During pregnancy and birth care providers are likely to offer internal examinations to see how things are progressing, but have you ever wondered what they are actually checking for?

Many women report internal exams during labor to be uncomfortable and anxiety-provoking. Some women describe them as ‘violating’. The big question is, are they really necessary? Do internal exams provide critical information to ensure a safe delivery or are they more for the convenience of care providers?

In this article, we’ll give you the low down on everything you need to know about an internal exam during labor and its purpose.

What is an internal examination during labor?

An internal exam is referred to by a number of different terms, such as vaginal examination (VE), pelvic or cervical exam or cervical check. The terms are used interchangeably but they all refer to the same thing. Outside of pregnancy, internal exams are part of women’s reproductive health checks to assess the reproductive organs – the vagina, ovaries, cervix and uterus.

They might be used for a specific purpose – for example, if the woman is experiencing pelvic symptoms, such as vaginal discharge, pain or bleeding. During pregnancy, labor and birth, pregnant women are offered vaginal examinations to check the cervix or the position of the baby; they might be recommended one before other routine medical procedures.

What happens during an internal examination?

Prior to any examination, your care provider should follow basic nursing and midwifery practices – for example, ensuring privacy and discussing with you the reasons for offering the exam, as well as any risks, benefits or alternatives. This is an opportunity for you to ask questions about the process, the likely findings or any changes to your care plan, based on the findings. Before the exam, you must have given your informed consent for your midwife or doctor to be able to proceed.

When you’re ready, you’ll be asked to bring your feet together and position them up towards your bottom, allowing your knees to relax outwards, or you might be asked to put your feet into stirrups. Depending on the purpose of the examination, your doctor or midwife might use a speculum to visually inspect the cervix or take swabs; alternatively, they might use two gloved fingers to feel for the cervix.

The examination should only last only a few minutes, at most, while the assessment takes place.

Reasons for performing an internal exam

Internal exams may be performed for a number of reasons, before or during labor.

Once you’re in labor, vaginal examinations will normally be performed routinely every 2-4 hours, depending on the situation, to note any changes to the cervix and to monitor the progression of your labor.

A cervical exam can provide a lot of information that cannot be gained from observing someone in labor. They by no means facilitate a vaginal birth; babies will still be born without a care provider performing an internal examination. However, where there are concerns about how things are going in labor, an exam can give some helpful answers.

Information about dilatation is the obvious one. When performing a cervical exam, your midwife or doctor will be able to feel how open (dilated) your cervix is. If more than one exam is performed during your labor, they can compare the results of the exams to monitor how things are progressing.

However, dilatation isn’t the only information that can be gained from an internal exam. It also indicates:

Effacement – referring to the shortening and thinning of the cervix
Consistency – how soft or firm the cervix is
Station – how engaged the baby’s head (or bottom) is in the pelvis
Position – the position your baby is in
Waters – whether the amniotic sac can be felt
PV loss – whether any bleeding or amniotic fluid can be detected.

Other reasons for the exam

Prior to induction of labor. An examination will be performed before starting the induction process to determine which method of induction is preferable, based on how ‘ready’ the cervix is
To perform screening tests. If there is uncertainty about whether or not your waters have gone, or whether you might be in premature labor, certain screening tests can be performed during an internal examination to gain further information
To perform a speculum exam. If there is any bleeding or if your waters have already gone, a speculum exam might be preferable to a digital exam (using gloved fingers), as it reduces the risk of infection, or further bleeding if the cause is unknown
Prior to medical intervention. A cervical exam might be offered or recommended prior to certain medical procedures or interventions, depending on the situation
To break the waters – artificial rupture of membranes (ARM). This is done during an internal exam using something called an amnihook or an amnicot
Prior to an assisted birth. This is done to assess your baby’s position before determining the best method for your baby to be born
After birth. It can determine whether you require any sutures (stitches) after birth
Emergency situations. In the rare cases of obstetric emergency, an internal exam might be performed in order to perform certain internal maneuvers to help either the mother or the baby. In some cases, this can be life saving

What does an internal examination feel like? Is it painful?

