How to Say “No” to This Birth Intervention

Let’s talk about vaginal examinations in labour.

What is it?

A vaginal examination is an internal examination of the vagina and cervix (bottom part of the uterus at the inside end of the vagina) and is sometimes called an ‘internal,’ ‘VE’, ‘vaginal exam’ or ‘internal examination,’ (Reference).

When a labouring woman arrives at a hospital, having an internal vaginal examination is usually the first procedure offered. It’s used to determine if she is in active labour (i.e. should she be admitted to the maternity ward).

Internals can be a source of discomfort, embarrassment and distress for some women (Ying Lai & Levy, 2002; Lewin et al., 2005).

In this article I’ll cover:

  • What is a vaginal examinations in labour?
  • The solution (how to avoid needing one)
  • Are ‘internals’ effective? A look at current research
  • Do women want and consent to this procedure? (Australian survey stats)
  • Why are they potentially problematic?
  • A script for kindly, but firmly, saying “no”

The solution

Let’s start with the solution.

Find a personal midwife to care for you in labour. 1) You can choose for your own midwife to go to hospital with you, or 2) have them attend your home birth, 3) or you can see if your local hospital has a ‘midwifery group practice’ where you’ll be cared for by a known midwife of a group of known midwives.

The way to avoid unnecessary vaginal examinations is midwife-led ‘continuity-of-care’ where a known midwife (or small group of known midwives) support you throughout your pregnancy, labour, birth and after birth. (The World Health Organisation endorses this type of 1-on-1 care so women can enjoy a positive childbirth experience.)

It’s possible to birth without ‘internals’. I’ve given birth twice and never had a vaginal examination in labour…like ever. Private midwives attended my home births. They checked my progress by gently placing a hand on my stomach through a contraction. They tuned into me.

In the days leading up to the birth, before I even went into labour, my midwife had been checking my progress. She would use her hands to (externally) feel my baby’s position in my belly, and feel to see how engaged she thought my baby’s head was. We’d smile, laugh a little in anticipation… and she’d say, ‘still a little while off yet I think‘, or ‘yes, could be any day now‘. We had fun.

The point is connection. If I get to the hospital I plan to birth in, and see the nurse for the first time… she doesn’t know me. She doesn’t know I’m 41 weeks and 1 day or that I’m having my second baby. She doesn’t know any of that. But my midwife did. My midwife had so many ‘progress markers’ to see that labour was progressing perfectly, that she didn’t need to rely on a vaginal examination.

To access this type of care, search for “private midwife in [your city]” or “midwifery group practice in [your city]”.

Are ‘internals’ effective? A look at current research

A high-quality research review of independent scientific evidence has found that ‘there’s no convincing evidence to support or reject the use of routine vaginal examinations in labour, yet this practice is common throughout the world’. (View report). In the researcher’s conclusions they remark, ‘it is surprising that there is such a widespread use of this intervention without good evidence of effectiveness’.

Downe S, Gyte GML, Dahlen HG, Singata M on ‘Routine vaginal examinations in labour’

‘It is surprising that there is such a widespread use of this intervention without good evidence of effectiveness’.

Do women want (and consent) to this procedure?

In a 2012 Australian survey, researchers asked women who had at least one vaginal examination: “Did your maternity care provider(s) discuss with you the pros and cons (benefits and risks) of having and not having vaginal examinations to check the progress of your labour/birth?” and “Who made the decision to have or not have vaginal examinations?”

Gold standard care is defined as women reporting that they made an informed decision to have vaginal examinations (that is, the pros and cons were discussed and they decided from all their available options). It was found that on average only 28% of the Australian women surveyed said they made an informed decision to have a vaginal examinations during labour. (This survey was a Queensland-wide pilot study. You can read more about it here).

Queensland Centre for Mothers & Babies. (2013). Consumer Evaluation Report of Maternity Care Performance in 2012: Mater Mothers’ Private Hospital. Brisbane, Australia: The University of Queensland.

This means that, without consent, more than 7 in 10 women were given a vaginal examination during labour.

The survey also offered direct quotes from women. One Australian women said, “…I was not asked if I wanted it nor was it explained to me. They just said now we are going to give you a vaginal examination.” Another commented, “My experience with the hospital was horrible. I felt vulnerable and bullied into things I did not want to do (eg. continuous monitoring and vaginal examinations). I feel that this experience significantly slowed down my labour resulting in an unplanned caesarean. More non-hospital birth options should be available.” (View report).

Research from the UK identify that many women: (1) want more information before deciding if they want this procedure done and (2) want more choice, i.e. they did not feel able to refuse the procedure (Lewin et al., 2005).

Why are they potentially problematic?

  1. The vaginal is an innately sexual body part. It is private. Having it felt by a stranger is sexual, no matter how kind or disarming or clinical they are. Sexual touch—outside of the context of sex with a loving partner—is awkward at best and traumatic at worst. A women’s ‘primal brain’ needs to know it is safe for labour to progress easily. Just because a sheet is draped over doesn’t necessarily make it feel safe.
  2. Labour progresses if the women feels safe. Internals are done as the primary way to check progress, yet they are invasive. Invasive procedures don’t make women feel safe. The cervix is a type of sphincter—it closes involuntarily if there are perceived threats. Thus, the exact thing that’s done to check progress is potentially halting progress. What’s wrong with this picture?
  3. The routine use of this examination tells me nurses and OBGYN’s aren’t trained in assisting normal physiological births. If they were, they would understand the counterproductive nature of internals (see above) and invent an effective method that helps them understand where a woman is at, while ensuring she feels utterly safe.
  4. 1 in 6 Australian women have experienced physical and/or sexual violence. 1 in 5 Australian women have been sexually assaulted and/or threatened. This procedure may trigger flashbacks for some people. Considering the high potential for negative triggering and the lack of evidence fore or against this intervention, I’m surprised that it is still the primary way of checking progress.

A script for kindly, but firmly, saying “no”

This script was adapted from one of my favourite writer’s script for How to say “no” to everything ever.

Example 1 :

Hey __________.
Thanks for offering to do a _______________.
I don’t feel right about this procedure, so I don’t want to go ahead with it.
Are there any alternatives we can talk about?

Filled in script:

Hey Jenna.
Thanks for offering to do a vaginal examination.
I don’t feel right about this procedure, so I don’t want to go ahead with it.
Are there any alternatives we can talk about?

Example 2:

Hi __________.
Thanks for suggesting I have _______________.
Right now I would prefer not to be checked, so I’m going to decline the __________.
Thank you for offering this to me.

Filled in script:

Hi Roger.
Thanks for suggesting I have an internal to check progress.
Right now I would prefer not to be checked, so I’m going to decline the internal.
Thank you for offering this to me.

Closing thoughts

What if care providers trusted the physiological birth process and didn’t to rely so much on ‘centimetre progress’?
What if internals were given by a known midwife, only if they were requested by the woman herself?
What if it was normal to give birth without a vaginal examination?