Are Vaginal Exams in Pregnancy Necessary?

by Laura Dana, LCCE, CD(DONA), CAPD

I haven't met many women who were happy to have an exam done while being pregnant. For that matter, I haven't met too many women who were happy to have it done while not pregnant, but what is the purpose behind performing the vaginal exam in pregnancy? If it is patient led, meaning that the patient is the one requesting it, what would be her reasoning? On the other hand, if it is physician or midwife prompted, what are they looking for and why?

It's certainly easier to be the examiner performing this function, but not always easy to be on the receiving end, and in pregnancy, this particular event can cause women to be uncomfortable, emotionally as well as physically. Having a vaginal exam is more like an invasion into the most personal of all our belongings...ourselves. However, let us take a look at this on a more clinical level.

Advantages of the VE in pregnancy

  • May find cervical anomalies, like early dilation and effacement, so that appropriate changes can be made to the woman's care, including bedrest, hospitalization, tocolytics, etc.
  • May show progress from exam to exam and therefore give a patient the satisfaction of knowing that her pregnancy is coming to an end, as well as give the physician/midwife encouragement
  • May stimulate the cervix so that a medical induction does not become "necessary"
  • May give the physician/midwife a comfort level that allows them to feel good about allowing a pregnancy to continue healthfully

Disadvantages of the VE in pregnancy

  • Doing an exam does not guarantee when labor is going to begin
  • VE exams can be very uncomfortable during pregnancy
  • May increase the risk of infection
  • May stimulate the cervix prematurely
  • May increase premature rupture of membranes
  • May give pregnant woman and/or her caregiver an unrealistic picture of the longevity of the remaining part of the pregnancy

Making the choice

There are real reasons for checking a woman's cervix to ensure a safe and healthy pregnancy, but just like so many "interventions" offered during pregnancy, it is important for each woman to be aware of the potential drawbacks to such a decision before she complies. What would be the reasoning for needing to "know what's going on" other than pure curiosity? Who exactly is directing the VE to be done? Consider the following scenarios:

  • Has this woman been scared by the "big baby" comment?
  • Has this woman had a history of preterm labor and/or a loss and as a result is she unsure that her body will cooperate and bring a healthy baby into the world?
  • Is she tired of being pregnant and just wanting to get it over with?
  • Is she trying to avoid a medical induction or Cesarean section?
  • Has her physician/midwife led her to believe that there is concern about the baby should the pregnancy continue?
  • Does this woman want instant gratification and want to hold her baby NOW?
  • Is this woman trying to avoid having to argue or fight with her caregiver?
  • Does this woman have "control" issues?

There are definitely real reasons for VE during pregnancy, but if a woman perpetuates a healthy pregnancy, what then would be the reason? So much of the research shows us that fetal and maternal outcomes are much better with the least amount of intervention. Do women consider the VE to be "intervention", "routine", or "necessary"? Ask three different women and you may very well get three different opinions. After all, it's a very personal decision to make, but has she actually considered the benefits and risks before allowing the exam to proceed? Does she know anything of alternatives to the manual VE, such as NST (non-stress test), BPP (biophysical profile), keeping track of kick counts, high level sonogram, or any other less invasive offerings? Does she know that the actual exam itself can bring on internal discomfort associated with cramping and bleeding?

As childbirth educators and doulas, we would mostly like to believe that "letting things be" is always going to be the best way, but that is just not true in all cases. However, even if you look at the CDC statistics about the increase in Cesarean section rates over the past 10 years and we are to believe that it is "necessary" for 25% of our population to "need" a surgical birth, that still leaves 75% who do not and who should, logically, be carrying healthy pregnancies and not be in "need" of VE, right? But then of course, we all know that "need" and "want" are two entirely different subjects, don't we?

References:
Courtois C. & Courtois Riley C. (1992). "Pregnancy and childbirth as triggers for abuse memories: Implications for Care" Birth 19 (4): 22-223.

Fraser W and Boulvain M. "Induction of labour: indications and methods." Journal SOGC. 1996;18:1125-31.

Hanson S. "To VE or not to VE? That is the question." Association of Radical Midwives. Summer 2003; 97.

Harger JH. (2003). "Cerclage and cervical insufficiency: an evidence-based analysis". Obstet Gynecol, Jan; 101(1):205.

Tallman N. & Hering C. (1998). "Child abuse and its effects on birth." Midwifery Today.45: 19-21.

United States Department for Health and Human Services (2003). "US Birth Rate Reaches Record Low: Births to Teens Continue 12-Year Decline; Cesarean Deliveries Reach All-Time High". CDC News Release.

Laura Dana, LCCE, CD(DONA, CAPD is a Lamaze educator and labor doula specializing in high risk pregnancy and multiple birth. She and her doula partner, Maggie McCarthy, own a company called Birth Options: Education and Doula Services in Orlando, Florida.

Copyright © Laura Dana. Permission to publish granted to Pregnancy.org, LLC.