Okay so there’s a lot of stigma and controversy around cervical exams in pregnancy and labor and why we should use alternative methods for measuring dilation without disrupting the birthing person. Licensed Midwives in FL state are required to offer a sterile vaginal exam upon an initial labor assessment. That being said, client’s have the right to waive this. Hopefully, labor progresses with obvious visual and audible indications, such as change in behavior, vocalizing, “purple dilation line” (we’ll cover this more shortly!), reporting increasing pressure, steadily building contractions, etc. until a baby is born. This is always our favorite! Believe us, we never want to disturb someone who is clearly progressing, no matter the timeframe.
The knowledge we’ve gained over the years has definitely shown us when cervical exams are unnecessary but also when they can be truly helpful. Combining our hands on experience and evidence based information, let’s chat about how & when cervical exams in labor can be beneficial vs. when they can be invasive. We’ll also cover some information regarding alternative methods for observing progress as well as cervical “sweeps”.
Normal labor progression can be many, many hours!! The margin of normalcy is extremely wide. For example in a primiparous birthing person (having their first baby, no previous live births) can take anywhere from 5.3-16.4 hours to dilate from 4-10 centimeters. A multiparous birthing person (having a subsequent live birth) may take anywhere from 3.8-15.7 hours to dilate from 4-10 centimeters. Dilating from 4-6 centimeters can take up to 10 hours alone (this would be including early and/or prodromal labor). The parameters for “active labor” have changed to 6cm for primiparous people and dilation occurs much more rapidly once the cervix has dilated to 6cm and is fully effaced, in both primiparous and multiparous people.
What is a cervical exam and is it different from a cervical “sweep”?
A cervical exam should always be performed in a sterile manner, never with a “clean” glove. It’s more accurately performed when the client is on their back or semi-reclining with squared up hips. Having a cervical exam on hands & knees, kneeling, squatting or in a birth tub may affect how/where the cervix is palpated or how low the baby’s head is sitting, it may also be much less comfortable for the client as well as adding time to the exam.
The sterile-gloved practitioner should explain the procedure before touching you and let you know that you may stop the exam at any point. Typically two digits are used to feel your cervix, assess dilation and thick/thinness of the cervix as well as baby’s position and station (how high or low in the pelvis).
This procedure is considered medical and should never, EVER be done without express consent from the client. In the event the client desires the procedure, thorough informed consent should be given before the cervical exam starts. A cervical sweep can be “added on” while receiving a sterile cervical exam, however this requires the practitioner to essentially stimulate the lower segment of the uterus through the entire length of the cervix, so it may be more intense than the typical dilation check. If the cervix is long and closed, a sweep cannot occur and would be quite painful, so there needs to be at least 1-2cm dilation already in order to complete the sweep.
Cervical sweep evidence shows an 8% reduction of formal induction, 12% increase in spontaneous labor, 9% increase in pre-labor release of membranes (without labor contractions starting). We were not able to find how fast, per se, sweeping encourages labor to begin, but the studies did show that sweeping increased the ripeness and overall Bishop’s score within 48 hours of the procedure. Please talk to your provider about this procedure if you’d like to know more. In a nutshell, sweeping doesn’t come without risk, but could be helpful in preventing a post-term pregnancy.
What is the purple line method of measuring progress or cervical dilation?
It is suggested that there is a “congestion”, or disruption of blood flow, that occurs as the baby’s head descends into the pelvis (station), which is thought to explain the correlation between cervical dilation and the appearance of a dark purple line beginning at the anus and extending up the gluteal cleft towards the sacrum. The purple line is only going to appear in about 75% of birthing people, of that population, 67.5% of Caucasian and 48.5% of BIPOC had a detectable purple line once active labor began. This method can be quite helpful in reducing unnecessary interventions or complimenting progress, but shouldn’t be relied upon for determining dilation.
The cervix is not a predictor for when labor will begin nor how long labor will last. More often than not it can give us an idea of how long labor could be if labor were to begin in that moment… but also not always! During our careers, we have seen primiparous people have a cervical exam of 3-4cm dilation, 90-100% effaced to pushing their babies out 60-90 minutes later. We have also seen multiparous people hanging out at 5-6cm dilation for weeks before going into labor or maybe 0-2cm dilation with little effacement go into labor and have their baby by the next day. And literally every other combination in between!
