PRACTICE ISSUE The vaginal examination during labour: Is it of benefit or harm?

Key words: of women achieving birth with minimal Authors: intervention (Tracy, 2006; Waldenstrom, Vaginal examination, intervention, physiological 2007).Whilst there is general agreement • Lesley Dixon RM, BA (Hons) MA labour, labour progress, assessment tool, that ARM, augmentation of labour and PhD Candidate , partogram. instrumental births are clinical interventions, Victoria University, Wellington there are many other acts or care practices Midwifery Advisor: The New Zealand that could also be considered an intervention College of Midwives. Introduction (Kitzinger, 2005). The New Penguin English Email: [email protected] For most women is a time of Dictionary defines intervention as the act of transitions and major life changes. Giving intervening, and to intervene is to come in or birth is a dramatic life event which has a • Maralyn Foureur BA, GradDipClinEpi PhD between things so as to hinder or modify them Professor of Midwifery profound influence on a woman and can create (Allen, 2000). If we consider a physiological Centre for Midwifery both positive and negative emotions (Beech birth to be one in which the woman is able Child and Family Health, & Phipps, 2004; Edwards, 2005). Birth is a to labour and give birth in her own space and University of Technology Sydney physiological process that can be shaped and time, with no interference to her physiological Australia influenced by societal expectations, culture rhythms, then any care practice that hinders and emotions and is seldom just ‘a biological or modifies this could be considered to be act’ (Davis-Floyd & Sargent, 1997). During an intervention (Kitzinger, 2005). This and birth women will come into would suggest that many actions undertaken contact and have care provided by midwives by a during labour could also be and/or the medical profession. Care that is considered an intervention. One such care Abstract: provided during labour has the potential to practice is the vaginal examination which can influence the labour and has an impact on Giving birth is an important life event and care be undertaken frequently and routinely during the woman’s feelings about her labour and practices that occur during labour and birth labour (Cheyne, Dowding, & Hundley, 2006). birth (Beech & Phipps, 2004). Midwifery In order to undertake a vaginal examination can have a lasting influence on the mother has a philosophy which seeks to sustain the (also known as an internal) the midwife and the family (Beech & Phipps, 2004). The health of the woman and baby throughout must break the woman’s concentration and use of regular, routine vaginal examination to the childbirth process and provide holistic interfere with the rhythm of her labour. She assess the progress of labour is one such care care which considers the social context and must ask the woman to adopt a in practice. There are two ways of viewing the personal identity of the woman (Lane, 2006). which the examination can be undertaken and vaginal examination during labour. The first Within this philosophy is the need to promote then perform what is an intrusive and very regards the vaginal examination as a physically and facilitate the physiological processes of intimate examination. It has the potential to invasive intervention which can have adverse birth (NZCOM, 2008) and to keep clinical cause distress and pain both physically and psychological consequences (Kitzinger, 2005). intervention during the birth process to a psychologically. The second sees vaginal examination as an minimum (NICE, 2007). essential clinical assessment tool that provides On the other hand, many would argue that the most exact measure of labour progress DEFINING INTERVENTION the vaginal examination is an essential clinical (Enkin et al., 2000). This paper explores these assessment tool which can provide reassurance two viewpoints in more detail and discusses Generally when we consider clinical to both the mother and the midwife that the interventions we discuss practices such as labour is progressing towards the birth. A the benefits versus the harms of undertaking a artificial rupture of the membranes (ARM), woman may ask the midwife for a vaginal vaginal examination during labour. Midwives intravenous syntocinon to accelerate examination as it reassures her that she is use a variety of skills and observations to assess labour, epidural anaesthesia, instrumental making progress. Whilst the majority of labours labour progress. The vaginal examination is an and caesarean births (Tracy, 2006). In will progress physiologically towards the birth, important clinical assessment tool that should many countries the rates of these types of for some women this may not be the case. The be used carefully when there is a need for intervention are increasing, whilst the rate of vaginal examination can provide information more information to help understand labour normal birth is decreasing (Tracy, Sullivan, which can be used to confirm normality or and whether it is established and progressing, Wang, Black, & Tracy, 2007). Interventions identify pathology. Regular cervical assessment taking into account both the potential harms of various kinds have become a routine part by means of a vaginal examination can provide and benefits. of intrapartum care with only a small number a measure of labour progress reassuring both

