When you’re pregnant, one of the first “tests” that doctors will do is internal exams. They want to know if your uterus “feels” pregnant. Most doctors will also start performing internal exams again in the final weeks of pregnancy (usually from about 37 weeks) to check for dilation and give you an idea of when your baby might come. But is this practice really evidence-based?
Why You May Not Need Internal Exams
Most women don’t even question it. Of course we get internal exams; it’s a part of pregnancy! Right?
Wrong.
Internal exams have become par for the course, but that doesn’t mean they’re evidence-based. In fact, a 2013 review showed that there is no solid evidence that vaginal exams are beneficial in labor.
A 2010 study looked at vaginal exams early in pregnancy, around 8 weeks, and found that they had no benefit.
A 2011 study looked at vaginal exams in the first trimester of pregnancy, when women showed up in the ER with bleeding or other symptoms — and still, it showed that in 94% of cases, internal exams had no benefit!
If exams have no benefit in the majority of symptomatic cases, then they clearly have no benefit in a normally-progressing pregnancy! There are, to date, no studies proving any benefits in a normal, healthy pregnancy.
Why Do Doctors Perform Internal Exams, Anyway?
Good question.
Historically, these exams date back to the early 1900s. We’re not quite sure why they got started. A lot of practitioners today will claim them as a “necessary” part of pregnancy.
Midwives will often perform internal exams only in labor, and then only upon request or once it is clear the mom is in or near transition. Some midwives will perform one early on, and/or if the mom is experience any spotting or other concerns, but this is much less common.
Many practitioners will claim that internal exams are necessary to “check on the pregnancy.” Does the uterus feel like it is expanding appropriately? Is the cervix closed (or, is it opening, if at the end of pregnancy)? Are there any polyps or anything unusual on the cervix (polyps are harmless, by the way)? Many practitioners feel better knowing that they’ve used one more diagnostic tool in their arsenal to check that the pregnancy is progressing normally, and many women do too — because they’ve been told that they should.
Why You Should Avoid Internal Exams
This doesn’t mean that you should actually consent to an internal exam, though.
They Don’t Provide Much (If Any) Information
Practitioners can feel the size of the uterus externally in most cases; they don’t need to do so internally (especially after 12 weeks). If there are symptoms, than an ultrasound, blood or urine tests, or other less or non-invasive tests can be used. As mentioned in the studies above, pelvic exams did not increase the diagnostic accuracy.
Information Provided is Often Unnecessary
Do you need to know how far you are dilated? Dilation is no guarantee that baby won’t come tomorrow…or hold out another few weeks. Women can and do walk around dilated up to 6 cm for weeks at a time, while other women do not dilate at all until active labor.
Do you need to check the size of the uterus at only 8 weeks along? If all other pregnancy signs and symptoms are normal, this is just extra, unnecessary information.
Risk of Infection
Every time an exam is performed, there is a risk of infection. Even with a practitioner wearing sterile gloves. Bacteria can be anywhere and everywhere, and introducing it to the cervix so directly increases the risk of infection. Since there is no benefit to the exam, this risk is unnecessary.
May Cause Bleeding
A woman’s cervix is extra sensitive during pregnancy, so unnecessary handling may cause it to bleed. While this is minor and temporary, it can certainly worry you AND your doctor, possibly leading to another internal exam and/or ultrasound, which would be unnecessary and could cause further problems.
May Give False Hope/Upset
Unfortunately, your uterus feeling “good” during an early internal doesn’t mean that you won’t lose the baby days later. It also doesn’t mean that if you are 3 cm dilated at 37 weeks that you will go early! (Nor does it mean if you are tightly closed and not effaced that you won’t have the baby that night.)
There is very little benefit to receiving vaginal exams during your pregnancy.
However, if there is a problem suspected with the cervix and there is no other way to get the information, a pelvic exam may be needed. For example, if you suspect that you are dilating and it is well prior to your due date, a pelvic exam could let your doctor know if your cervix is changing and if steps will be needed to stop pre-term labor.
What About Pelvic Exams During Labor?
Do you need vaginal exams leading up to labor, or during labor?
Leading up to labor, there is no possible way to tell when you will go into labor based on a cervical exam. It is possible to be 6 cm dilated and fully effaced (usually with a fourth or fifth baby, not your first!) and not go into labor for a month. It is also possible to be completely closed and go into labor within hours. Your cervix’s stats are not predictive of labor.
It is possible (though still not likely) that you will know “your” pattern once you are having your second or third baby, and will be able to tell if you are likely to go into labor soon, but every baby is different so this is highly unreliable. Plus, if you need to, you can learn to check yourself, which would minimize the risk of infection.
(Small side note: I had an hour or so of mild contractions 9 days before my oldest son’s birth, during which I went from about 1 to 3 cm, which is where I was when starting labor. And it was still nine days until I went into real labor.)
During labor, vaginal exams aren’t really necessary either. Early in labor they don’t tell you anything. You may or may not be dilated, but as long as you are contracting, you are probably in labor (I say “probably” because you may have strong Braxton-Hicks that will go away after a few hours).
As long as you are full term, it doesn’t matter either way. Relax, go to bed, do whatever you feel like.
