Cervical Checks at the End of Pregnancy - A Help or a Harm?
In our system, it has become normal for a woman to have her cervix routinely checked at prenatal appointments as she reaches full term and every week during that time until her baby is born. Like many things in our maternity care system, just because it is common or routine does NOT make it in the best interest of you or your baby.
I'll get right to it: There is no evidence to support routinely touching and checking on a woman’s cervix at the end of pregnancy. None. In fact, it could actually be harmful.
The status of a woman’s cervix through a cervical check (also called vaginal exam or pelvic exam) means pretty much nothing except where it is at that exact moment. A woman can go from a firm, tightly closed cervix in the afternoon and have a baby that evening. She can have a soft, 4cm open cervix one afternoon and not give birth until a month later. A cervix can even go *back* in dilation. Think about what might happen when you get that feeling you might need to have a bowel movement but then the doorbell rings! It can work in a similar way. The cervix is a dynamic sphincter (dynamic as in changeable although I do think it’s pretty awesome as well!). It responds to our hormones which respond to our emotions or current situation. As the saying goes, "the cervix is not a crystal ball." (Okay, it's a saying in the birth world, at least.) It cannot tell you how long until you will have your baby. How it is at any given appointment means virtually nothing.
Why not "just" get checked anyway? Well, studies show that weekly checks increase the risk of a woman’s water breaking prematurely. This is important. One study showed a threefold increase in risk for women who had routine checks versus those that didn't (6 to 18%). A premature rupture of membranes (PROM) puts her and baby at greater risk for birth before baby and her body are ready. When baby isn't ready but forced out before his or her time, it increases the risk of NICU admission, trouble breathing, infection, and more. A water broken too early also increases the risk of infection for mom and increases the use of unnecessary interventions like induction and pitocin which then have their *own* risks to mom and baby.
The cervical check itself also increases the possibility of infection. Any time someone introduces their hand or an instrument into your vagina, there is a risk of bacteria entering and causing an infection. As many women can tell you, a cervical check can also be mildly uncomfortable to extremely painful, depending on the woman's anatomy, as well as the skill of the provider. It can cause cramping or spotting later that causes unnecessary worry and discomfort. For someone with sexual trauma in their past, a vaginal exam can be especially important to avoid, especially when it is being done without reason or with manipulation or coercive language. Let's not forget that this is one of the most private and sacred parts of your body and deserves to be treated as such. Put bluntly, no one should be touching or in there without marital or medical reason.
Possibly the most significant drawback? Cervical checks can be be extremely manipulative when their result offers false hope or false discouragement in themselves or from the provider. "I think I'll see you back here in labor tonight!" or "You're 0 centimeters, we might need to schedule you for an induction" should both be met with the same skepticism. Most commonly, a woman hoping to be dilated who isn't almost always begins to feel defeated and lose trust in herself and her body when there is no basis for that at all. It's also important to note here that cervical checks are subjective! They are an estimate using manual non-visible assessment and not an exact measurement.
Is there ever a time when one might be helpful during pregnancy? Sometimes a check can be helpful if an induction is on the table. A check can determine how ready and responsive the cervix might be to pitocin or whether it needs to be "ripened" with an artificial prostaglandin first (usually Cervadil). It might also change what type of induction is offered, possibly whether using a Foley bulb could work or artificially rupturing membranes might be effective and give a woman more options. But again, the cervix can change quickly so take that into account when making decisions and when the check is done versus when the induction is actually started. Things can change by then.
Providers practicing the midwifery model of care (which, important to note, is not all midwives) will not routinely check a woman's cervix. In fact, this is a great question to ask when you are interviewing and choosing a provider, whether midwife or doctor. However, if you do choose a conventional provider and do not want these checks, here are a few tips:
Easiest way to decline? Don't take off your pants or skirt. There's no need to change clothes for routine prenatal appointments! Simply don't change into a gown or take off your clothes.
When your provider tells you it's time to do a check, simply say you won't be getting any checks during this pregnancy. (Red flag alert: if they do want to do one it should always be presented as a question where you are understood to be making the decision and asked your preference, not where you are being told what is going to happen.)
Using the word "consent" is helpful. That word has legal connotation and using it is a sign that you know your rights. This can be done kindly, of course, but unequivocally. "I'm not going to consent to a check today, thank you."
Other options "I won't be getting a vaginal exams today." "I'm not doing that today, thank you." "I'm not comfortable doing a vaginal exam today/this pregnancy." "I'm declining vaginal exams this pregnancy."
If you feel like it would be helpful, you can print off Evidence Based Birth's post here and bring it to an appointment.
If your provider tells you that you "need" one, ask questions. "How will this information be important for me right now?" If they tell you something that isn't true, like about knowing when you will go into labor or even if you are "able" to have a vaginal birth (yes, sometimes providers will use a check to say something like that!), push back. Continue to ask questions "Can you show me evidence that says that? Everything I've read says the opposite." If they keep pushing or do not respect your voice and consent, consider whether you should look into other provider options.
Always remember, no one has the right to coerce or talk you into a vaginal exam. It is always within your right and dignity to decline and that should be respected. No matter who or where it is, violations of that should be deemed exactly what they are: assault or rape.
Skipping routine vaginal checks at the end of pregnancy is evidence based, is almost always safer for you and baby, is a great way to learn how to TRUST your body and its design, and is good practice for taking responsibility for your body, birth, and baby. You have every right and motivation to decline any check you do not truly want. Remember, women have been giving birth for millenia without someone sticking their hand inside of them to check on things. Your body is just as capable as the billions of women before you who have birthed their babies without ever being checked. Know that any intervention requires your consent and you should be comfortable that it is a good choice for you and your baby.