New Zealand College of Midwives • Journal 42 • May 2010 21 the midwife and the woman that labour is Whilst many still consider a dilation rate of some women a rate of 0.3cm an hour may also progressing toward the birth in a normal way. 1cm an hour to be the norm for labour based be considered normal but consideration of on Friedman’s curve (Arya, Whitworth, & other factors such as the frequency and quality How should midwives view the vaginal Johnston, 2007), this rate of cervical progress of uterine contractions and state of wellness examination during labour? Is it an intervention has been challenged by more recent research of mother and baby should also be taken into or an essential clinical assessment tool? This from both midwives and obstetricians (Albers, account (Albers, 2007). paper examines this dichotomy in more 2007; Gurewitsch et al., 2002; Lavender, depth by reviewing the research around Hart, Walkinshaw, Campbell, & Alfirevic, Our understanding of labour progress has vaginal examination and labour progress. The 2005; Zhang, Troendle, & Yancey, 2002). been developed without input from women and may not resonate with the woman’s actual arguments for and against vaginal examinations Albers (2001) used nine midwifery sites in experience of labour as it progresses to birth. are examined, along with a discussion on the the USA in which there were care measures Labour is a unique process which only women benefits versus harms of undertaking vaginal to keep birth normal such as social support who labour and give birth have experienced. examination during labour. and non pharmacological methods of pain relief, activity and position change. With data Any theory of labour progress should be able from these centres she was able to calculate to describe physiological labour as experienced Background descriptive statistics collected over one year by women. Walsh (2007) argues that the early from 2,522 women. Her results demonstrated descriptions of the rhythms of labour are based Defining labour progress a slower progress of labour without an increase on clinicians’ knowledge and are not woman The seminal work defining labour progress in complications for the mother or baby. centred. Midwives have invented euphemisms was undertaken during the 1950s by She suggests an alternative rate of cervical for early labour because to record a long length Emmanuel Friedman an American dilatation of between 0.3cm and 0.5cm per of labour puts the woman at risk of intervention obstetrician. He argued that of all the hour (Albers, 2001). once admitted to hospital (Walsh, 2007). For midwives it is important that our understanding observable events that occur during labour Zhang et al (2002) analysed retrospective labour of labour progress remains woman centred such as uterine contractions and descent of information from 1329 nulliparous women and incorporates the woman’s perspectives and the presenting part, it was cervical effacement provided with contemporary obstetric care. understanding of labour progress. and dilatation which he identified as being Their sample included women with epidural the most appropriate measure of overall analgesia and oxytocin augmentation. Whilst Frequency of vaginal examination progress (Friedman, 1954). The concern these interventions would not usually be With labour progress defined by measurement was that a prolonged labour increased the considered a part of physiological birth, the of cervical dilatation the question arises incidence of adverse outcomes for the mother authors argued that they wanted to provide as to how often the measurement should and the baby. Time parameters were defined parameters of contemporary childbirth. Their be undertaken. At present there is little so that abnormalities of labour progress could results demonstrate marked differences to the consensus on the optimum timing of vaginal be identified and action taken. Friedman Friedman curve. They found the dilated at examination during labour (Enkin et al., 2000). developed a cervicograph to provide clinicians a substantially slower rate in the active phase than In practice there is a range of frequency with with an objective way of measuring labour Friedman’s curve, taking twice as long to dilate some studies describing vaginal examinations progress (ibid) and which was later developed from 4 to 10 cm (5.5 hrs versus 2.5hrs). They being undertaken as often as every two hours to become the partogram. However, whilst suggest that it is not uncommon for there to be no Friedman described labour progress in perceivable change for more than two hours prior (Lavender et al., 2005; Pattiinson et al., 2003), what he considered a ‘normal labour’ the to 7 cm and that the rate of cervical dilatation whilst Albers (2001) stated that in her study understanding of what constituted normal was below 1 cm per hour. They conclude that clinicians undertook a vaginal examination was culturally influenced. The expectations the criteria for diagnosing prolonged labour or ‘periodically’, when maternal behaviour or and understanding of labour during the 1950s dystocia are currently too stringent for nulliparous clinical signs suggested a need for one. were vastly different to our contemporary women (Zhang et al., 2002). understanding of physiological birth. In his Partograms to monitor normal labour sample Friedman did not exclude women with In their observational, longitudinal study progress of 403 multigravid