Internal Exam In Pregnancy and Labour – Are They Necessary?

Internal Exam In Pregnancy and Labour – Are They Necessary?

There is absolutely no need for any internal vaginal exams during a normal pregnancy. The average healthy woman can manage her entire pregnancy without one.

Most women will be offered a pap smear at the first consult if they haven’t had one recently, but they can decline and say that they’d prefer their regular GP to do it for them.

Internal exams are not needed to determine dates either, if the woman can give a good menstrual history. If she cannot give an accurate date of her last menstrual period, then she can request an early ultrasound. Depending on the gestation of the baby, an internal ultrasound may be used, but you can say no if you wish.

If the doctor suggests he or she needs to examine you to determine that everything is normal, then you can state that you have no problems with menstruation, intercourse, frequent UTIs, abnormal vaginal discharge or any other gynaecological problems, therefore there is no reason to suspect any abnormalities.

You would be wise to have an exam to exclude abnormalities if:

  • You do have a history of gynaecological problems
  • You have a history of infertility problems
  • If your mother used diestriol during pregnancy with you, or,
  • If you have painful intercourse

Internal Exams and Strep B Testing

The 37 week swab for group B strep is not a reason for a vaginal exam. You can just ask for the swab kit and take the swab yourself (in the consultants toilet). Once completed, you can present him/her with the swab, all sealed and ready to go to pathology.

Internal Exams and Induction of Labour (IOL)

If a woman requests an induction of labour then she will need to consent to a vaginal exam so that the doctor or midwife can decide what form of induction will the best for her. Obviously the waters can’t be broken if the cervix is closed.

“I had SO many [internals] with my daughter’s labour – 10+ with my induction that I could remember and there may have been a few more. They were horrible and totally unnecessary in my mind. They did nothing to help me, nothing to help the midwives and doctors, other than one after 35 hours of labour when I was told that I was 9cm dilated with an anterior lip and it was time for a caesarean. I also vomited during one of them it was so painful to have during contractions and I swore if I ever laboured again I wouldn’t have so many, that I would refuse until I wanted one, not the doctors/midwives for curiosity sake which is what it felt like to me. Pity I never went into labour with my son, but when I spoke to the midwives before he was born they noted that I wasn’t happy with vaginal exams and would only have them if absolutely necessary.” — Tanstar, BB Forum Member

Internal Exams and Labour

Internal exams may not be medically necessary for many women, they are done mainly as an information seeking procedure to ascertain things like:

  • If a woman is actually in labour
  • To positively identify the presenting part of the baby i.e. head or bottom
  • To determine whether the head is engaged if there is doubt
  • To ascertain whether the forewaters are intact or to rupture them artificially
  • To exclude cord prolapse following rupture of membranes, especially if the presenting part of the baby is ill-fitting
  • To assess the progress or delay in labour
  • To apply a fetal scalp electrode
  • To confirm full dilation
  • In the presence of twins to ascertain the lie of the 2nd twin and puncture the amniotic sac

This may look like a long and useful list of things that internal exams can do, but they do not always produce accurate results.

If a vaginal exam is worth doing at all, then its worth doing properly – i.e. with preparation done thoroughly and not a rushed procedure. Beware of the casual ‘quick feel’ just to see where baby’s head is. It’s often misleading or inaccurate with the results and it would have been more productive to take the time to do a proper exam, even if it meant some discomfort and moving from a comfortable position to get accurate and relevant information.

“I had one during labour – my Ob asked if I wanted one to see how far along I was. The midwife said I didn’t have to if I didn’t want to. It bloody hurt! I thought I tried to kick the Ob – my husband says I didn’t, but he was ready to! I wish I’d listened to the midwife. Having read up (after the fact) on BellyBelly and other places, I wouldn’t agree to a vaginal exam during a future pregnancy or labour unless there was a compelling reason.” — Malakili

Make sure that:

  • You understand why the exam is being done and what the examiner hopes to ascertain from it
  • The procedure is explained to you and you are asked if you consent to it or not
  • Inform the examiner if you have a latex or any other contact allergy
  • You have an empty bladder
  • You are warm
  • Are comfortable
  • Adequately covered
  • Privacy is ensured
  • Ask for extraneous people to leave the room
  • Lie flat and squarely on your back with your bottom on the bed
  • Breathe deeply throughout the exam
  • Try to relax your pelvic floor muscles
  • Ask the examiner to explain clearly to you what he finds on exam.

“I was happy to have both of them (VE’s), but was p*ssed off about the S&S (stretch and sweep, which was also performed at the same time). I didn’t ask for it, didn’t want it, didn’t like it and it wasn’t necessary.” — Snacks

As a midwife, there are several reasons I would do a vaginal exam and several reasons I wouldn’t.

