Cervical exams and subjectivity in labor
Childbirth is a complex and often unpredictable process, and Cervical Exams are one way that healthcare providers attempt to assess how labor is progressing. However, these exams are not without controversy, as they can be subjective and uncomfortable for the birthing person.
Before diving into everything cervical exams, it is important to note that anytime a care professional touches you, if for a temperature check or more invasive procedures like a cervical exam, they need to ask for consent ahead of time.
It has become common practice in modern medicine that the white coat receives full authority, no questions asked. Asking questions and understanding procedures better before they happen is one way to mitigate iatrogenic (healthcare provider caused) trauma.
Trust your body and be sure to advocate for yourself if any exams come up that you do not want or need. Having a birth doula or a designated family member as your advocate can help you in times when you may not have the voice for yourself.
In no way should cervical exams be scary or threatening. They can be a useful tool to measure your labor but do not show the complete picture. So, let’s dive into all things cervical examination!
what is a cervical exam?
Cervical exams involve a healthcare provider manually checking the dilation of the cervix, which is the opening at the bottom of the uterus that leads to the birth canal (vagina). The provider may also assess the effacement, or thinning, of the cervix and the position of the baby's head. These exams are typically performed during prenatal appointments as well as during labor.
Note: If your care provider tells you that these are not optional, this is a red flag. You have full permission to say yes or no to any cervical exam.
the process of a cervical exam
The process involves you laying on your back with your legs in a butterfly position. This allows for the easiest maneuvering for the provider. Your provide will put on special sterile gloves often times using a water-based lubricant to avoid friction. Then they insert their fingers and sometimes much of their hand into your vagina, looking for the cervix.
Keep in mind everyone has a different body, sometimes cervices can be posterior, meaning that they face the back of your body. You can have a long and short cervix. These differences all play into the ease, comfort, and accuracy of the measurement during a cervical exam.
As they feel around your cervix, your healthcare provider is checking to see how far apart their index finger and middle finger are. Based on this width, they can “measure” or guess how dilated your cervix is.
Check out Midwife Nation for more detailed information about what is a cervical exam.
If your provider cannot fit their finger into your cervix, it would be considered 0 cm or closed. If they can fit their index finger in your cervix, you would be about 1 cm dilated.
Interpreting cervical dilation
One of the main criticisms of cervical exams is their subjectivity. Different healthcare providers may have different interpretations of how dilated the cervix is or how far the baby's head has descended. This can lead to inconsistencies in care, as one provider may decide to intervene based on their interpretation of the exam while another provider may not.
The subjectivity of cervical exams can lead to changes in your care especially when your healthcare team looks at all aspects of your labor and not just the cervical exam itself. Sometimes the result is letting you continue to labor as you have been, other times this might mean adding Pitocin through an IV to increase the strength and rate of your contractions.
Cervical dilation can have direct effects on your mindset. Some families can become defeated when they hear these numbers, thinking that they are further along in childbirth then they actually are. It’s important to figure out how this number may alter your mind, you can always choose not to hear the measurements.
In certain cases, the subjectivity in cervical exams can confuse families and make them question the reputation and knowledge behind different members of their care team. Check out the real life examples below.
Why are the interpretations of cervical exams so subjective?
There are many reasons why cervical exams in labor are so subjective and therefore interpreting them can be difficult. Your baby’s head, experience level of the nursing staff, hand and finger size, as well as, your individual body are all factors that can contribute to the subjectivity of these exams.
baby’s head versus the cervix
Throughout your labor, your cervix continues to soften, thin, and dilate in size. Your baby’s head is also changing shape and molding to your body in order to fit through your pelvis and through your vaginal outlet.
As you will see after your baby is born, their head is full of rolls and is squishy to the touch. It can be difficult to assess during the cervical exam what is your cervix and what is your baby’s head, leading to differences between your healthcare teams cervical assessments.
hand and finger sizes
Additionally, everyone has different sized hands and fingers. Generally, if your provider can fit 2 fingers into your cervix, then you are two centimeters dilated. Get out a measuring tape and test to see the width of your index finger and middle finger combined, mine is more than 2cm. Because everyone one who conducts cervical exams is of different size, their measuring utensils (their hands) are different size too.
experience with cervical exams
The individuals who are conducting these exams also makes a difference in their reliability, subjectivity, and accuracy. With no offense intended for newer nurses or students, their accuracy is going to be far lower than more experienced nurses or doctors with a large practice versus residents who are beginning their career. Cervical exams take practice.
blind measurement
The final reason why cervical exams can be so subjective is because it is a blind measurement! Unless you used a speculum and a measuring tape inside your vagina, there is no visual indication of where your cervix is at.
Despite these factors, cervical exams are still commonly used during childbirth. Some healthcare providers argue that they are necessary to assess how labor is progressing and determine when interventions, such as induction or cesarean section, may be necessary. However, there is growing recognition that cervical exams should be used judiciously and with the birthing person's consent.
Real life example of cervical exam subjectivity from my experience as a birth doula
A perfect example of cervical subjectivity occurred while I was supporting a birthing family in March. Their nurse had conducted a cervical exam stating my client, Mary (name changed for privacy), was 6cm dilated. Her physician came in about an hour later to check on her and asked to perform a cervical exam, Mary agreed, and the provider noted that Mary was at 4cm.
After her physician had left the room, I could visibly see how upset, confused, and defeated Mary was. Receiving these conflicting numbers sends a flurry of emotions and feelings throughout the body, causing Mary to believe something was wrong. This is where our healthcare teams need to communicate better, before stressing out the families they serve.
Mary was able to relax and feel confident again as we talked about this subjectivity, especially when she was reassured that she did not regress in labor dilation. In labor your body and cervix moves forward, there may be stalls, or longer durations at a particular dilation, but your body does not begin to close again until after your baby is born.
Cervical dilation does not give any clues to how quickly labor will continue to progress. I have been apart of many labors where women move from 6cm to 10cm within an hour. And then I have been apart of others where labor from 6cm to 10cm takes 4 hours or more.
alternatives to cervical exams and how to advocate for yourself during childbirth
One alternative to frequent cervical exams is the use of non-invasive methods to assess labor progress. For example, monitoring the strength and frequency of contractions or using ultrasound to estimate the size and position of the baby can provide valuable information without the need for manual exams.
Another approach is to limit cervical exams to situations where they are truly necessary, such as when there is concern about the baby's well-being or when a decision needs to be made about whether to intervene in labor. In these cases, healthcare providers can explain the rationale for the exam and obtain the birthing person's consent before proceeding.
How to advocate for yourself:
Create a birth plan and explicitly state you do not want cervical exams
Ask for the detailed reason why they want to check your cervix
Discuss other ways that your provider can measure your labor progress
If you do have a cervical check, you can ask your care team to not tell you your cervical dilation.
Conclusion on cervical exams and their subjectivity
Ultimately, the use of cervical exams during childbirth is a complex issue that requires careful consideration of the risks and benefits. While they can provide valuable information about labor progress, their subjectivity and potential for discomfort and infection should not be overlooked. Additionally, cervical exams do not tell you things like how quickly your labor will progress, when your baby will be born, or whether your induction will be successful.
Healthcare providers and birthing people should work together to determine when and how cervical exams are used, with a focus on promoting the health and well-being of both the birthing person and their baby.
My hope is that this blog post added to your knowledge of cervical exams and empowers you to use this information throughout your labor and birth journey. As always, wishing you RADIANT light as you birth your unique way.