women in spontaneous malpresentations, malpositions or multiple When measurement of the cervix has been labour, Lavender et al (2005) found that and the usual care practices of the undertaken there is a need to record and assess progress was dependent on the initial cervical day were to give women enemas, pubic shaves dilatation at presentation in labour. They progress. Many countries and hospitals use a and high levels of strong medication. Women conclude that a universal definition of failure partogram to record and assess whether labour were left alone, unsupported and expected to progress and therefore pathology during is progressing within normal parameters. Based to labour on their beds. Subsequent research labour is inherently difficult to identify on Friedman’s (1954) original cervicograph, the has developed our understanding of the because labour is a complex combination of partogram was developed to enable clinicians complexity of labour and how the interplay physiological and psychological processes. to identify labour dystocia (Philpott & Castle, of hormones (which are necessary for labour 1972). However the benefits or harms of using to move towards birth), can be influenced Albers (2007) argues that with an improved a partogram are still under debate (Lavender & by isolation, lack of emotional support, and understanding of the physiological processes of Malcolmson, 1999). There is little consensus the inability to move with contractions into labour there is a need to ensure patience with about the use of the partogram and a variation positions in which gravity assists labour the labour process. The first stage of labour is in types of partogram used in many units in (Buckley, 2005; Enkin et al., 2000; Foureur, far slower than 1cm/hour and a rate of 0.5cm the United Kingdom and around the world 2008; Odent, 2001). an hour can be considered normal. Whilst for (Lavender, Tsekiri, & Baker, 2008). There are

22 New Zealand College of Midwives • Journal 42 • May 2010 concerns that rigid interpretation of cervical midwifery profession of how we define and these factors can be variable, overall the dilatation without consideration of other monitor physiological birth. If we accept that vaginal examination is an important skill that indicators of labour progress could result in the vaginal examination is an intervention, is it midwives should develop and which can help increased levels of other clinical interventions a tool that should be used in a regular, routine them to interpret labour rhythms and signal (Albers, 2007; Lavender, O'Brien, & Hart, way to ensure that labour is progressing? deviations from the physiological process. 2007). Many partograms have an expectation Indeed for many midwives it has been the use that regular vaginal examination is done In their exploration of the nature of childbirth of the vaginal examination that has helped routinely and regularly (every four hours) so knowledge, Downe and McCourt (2004) them to develop their skills in observation that the progressive dilatation of the cervix can suggest that, when assessing whether an of labour by improving their abilities to be assessed, monitored and documented. intervention should be undertaken for an understand the signs of labour progress individual, the extent of the benefit or harm that may vary with each woman. For newly In many countries intrapartum care is provided should be considered along with other graduated or less experienced midwives the by multiple caregivers (Hodnett, 2000) and aspects of the physical, social, spiritual vaginal examination can be seen as a means women receive care in an unfamiliar hospital and psychological environment (Downe & of developing an improved understanding of setting from midwives who are not known to McCourt, 2004). What then are the benefits each individual woman’s labour as it progresses them (Albers, 2007). In these circumstances and what are the issues or concerns that could towards birth. Having the skills to understand there can be differences between how each cause harm to the mother or child when and interpret labour is important to midwives midwife provides intrapartum care as well as undertaking a vaginal examination? and is developed through the experience of how they interpret the progress of labour. In working with and being alongside women these situations using a partogram can be a The benefits versus the during their labour. valuable means of exchanging information harms of the vaginal and it can help in the handover of information between caregivers, other health practitioners examination Psychological harm and physical and between shifts (Lavender & Malcolmson, pain Benefit and rationale for 1999). By providing a visual representation of Vaginal examination can be distasteful for undertaking a vaginal examination the labour it can be a mechanism for ensuring some women due to the intimate nature of that the capture and exchange of information Whilst the majority of women will have a the examination and can be very distressing is available in a pictorial/graphical format. The physiologically normal labour and birth there for others (NICE, 2007). Devane (1996) partogram can be a valuable mechanism for are a minority who will not. Understanding suggests that prior to childbirth, women standardising labour care especially when there when a labour has deviated from the normal regard the as mainly associated with are multiple