I would do a vaginal exam if…

  • If the woman requested the exam because she needed to know what was happening
  • If the woman felt she needed to focus and couldn’t because she was afraid she was giving labour too much or too little attention too early
  • If the woman was Group B Strep positive and thought she’d ruptured her membranes, so we could begin the antibiotic regime (if she’d chosen to do so)
  • If the woman was feeling despair that she couldn’t continue without analgesia and we’d exhausted all options
  • If the woman was labouring at home but planning to go to hospital for the birth
  • If the woman was deciding whether or not to have pain relief i.e. how close to birthing she was
  • If the dilation would decide what course of action the woman would take next, i.e. go for a walk on the beach, get in the pool, collect the kids from school, call the babysitter, notify the mother or birth supports, get hubby home from work, send hubby to work!

“(my doctor) was very rude and I hated the whole experience. He found me to be 7 centimetres dilated when he did the exam and I was not having any pains at all. He sat there with his hand up me while exclaiming to the nurse, ‘oh my god, you wont believe it’, and to me, ‘are you sure you don’t feel any pain?‘. Made me extremely uncomfortable, he didn’t remove his hand until I asked him to.” — Scorpio Queen

I wouldn’t do an internal exam if…

  • If the woman asked me not to
  • If the woman was a sexual abuse survivor and was not comfortable with an exam
  • If I thought the woman was in the latent phase/early stages of labour, as it would only discourage her. I’d encourage her to rest instead.
  • If I wanted to know if the cervix was fully dilated. I’d just wait and see!
  • If I thought the baby was in posterior position – there is nothing I can do about it if it is!
  • Unless my findings were going to alter what we were doing.

“I think a good midwife can tell by looking at a woman how dilated they are… so they are a tad over-rated. Far too many are done just in case… just to check. Stop poking babies on the head!” — yogababy (midwife)

It’s inappropriate to do an internal exam:

  • Because the shift is changing and, ‘we want to know where you are at’.
  • Because the staff want to know where you are at in your labour but don’t have the time to sit and observe or be with you.
  • Because ‘the anaesthetist is going home and doesn’t want to be called back in an hour to give you an epidural’ (unless you have indicated you are considering one)
  • Because the Registrar is going off duty and wants to hand over your care to the incoming Registrar.
  • Just to check how you are doing
  • Because it is hospital policy to do routine 4-hourly vaginal exam
  • Because your obstetrician wants to be present for birth but not to be standing around for hours waiting, or miss the whole thing (unless you specifically want your obstetrician present).

When Internal Exams Are Contraindicated (Not Recommended)

  • If the woman refuses the procedure for reasons of culture or FGM etc
  • When there is a placenta praevia
  • With extreme care when there is any abnormal vaginal bleeding pre-natally
  • Unnecessarily if the woman is GBS positive with ruptured membranes
  • If the woman has an active herpes lesion

There was an article in a medical journal, the Lancet, some years ago written by an obstetrician. He wrote that he couldn’t see the whole point of information seeking vaginal exams, especially trying to work out what position the baby was in (i.e. posterior, transverse). He noted that there were only 3 diagnoses which counted. The baby is:

1. Coming out soon
2. Coming out later
3. Not coming out at all

I think he has something there – people make it all so complicated when its all fairly simple!

Who’s Having Internal Exams?

BellyBelly midwife, Alan Rooney says: "I have never had a homebirth mum request a vaginal exam. I think that, in hospitals, many mums expect to be given a vaginal exam. In my experience, when I have admitted a woman in labour, a frequent question I get is, ‘Do you need to do an internal?’ or ‘When are you going to do the internal?’ or some such question.

I do not believe that women are happy to have vaginal exams, but I think that most women accept them as an expected part of pregnancy. I am sure that if they were given all the facts then a lot more women would be saying no to vaginal exams.

I would imagine that the risk of infection is quite low from a vaginal exam, but there is still a risk. And the more often someone goes sticking their fingers in, the higher the chance of introducing an infection. This is more of a concern if the waters have broken, as not only can you give the mum an infection, but you could also give the baby one."

If You Want to Avoid Pain Relief Or Interventions – Avoid an Exam!

Birth Attendant and BellyBelly’s Creator, Kelly Winder, says: "Vaginal exams can be the final breaking point for women in labour. If they have an internal and are disappointed at how dilated they are, it can be the reason they choose to either give up, have that epidural or other intervention because they feel they have nothing left to keep on going. They believe that the end is far in sight and have no idea that if they were just left alone to do what they need to do, they may dilate much faster than they think. Whatever time it took them to get to 4 centimetres dilated, for example, does not mean they have double or more the time to go – early labour tends to be slower! We must have faith in our bodies to know the way, not two fingers.

No-one knows how quickly or slowly a woman will dilate, but knowing an actual number (and knowing that you’re not there yet) during labour can severely throw a labouring woman off track. Sure it could motivate you too, only if you’re almost there – but why risk it?

