adequate, but some would consider that by not doing a VE I had been lazy or neglectful. As you don't know who you are going to hand over to, I have decided where I am in the shift makes a difference as to whether I need to do a VE or not.
Regrettably, this is hardly woman-centred care, but more about getting on with your colleagues. It is also useful for the midwife in charge of the shift to know what is going on, especially as it gets towards handover time, and so a lot depends on your relationship with them.
The other issue for hospital midwives, is the requirements of your employer's policies and guidelines. Of course we each have our own professional autonomy, and professional judgment. But it all depends on the ethos of the place you work in, and how you feel about yourself. Ideally there will be someone around who is open to discussion about different ways of practising.
What are the advantages of avoiding VEs?
The advantages are mostly to the woman, in that she does not have to go through an unpleasant, painful and demoralising procedure. A VE is often the first thing that happens to a woman on admission to the labour ward, if she is very distressed by it, what effect will this have on the rest of her labour? I think it is important to stress that the advantage is to the woman, we should acknowledge the fact that what we do often centres on the needs of midwives and doctors.
For the midwife, it keeps you on your toes! It makes you learn about other ways of assessing a woman's labour. It is less distressing for the midwife as well, as it not pleasant to cause someone pain and deprive them of their dignity. And with multips at least, what do we gain from it? The knowledge that someone might deliver in six hours, or perhaps half an hour? I think also that it can help to give more individualised care in hospital.
I think the key is that we need to justify why we are doing one, rather than why we are not doing one. However, ironically, I think midwives need to be proficient at doing VEs. If one is to be done, you need to get as much information as you can regarding effacement, station and position, as well as dilatation, and generally the best way of learning is through practice. I do not think we can avoid all VEs, and until someone invents some sort of 'cervicoscope' they are going to continue to be one of the tools of the midwife's trade. However, perhaps we can learn to use them a bit less often.
So, to conclude, I would ask you to think carefully about whether it is really essential to do that VE. What will you find out, and what will you do about it if you do one? And what will you find out, and what will you do about it if you don't?
The author can be contacted at: Suehanson@btinternet.com
LW updated February 4, 2005