caregivers who have no pre-existing physiological processes and the reasons for sex and therefore has a sexual function but relationship with the labouring woman. the deviation are important (Thorogood & during labour and with the first vaginal Donaldson, 2006). Vaginal examination examination it changes status as the role of Arguably, when there is continuity of midwifery provides a variety of information, such as the vagina for giving birth becomes more care – as there is in New Zealand for the fetal presentation, position and descent of significant. He argues that the vaginal majority of women (Ministry of Health, 2007), the presenting part along with information examination can cause anxiety and be midwives can observe and individualise care on cervical effacement, consistency and embarrassing for both the woman and the for that woman depending on the labour, their dilatation of the cervix (Thorpe & Anderson, midwife (Devane, 1996). observations of the labour and the preferences of the woman. In New Zealand the Midwives Handbook for Practice (2008) states that the midwife should identify when there is a need for vaginal examination and discuss this The vaginal examination is an assessment with the woman (NZCOM, 2008). Decisions and care provision during labour important skill that midwives should be based on individual needs with midwifery care provided accordingly (ibid). In should develop and which can contrast, in the United Kingdom (UK) where there is less continuity of carer and a higher help them to interpret labour likelihood of multiple caregivers during labour, the NICE guidelines for intrapartum care rhythms and deviations from the (2007) recommend that vaginal examinations be undertaken regularly and routinely (every physiological process four hours) once labour is established to ensure that the labour is progressing towards the birth (NICE, 2007). 2006). When put into the context of what However, for some vulnerable women the The United Kingdom and New Zealand have is happening to the woman and her labour vaginal examination can be more than just different models of midwifery care which with regards to the length, strength and embarrassing, it can cause feelings of loss influences how midwives within these countries intensity of the contractions, the midwife can of control and have psychological sequelae. practice. However, regardless of where a midwife improve her understanding of that individual Parratt (1994) undertook a small qualitative practices there remains a concern within the woman’s labour. Whilst interpretation of study exploring the childbirth experiences

New Zealand College of Midwives • Journal 42 • May 2010 23 of women who were survivors of incest. She of washing the woman’s genitalia. This she half of the women reported that the vaginal found that intimate touch could be linked argues could be a strategy to establish power examination was painful and distressing at some to unpleasant associations for these woman. differentials (ibid). point with 42% reporting it would have been Many aspects of childbirth triggered memories difficult to refuse the examination. of the incest, however internals and touching Bergstrom and colleagues (1992) also found of the vagina during labour caused feelings issues of ritualisation of the procedure and There is little other formal research looking of vulnerability and loss of control (Parratt, the exercise of power over the woman by the specifically at the woman’s perspective of pain 1994). Parratts’ research is supported by caregiver during labour in their USA-based during vaginal examination, and none which Robohm & Buttenheim (1996) who explored ethnographic study. They examined the takes into account continuity of care models the gynaecological care experiences of frequency and use of the vaginal examination of maternity, informed consent, and shared adult survivors of childhood sexual abuse, during the second stage of labour (Bergstrom, decision making. What is available is found in compared with non abused women. Using a Roberts, Skillman, & Seidel, 1992), birth stories or other anecdotes from the United self administered survey they found that the revealing a variation of between two and 17 Kingdom. These suggest that women find survivors reported more intensely negative vaginal examinations whilst for one woman vaginal examination painful regardless of who feelings during a vaginal examination than the procedure was done following every is undertaking it, whether midwife or doctor did the non abused women (Robohm & contraction. The stated purpose of using a (Beech & Phipps, 2004). Whilst pain is part Buttenheim, 1996). vaginal examination during the second stage of a physiological labour, the ability to work was to assess the woman’s bearing down efforts with the pain is complex and may be influenced Menage (1996) investigated whether and to teach the woman how to push correctly by psychological, spiritual and cultural factors trauma experienced during obstetric and (ibid). Bergstrom et al (1992) question the as well as the physical presence of pain (Leap gynaecological examinations could lead to post necessity of the procedure at this time and & Vague, 2006). It would appear that, unlike traumatic stress disorder. She found that out suggest that the vaginal examination sends an other clinical assessments such as palpation and of a self-selected sample of 500 women, 100 implicit social message