A client of mine had an internal and was found to be 4 centimetres dilated. She was devastated after labouring all day, and it took much work to get her focused and back on track, allowing her body to labour without distraction and stress. Not only that but her parents then turned up uninvited and again she had lost focus! We quickly dealt with that, but after a few good hours of hard work in the bath, focusing on the CalmBirthing techniques she had been learning, she had her baby soon after – not bad for someone who was 4 centimetres only a few hours earlier. She could have given up and opted for pain relief thinking she would have many hours to go – but she dilated quickly after the internal with the right support. It’s so unfair to a labouring woman to have to go through that, the feeling of defeat or seeing a mountain in front of them when they have already worked so hard – this is why I believe it’s best not to know or have internals unless there is a really compelling reason. As well as this, if you are not dilating fast enough for the hospital or doctor, then it’s a reason for them to initiate further intervention like the syntocinon drip or rupture of membranes etc. I highly recommend couples hire a doula to help them navigate this and many other issues that may potentially arise during labour."

“I felt that I had too many but seeing as everything now is hazy, I wonder if they were necessary? I only wanted one in particular when I was 7cms and 3 hours later I wanted to know if I had progressed. Turns out I hadn’t and I chose to have an epidural.” — Tanstar

What If I Don’t Want An Exam?

A labouring woman should expect that she will need a vaginal exam prior to receiving pain relief (other than gas).

If the hospital doesn’t do waterbirths, then they may not let her in the pool/bath without an exam, as they’ll be anxious that she’ll give birth there. Sometimes its a bit of a trade-off to get what you want.

Plenty of women have never had a vaginal exam during labour, simply by refusing to consent. This is the most powerful tool. If a woman is not convinced that there is a good reason for the exam as per above, then she can just say NO.

Ask what the reason is for the vaginal exam, what information they hope to obtain and how will it alter labour management. If the woman has ruptured membranes she can state that, ‘every vaginal exam I have increases my risk of infection, so is it really crucial that I have one now’? It might be a bit heavy for you but it works.

You could explain to the doctor or midwife that you are very uncomfortable with the concept and don’t want to be stressed any more than you are already. If denying consent is too difficult or the staff pressure you, then if you protest enough they will cease. Hysteria or (fake) tears almost always work!

If refusing is too difficult or confronting then use delay tactics, they work very well.

  • ‘After this next one i’ll move to the bed’ (next 5 or 6 pass)
  • ‘I must to go to the loo first’
  • ‘I want to have a quick shower first’ (stay in the shower)
  • ‘I can’t cope with the idea just now, let me think about it’
  • ‘I want to wait until my husband/sister/doula is here’
  • ‘I am wet from the bath/shower, I want to dry off/am cold’

Evasion is very effective also:

  • ‘I can’t lie on my back, it’s killing me’
  • (Hiding in the loo) ‘I have to pee’
  • (Under the shower) ‘I don’t want to get out just now’
  • (Being slow to get out of the bath/pool) ‘I can’t move just now"

White Lies

We had a woman birth last week who just told the staff she had severe vaginismus and the whole idea of a vaginal exam was simply out of the question! She had no vaginal exams done at all.

Another told the staff she was Muslim – as they had no female registrar present, a vaginal exam was out of the question.

Another very young woman told me boldly that she just ’didn’t DO vaginal exams’! She also managed to escape the syntometrine injection for the 3rd stage (placenta) by stating emphatically that:

‘Oh no, I couldn’t possibly have that (drug), I don’t DO needles!" She managed to scoot around hospital policy very neatly by just stating the obvious, that she didn’t DO these things and wasn’t about to DO them now! No one seemed offended about it and I had a secret smile – I really admired her simplicity! How can you argue with such simple logic?

It’s like telling a vegetarian that they must eat meat right now for ‘their own good’ when they never eat meat normally. They’d say the same thing wouldn’t they? I can’t do that! I don’t DO meat’!

What If My Doctor Or Midwife Tells Me I Have To Have One?

Again ask why – ask specifically, is there a problem? What is the reason for the vaginal exam, what info they hope to obtain and how will it alter the labour management?

It’s very important to ALWAYS remember that when you are in a hospital, no-one HAS TO DO ANYTHING! All treatment is by consent and patient choice ONLY. Policy is not law and procedure being done against your will is grounds to sue. Doctors / midwives need YOUR permission to do anything to your body. If they aren’t convinced there is a good reason for a procedure then decline it.

What Do Others Think?

Find out what BellyBelly Forum members think about vaginal exams and if they’d accept or refuse them here: Vaginal Exams / Internal Exams – How Do You Feel About Them?

Last Updated: December 8, 2014


MIPP (Midwife in Private Practice)

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