You don’t even need exams if your water breaks — and the risk of infection rises once your water has broken, so avoiding exams is an even better idea. There is a special paper you can use when you go to the bathroom. It will change color if what dribbles on it is really amniotic fluid.
Once you’re well along in labor, you may want to be checked to see if you are making progress. This is up to you. Some women feel like regular “progress reports” are encouraging. Other women, though, may be discouraged if they are not very dilated or not progressing quickly, and this could slow progress even further. It’s best to keep exams to a minimum unless you really, really want to know (and can’t/don’t want to check yourself).
Some doctors or midwives like to check every hour or at least every few hours to get a sense of how you are progressing. This is problematic in a hospital setting, because doctors will make decisions on whether or not to augment labor based on dilation. Cervices do not have clocks, and do not dilate steadily and predictably. Labor progresses as the cervix dilates, effaces, and baby moves down. These all happen at their own rates. Some women dilate first and then baby moves down. Others have baby move down first and then dilate. A pelvic exam can lead to arbitrary guidelines that are not at all evidence-based, which can lead to Pitocin, which can lead to fetal distress, which can lead to an “emergency” c-section.
There is no way to know, even during labor, how long things will take or what progress is “appropriate” for any given woman. As long as she and baby are doing fine (based on baby’s heart rate and movements, and how she says she is feeling), there is no reason to put time limits on labor. Pelvic exams can prove very discouraging and can lead to unnecessary interventions.
Additionally, sometimes dilation checks can lead to different estimations. Different practitioners can measure differently. The cervix can stretch more during a contraction. Sometimes practitioners will say there is a “lip” (which is actually fairly normal during the dilation process, as the cervix and the baby’s head are not perfectly round). Finally, not all babies’ heads or moms’ pelvises are the same size, so 10 cm is average — some moms are ready to push at 8, and some not until a bit beyond 10. If mom is feeling like she needs to push at 8 and baby is moving down well, there is no reason she must wait until exactly 10!
Ultimately, birth is not a medical condition and in most cases, doesn’t need the type of “management” that occurs. Saying no to pelvic exams is just one way to have a more hands-off experience, which is better for mom and baby — until or unless there is an indication of need for intervention.
The upshot? Minimize vaginal exams. Be aware that there are risks, that everyone’s body and every pregnancy is different. If you don’t feel comfortable, don’t do it unless truly necessary.
I didn’t even know they weren’t routine & necessary – so thanks for this article. I went into my first appointment assuming I’d have one. When I went in at my first appt at 9 weeks, I hadn’t had an internal exam or pap smear in over 18 mos, so my CNM did one. I suspect that she would not have performed one if I’d been “up to date” on my exams (she works out of an OB’s office). In retrospect, I’m glad she did.
She found a cervical polyp, and while she was very honest that it wasn’t anything to be concerned about, I had fair warning up front about the potential for spotting or bleeding, and given some suggestions for what could cause it, and the appropriate time to call for a check up. As a first-time mom-to-be, it has been very reassuring and saved me two or three hour-long trips to have a check-up.
I haven’t had any further internal exams, and at my orientation classes I’ve been told that from here on out my CNM would be pretty hands off, so I don’t expect much in the way of future checks until D-day =)
Thanks again for the great info.
another great thing about my home birth midwife? NO INTERNAL EXAMS. in my 4th pregnancy, none. i asked for some towards the end of my 3rd (4 centimeters and completely effaced for one month and she was not coming out until she did), but none during labor which was wonderful. even when it came to pushing, she just let it go naturally. i did have an internal on my last physical (with my regular doc, who i don’t ever see, and i was 6 weeks pregnant) and i requested no pap. she mentioned my uterus was large and high (normal for me) but i let her do the exam for her own sake, not for my or the baby’s health.
[…] Internal Exams […]
I am SO glad that you wrote this!
I have always been of the opinion that pregnancy, labor, and childbirth are completely natural, normal processes that my body knows how to do without need for outside intervention. Like, my body was *literally* made to do exactly this!
In the absence of maternal or fetal distress, the only real purpose served by an internal vaginal exam is to prop up the otherwise insecure ego of an allopathically trained OB/Gyn,thereby perpetuating patriarchy, mansplaining, and misogyny.
Our society teaches a woman that she cannot possibly know her own body better than a man. We teach women that they cannot trust themselves to know, understand, and heal their their own bodies without approval from some external authority. Like needing a priest because you don’t have gods phone number.
It’s nothing short of institutionalized rape culture. I’ve never had an ON give me the option of not having one, nevermind ask which I prefer. My pregnancy and birth experiences with my daughter…well let’s just say I wouldn’t wish them on my worst enemy.
Just one more reason out of a thousand that I will never trust another MD. At this point, I’d sooner amputate my own arm than look to an MD for assistance removing a splinter.I
It would have been quite useful to know back in high school that “Guillian Barre” is just MD French for “flu vaccine injury.” Took me twenty years of pain and misery, letting them poison me with hundreds of toxic scripts before I finally figured out how to conjugate *that* verb.
“Fibromyalgia,” “CFS,” and “Lupus” are simply the new jargon for what once was termed “Hysteria.” You can take the uterus out of the woman but apparently that’s just a good start.
@Lydia976