A note on vaginal exams:

Vaginal exams have a bad rap in midwifery and I’d like to debunk some of the myths in an effort to bring balance to this profession that has shunned ‘medical model interventions’ to the point of extremes.

• You should avoid exams at the end of pregnancy

Routine exams starting at 36 weeks should be avoided, so should un-informed, non-consented cervical strip/sweeps. But, avoiding all exams at the end of all pregnancies is basically the same as always doing one. Assessing the cervix and babies position at the end of pregnancy is a tool - and appropriately employing this tool can save countless fruitless hours of non-productive labor, failed inductions, failure to progress diagnoses, and unnecessary transports. Bottom line question to ask and discuss with your client: “What would we do with the information gained in an exam?” If the answer is nothing - wait for labor - that's not a useful assessment. But if a more complex decision-making process is at hand, this assessment might be just the data you need to help inform a choice that decreases stress, worry, anxiety for birther AND midwife. For instance, if you can't tell if baby is head down at 39 weeks - an internal exam even on a closed cervix can show the characteristic bounce of the head OR NOT and is VERY helpful data for decision-making.

• A good midwife should be able to assess labor progress without an internal check

Bull. A good midwife gets better and better at ‘seeing’ where their client is in labor the more experience they get, but there is never going to be 100% accuracy. Again, if you have a choice point and need the data to help make a decision - then offer/recommend, get consent and do one.

• Moms don't want vaginal exams

Actually, birthing people often DO want to know if they’re progressing, especially in dysfunctional labor. When you make this judgement call for them without discussing it, you rob them of sovereignty.

• It's all squishy in there anyway - I wouldn’t learn anything helpful

If you think this, than you obviously haven’t done very many exams. Once you understand the biomechanics of birth, you can start doing exams. I maintain that it isn’t until 100 births past licensure that you become an expert at the vaginal exam and that's only IF you do exams at most of those births. You only learn this if you do it regularly, so do all your future clients a favor and get good at this skill.

• If the water has broken, its especially important to avoid exams

Nope not true. It’s especially important to know what position a baby is in at the start of labor, if you don't know this, the risk of infection is less than the risk of unplanned breech, or prolonged dysfunctional labor for other malpresentations.

• Doing an exam increases the chance of unintentional AROM

I don't think so. I've been doing exams when warranted for clients for almost 25 years and I have only had one unintentional AROM in all those clients and within 4 hours of that AROM at 4 cm, she spiked a fever. Infection does not develop that fast, she had chorioamnionitis brewing already, that's what caused the bag weakness in the first place. Vigorously stripping the membranes can increase the AROM risk, but for full-term, risk-assessed, normal clients a midwife gently, slowly assessing (not moving) the cervix, bag, and baby does not bring anymore risk then sex at term in my opinion.

• Labor plateaus are normal

No, they’re actually not. I know this is controversial, but I will hold firm on this. Labor plateaus always spell dysfunction. Do we tolerate them - even encourage them sometimes - yes. But once active labor has started - NORMAL labor is progressive. If it's not, it needs investigation - a vaginal exam is one of the best ways to investigate and assess what is going on.

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