Women’s experiences of vaginal examinations vary greatly, and can be dependent on a number of factors, including:

The environment or care setting
Their emotional state
Others who are present
Biomechanics
Previous experiences and previous medical, birth, sexual, and psychological history. All of this positively and negatively influences women’s satisfaction.

There isn’t any one experience of a vaginal examination. Some women don’t mind them and some can find them uncomfortable, unpleasant, painful and even traumatizing. There isn’t a right or a wrong way to feel towards them. Whatever your feelings might be, they are valid and should be respected.

Potential risks and discomfort of internal exams

As mentioned previously, everyone’s experiences of internal exams are varied; some find them ok, and others can find them uncomfortable or painful. This can be dependent on the situation and the reasons why or when one is being performed.

An exam might feel more uncomfortable prior to (or during) labor if the cervix remains quite ‘posterior’ (towards the back) or behind your baby’s head. This can make the cervix more difficult to reach, which some people find uncomfortable.

Some people might find a membrane sweep uncomfortable for the same reason.

If the cervix is posterior and difficult to reach, some care providers will ask you to make a fist with your hands, and place them under your bottom. This helps tilt the pelvis to make the cervix easier to reach. It can feel uncomfortable and restricting, and might even be triggering for some people. An alternative is to use a rolled up towel under your pelvis or bottom, instead of your hands, which will have the same effect without feeling so restrictive.

As with any procedure or intervention, certain risks are involved, which should be discussed.

Potential risks of internal exams include:

Risk of infection. Anything entering the vagina increases the risk of bacteria ascending, past the cervix, towards the baby. The more exams performed, the greater the risk of infection
Risk of accidentally breaking the waters. Occasionally the waters can be ruptured or broken unintentionally during an exam. This can be problematic if the baby is in an unfavorable position, or is not already engaged in the pelvis
Risk of cord prolapse, if the baby’s head is not engaged
Increased risk of bleeding, if there are known placental issues
Discomfort or pain
Interruption to labor ‘flow’
Interruption to birthing hormones
Change of maternal position.

Women’s experiences of cervical exams

Your care provider should aim to do whatever will make you feel as comfortable and relaxed as possible. You can ask to have someone with you, such as your partner or friend, to make you feel more relaxed. There might also be an additional health professional in the room, known as a chaperone, who can assist with basic tasks, but who will also be sensitive to your needs and provide reassurance throughout the process, if needed.

Many women prefer female providers to perform the exam, and you can request it if you prefer. Most women ‘tolerate’ vaginal examinations, as they believe they’re a necessary and unavoidable part of the process during normal vaginal birth. However, for many, they can cause significant distress, embarrassment, pain, and, for some women, even PTSD (post-traumatic stress disorder); they can also reinforce outdated gender roles and power dynamics.

In research examining women’s experiences of vaginal examinations, the most frequently reported response was pain. Many women reported embarrassment and 82% of women reported pain associated with the cervical exam.

Midwives and physicians must understand women’s feelings and experiences during internal exams, in order to improve their own practice. They should only be conducting intimate examinations when necessary. The sensitive nature of VE’s for both the provider and the woman necessitates greater concern.

Vaginal examinations: the research

Vaginal examinations are seen as a routine and standard aspect of labor care for all women, regardless of risk within mainstream care. They’re used as an assessment tool, and a frequent and core procedure used to manage labor progress.

However, following recent research their effectiveness in assessing cervical dilation and labor progression and their acceptability to women have come into question. Despite their common use, there remains a lack of good quality evidence that supports the notion that routine VE’s improve outcomes for mothers and babies.

Some argue that although monitoring can detect certain abnormalities in labor progression or fetal positioning, which might cause harm to both mother and baby, routine vaginal examinations also have the potential to lead to over-diagnosis of labor dystocia, leading to a cascade of medical interventions, including augmentation and cesarean birth.

For some, a slow labor might be a variation of normal and, as long as both mom and baby are well, evidence suggests that duration of labor, or cervical dilation alone, shouldn’t be used to decide whether labor is progressing normally.

It’s important for practitioners to be aware of this as the increasing level of medical intervention in birth is causing concern, and not without consequence. This knowledge will also potentially decrease laboring women’s unnecessary suffering from the pain and discomfort associated with these examinations.