communicating the fetal heart auscultation, the act of undertaking a gave a history of an obstetric or gynaecological power and authority of the caregiver. They vaginal examination to assess cervical dilatation procedure that they found was distressing or argue that this demonstrates an inherent can cause embarrassment, vulnerability and terrifying. Of these 100 women, 30 fulfilled philosophy of distrust in the woman’s ability further pain during labour which is often the criteria for diagnosis of post traumatic to give birth unaided (Bergstrom et al., 1992). already an intensely vulnerable and painful time stress disorder. These women described feelings for women. of powerlessness during the procedures, Both Bergstrom et al., (1992) and Stewart felt that they had been given inadequate (2006) have used a critical feminist approach The use of vaginal examination can also be information, had experienced physical pain within their research. In this approach women seen as disempowering for women with the and found an unsympathetic attitude on the are viewed as oppressed by a patriarchal perception that the childbirth professional part of the examiner. Nine of the women had a culture. Women’s experiences are the will trust the ‘science’ rather than woman’s past history of sexual abuse or rape in addition focal point of the research and the issue is knowledge of their body or their labour to the obstetric or gynaecological trauma understood from the woman’s viewpoint. Issues (Beech & Phipps, 2004). This may occur (Menage, 1996). Despite the small sample sizes of power and gender control can be identified when the woman is labouring well but on and the subjectivity of the participants these more easily using this approach. vaginal examination is found to be ‘only’ four studies provide an important insight into how centimetres or where the woman feels like intimate touch can be perceived by vulnerable Contrast this approach to that taken by Lewin pushing but has to have a vaginal examination women during childbirth. and colleagues (2005) in a quantitative survey to confirm that she is truly ready to push (Beech of primigravid women and their perceptions of & Phipps, 2004; Halldorsdottir & Karlsdottir, The behaviour of midwives when undertaking the vaginal examination. The focus of this small 1996). Women can also lose confidence in their a vaginal examination also suggests a level of survey of 73 primiparous women was to explore ability to labour if they discover that there has embarrassment as well as possible issues around the women’s perceptions of vaginal examination been less cervical dilatation than expected. In power and control. In her study exploring during labour in three different maternity these circumstances midwives describe using the midwives and women’s experiences of units in the UK (Lewin, Fearon, Hemmings, distraction techniques as a means of waiting vaginal examination in labour Stewart (2006) & Johnson, 2005). Respondents were asked to longer before undertaking a vaginal examination found that the midwives behaviour suggested fill out a questionnaire posted to them within (Dixon, 2005). high levels of discomfort when undertaking a month of giving birth. The questionnaire a vaginal examination. Stewart (2006) used a had statements about vaginal examination Infection critical ethnographic approach to focus on how from which the women could indicate a range the vaginal examination is discussed with the of responses in agreement or disagreement Infection in the form of puerperal fever has woman and how it is undertaken in practice (using a Lickert scale). The results suggested been described as early as 1599 and has always by midwives. She found two main themes that ‘an encouraging measure of contentment with been a threat to women’s health and their lives she describes as sanitisation through action and the privacy, dignity, sensitivity, support and (Loudan, 1992). Following the introduction of verbal sanitisation (Stewart, 2006). Stewart frequency with which vaginal examinations antibiotics and improved hygiene and health suggests that midwives use a number of verbal in labour were managed’ (Lewin et al. 2005 p status for women, death from puerperal fever and physical strategies to distance themselves 267). The use of a questionnaire restricted the has become extremely rare in contemporary from vaginal examinations. These included the ability of the women to provide information society. However, the vaginal examination use of abbreviations or euphemisms, whilst in their own words and therefore provide real continues to carry a risk of introducing some midwives also used a ritualised method insight into their views. Despite this, nearly infection with chorioamnionitis occurring