So, there is certainly a time and a place where this information is very beneficial. Cervical exams in labor may help establish a baseline/starting point for the provider and following a client’s labor curve (as this is different for everyone!), identifying if a protraction or arrest disorder of labor has presented, if malpresentation/malposition is suspected, or if certain symptoms of progress have presented but no change occurs or regression of symptoms occur.
When are cervical exams indicated?
We had a client having beautiful signs of progress and a gorgeous labor pattern who had waived a cervical exam for several hours, eventually requested an exam because there hadn’t been much change. The baby was extremely low and causing the typical “transition” labor pattern, increasing pressure, nausea, etc., however the cervix had unfortunately gotten “trapped” behind the baby’s head, so while the body was progressing, the cervix couldn’t. The client had done the Spinning Babies, before and during labor, exercised regularly, ate a balanced diet and all of the other things one can do to prep for a natural birth.
On the flip side, we had a client who already had children, desired a hospital birth and was experiencing prodromal labor for months. The client had asked starting at 37 weeks for “membrane sweeping“ at her visits. For 2 weeks in a row, she was 6cm dilated, more than 60% effaced and having bloody show every time we performed a cervical sweep, thinking this could encourage labor to begin. Ultimately it would throw her into very intense prodromal labor, only for it to stop after a few hours. She opted for an induction at 39 weeks. That baby was likely going to stay put until they decided they were ready, no matter how “favorable” mom’s cervix was.
To speak to mal-presentation and mal-position, we have also had a few people over the years, having a first or subsequent baby, had cervical exams in their labors and found their babies were breech. Breech is a variation of normal presentation in pregnancy/birth, but unfortunately vaginal breech deliveries are quickly becoming a lost art. FL law doesn’t permit Licensed Midwives to attend breech deliveries at home but we were able to determine the position of the babies and get the parents safely transferred. I’ll mention also that ultrasounds and/or cervical exams were done and confirmed head down position within the last few weeks to even days before these labors began.
Our goal here at Clover Leaf Midwifery, as well as many other practices in our community, is to wholly support our clients in the way they want and need whenever possible, while providing suggestions and assistance where we see it could be beneficial. We may suggest a cervical exam if we notice fetal intolerance during labor, suspect labor protraction or mal-position. We will always communicate our thoughts so we can work together to establish new needs or potentially discuss if and when medical interventions may be indicated and helpful in achieving a healthy, vaginal delivery, free of regrets or emotional trauma.
All that to say, we absolutely hope to not check you in labor! We’ve been honored to assist many families having their first or 8th babies and never needing a cervical exam. One very special mama had all three of her babies with me and never had a single cervical exam in any of her pregnancies and births!
If you would like us to cover additional topics or if you’re curious about our stance on things, such as common herbal induction methods, pre-labor release of membranes, newborn medications or *anything* else… Please don’t hesitate to comment here or send your thoughts and suggestions through our website or emailed to: support{at}cloverleafmidwifery{dot}com
Love, Light and Informed Consent!
Resources
Ehsanipoor, R. M., & Satin, A. J. (n.d.). Labor: overview of normal and abnormal progression. UpToDate.
Retrieved from:https://www.uptodate.com/contents/labor-overview-of-normal-and-abnormal-progression?search=normal%20labor&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
Masoumeh, K., Morvarid, I., Fatemeh, T., & Habibollah, E. (2014, November 16). The Diagnostic Accuracy of Purple Line in Prediction of Labor Progress in Omolbanin Hospital, Iran. National Center for Biotechnology Information.
Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4329935/pdf/ircmj-16-11-16183.pdf
Dekker, R. (2020, November 10). EBB 151 - Updated evidence on the pros and cons of membrane sweeping - Evidence Based Birth®.
Retrieved from: https://evidencebasedbirth.com/updated-evidence-on-the-pros-and-cons-of-membrane-sweeping/
コメント