This knowledge supports the latest World Health Organization (WHO) recommendations for labor and also supports the move away from the Friedman’s curve as the gold standard of care.

More research is required into women’s experiences and their feelings surrounding routine vaginal examinations in labor.

When do internal exams start during pregnancy?

At the beginning of your pregnancy, your doctor might offer an internal examination and general ‘well woman’ check to make sure everything is as it should be. The exam will often form part of the routine first trimester screening process and might include various swabs and a pap smear, as well as regular lab tests.

Unless any concerns occur earlier, routine examinations tend to be offered again from about 35-36 weeks gestation, as your body prepares for labor.

The frequency and scheduling of these cervical exams will differ between care providers and care settings. In the midwifery model of care, a cervical exam isn’t normally offered until much closer to your due date, and sometimes not even until past 40 or 41 weeks.

Before deciding on care providers, it’s good to understand what their standard practice entails, and whether they’re willing to deviate from it.

To read more about choosing a care provider read our article Who Cares in the US? Choosing A Maternity Care Provider.

Can I refuse an internal examination during pregnancy?

It is absolutely within your right to decline any aspect of your care if it doesn’t feel right for you, and you do not need to provide a reason.

It’s okay to ask questions or to ask for further information or time to be able to make an informed decision. If you still decide it’s not for you, it’s perfectly acceptable to say no. When it comes to examinations – particularly a cervical exam – nobody can touch you without your prior informed consent.

To learn more about this topic, read our article Vaginal Examinations | You Have The Right To Say No!

Does an internal examination bring on labor?

There are many misconceptions about accepting routine vaginal examinations in the run up to your birth – for example, that a VE will either bring on labor, provide information on when labor will begin or even predict whether a vaginal birth is possible. Unfortunately, none of these is true.

A vaginal examination can provide potentially helpful information in relation to the cervix and your baby’s position; however, even in light of that information, your body will not go into labor unless it’s ready to do so, and an exam cannot predict your chances of successful vaginal birth.

Do you check my cervix before induction?

It’s common practice to perform a cervical exam before the process of induction begins. Information gained from examining the cervix can help determine the most appropriate method of induction.

Prior to labor, the body undergoes changes to the cervix to prepare it for labor. This process is known as cervical effacement and can be detected on examination. Determining the extent to which this has or hasn’t happened gives the clinician an idea of how ‘favorable’ or ‘ready’ the cervix is.

Pelvic exam during labor

Pelvic exams during labor are often offered, and performed on a regular basis to assess progress in labor – usually every 3-4 hours, depending on the situation.

An examination in labor can provide information on cervical effacement and dilation, but also on your baby’s position, descent (station) and engagement, whether your baby’s head is molded and whether or not your waters are intact. This type of information can be helpful in certain circumstances – for example, if a problem is suspected.

Indications for internal exam during labor

The most common reason cited for performing an internal examination in labor is to assess labor commencement or labor progression. As we’ve seen, however, this can be problematic; internal examinations can often contribute to the snowball effect of medical intervention, which is not without consequence.

Although some helpful information can be gained from vaginal examinations, they can also be problematic because they only give information on what is happening at that precise moment; they cannot accurately predict what’s going to happen next. What’s happening with the cervix one minute, can change very quickly in the next. I’m sure we’ve all heard stories of people who are ‘not in labor’ or ‘only 2 cm’ and then suddenly a baby is born in a very short period of time.

Unfortunately, not all labors (or cervixes) are the same, and they certainly do not ‘perform’ in the same way. We need to be mindful of that when using those findings as the sole basis of our decision making.

Are internal examinations necessary?

Internal exams during labor are often routine, but are they really needed? The short answer is no, not always. Unless there are concerns about the baby’s wellbeing or the progress of labor, internal exams are not medically necessary.

Frequent vaginal exams are done out of habit, but each exam comes with risks, such as infection or the introduction of bacteria. Too many internal exams can also be uncomfortable and stressful for a mother in labor.

Remember, you have every right to say no to any kind of examination if it doesn’t feel like the right thing for you (or your baby) at that particular moment. It’s also OK to change your mind.