24 New Zealand College of Midwives • Journal 42 • May 2010 in between 8 and 12 women per 1000 births judgement that enables midwives to monitor abnormal or disrupted rhythms which may (Lumbiganon, Thinkhamrop, Thinkhamrop, the physiological labour as it moves towards indicate prolonged or obstructive labour. & Tolosa, 2004). Vaginal organisms can be birth from a variety of clues. Within the In particular how do midwives assess that introduced into the cervical canal even during midwifery profession there has been discussion labour is progressing physiologically and sterile conditions (Imseis, Trout, & Gabbe, on other means of assessing physiological what is the evidence around what should 1999) with increased rates of infection in labour as it moves towards birth (Hobbs, 1998; be considered the normal parameters of a women who had vaginal examinations after Stuart, 2000; Warren, 1999). Burvill (2002) physiological labour? There is also a need for premature (Lewis & suggests that midwives have many ways of research exploring the woman’s perspective Dunnihoo, 1995). Babies are also at risk from knowing when a woman is in labour and that of labour as it progresses towards birth and ascending infection with 30% of neonatal they are skilled in diagnosing labour onset the impact of continuity of midwifery care in infections caused by group B haemolytic in women by interpreting the cues provided these situations. Does knowing the midwife streptococcus thought to be caused by vertical without physically interfering with a woman's make vaginal examination less painful for transmission from an infected mother (Stade, body and birthing process (Burvill, 2002). This the woman? To date contemporary research Shah, & Ohlsson, 2004). Therefore the vaginal has been reinforced by research undertaken by suggests that patience with the physiological examination can increase the risk of harm for Cheyne, Dowding & Hundley (2006) which process is required and that there should be a suggests that midwives used information cues women and their babies. reassessment of the current time parameters from the women to help them diagnose labour and the need for partograms especially when including the physical signs such as strength, there is continuity of midwifery care. Discussion frequency and regularity of contractions along with how the woman was coping and what Whilst the use of vaginal examination has a Intrapartum care should be individualised to supports she had around her. However, the long midwifery tradition (Donnison, 1988), the the woman and there is a need to balance the midwives did also consider that the vaginal expectation of regular, routine use to monitor benefits of undertaking a vaginal examination examination was an important factor in cervical dilatation has only developed since with the potential harm that may be caused by establishing whether the woman was in labour. the 1950s, and has an underlying discourse of the intervention itself. The use of the regular They suggested that there were many aspects controlling the parturient body through use of routine vaginal examination is questionable of the assessment that should be considered time limits. when the midwife is seeking to individualise such as cervical consistency, confirmation of care to each woman in labour. presentation and application of the presenting Midwives have a body of knowledge that part, and effacement in conjunction with is unique to midwifery. It is a combination cervical dilatation when making a judgment as of knowledge, experience, intuition and to whether labour was established (Cheyne et Conclusion al., 2006). Vaginal examination is a physically invasive procedure which can have psychological Arguably a vaginal examination during labour consequences causing disruption to the can be considered both an intervention and natural body rhythms as well as emotional an essential clinical assessment tool. Assessing A VAGINAL and physical pain (Edwards, 2005). The birth cervical dilatation can help midwives determine process is individual to each woman and there whether there is a normal presentation EXAMINATION is a wide range of what can be considered and rhythm to the labour. However, it can physiological. At the same time, the vaginal also disturb the fine balance that supports DURING examination is also an important and essential physiological birth. assessment tool which can help midwives understand labour and whether it is established LABOUR CAN Understanding the normal rhythm of labour is an important facet of midwifery and progressing (Cheyne et al., 2006). It can BE CONSIDERED care, and whilst the actual mechanisms that reassure both the woman and the midwife that initiate and promote labour are complex the labour continues to be physiological in its BOTH AN and poorly understood it is generally rhythms. agreed that labour progress is mediated by INTERVENTION hormones that stimulate and govern uterine Arguably, the vaginal examination can be contractions (Baddock & Dixon, 2006). considered both an unnecessary intervention AND AN Effective contractions lead to progressive and an important clinical assessment tool. It dilatation of the cervix and to the birth of may be an unnecessary intervention if used ESSENTIAL the baby. However, there are some conditions routinely and as part of standardised labour such as malpresentation, cephalo-pelvic care. Vaginal examination should be used disproportion and obstructive labour which judiciously when there is a need for more CLINICAL lead to a prolonged and difficult labour or information that cannot be gained from birth and a need for obstetric intervention observing the various external aspects of labour. ASSESSMENT (Thorogood & Donaldson, 2006). More Interpreting labour progress is complex and research is necessary to improve our requires experience, knowledge and judgement TOOL understanding of the normal rhythms of which is aided by continuity of care from a labour for physiological births, as well as the midwife known to the woman.

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26 New Zealand College of Midwives • Journal 42 • May 2010