Wednesday, 22 January 2014

Sharing the Skills: Supporting birth without the use of vaginal examinations

I have struggled to write this particular post for the past week or so; do I reference, don't I reference. Am I trying to be the 'expert'?  Is this formal, informal.  Argh - round and round I go!  Until a colleague reminded me this is a BLOG post, meaning it's an informal piece of my opinion (see disclaimer thingy).    and breathe........

I can still remember the first Vaginal Examination (VE) I preformed as a student midwife.  I remember two things mainly:

1. I had no idea what on earth I was feeling!

2. That this was a very invasive procedure.

Many units have a 4-hour guideline for VEs to asses the progress of labour; this routine assessment has no real evidence to support it and is still of unproven value in routine midwifery care, despite being recommended by NICE (it is important to acknowledge, that NICE states women should be offered a VE).  VE's can be a very helpful tool in understanding a labour when perhaps midwifery intervention may support the woman in keeping her labour normal, when clarity around labour progress is appropriate, and / or if it will affect the plan of care.  When used as the marker for progress in labour only, VEs can cloud the midwives understanding of what is happening in the woman's birth story and cause the woman to doubt her own body.

The art of Midwifery is the 'big picture', and it is through many different signs that a midwife may recognise where a woman is in her labour.  This awareness is not 'taught', but learnt: learnt from the women as you observe undisturbed birth, learnt from sitting and quietly absorbing the behaviours unfolding in front of you, and learnt from not starting from a place of 'knowing best'.  As a result of this, the thoughts below are not a 'check list' of progress in labour, simply prompts to help you consider the physiology of what may be unfolding before you.  Remember also that all women are different, and every woman and birth can unfold in a way that is unique for them.

Let us consider then, alternative ways of recognising a labour that is progressing:

How low can you go?
When I was a student midwife, I heard the wonderful Jane Evans speak on Breech birth.  In her talk, she described how women get 'closer the the ground' as their labour progressed.  In labour, as those powerful surges increase in intensity, the woman finds it harder to be upright and conserves her energy by moving into positions that bring her down - usually into the all fours, or leaning over a sofa etc.  As a guide, the closer she is to the ground and needs to stay 'grounded', the further along in her labour she is likely to be.

Those wonderful noises
Experienced midwives can often tell where a women is in a labour from those lovely noises she omits; Liz Nightingale wrote an excellent article in Midirs on noises in labour which is well worth getting your hands on. Women, under the influence of Oxytocin in labour, start to withdraw into themselves.  Talking and conversation dwindles (and so too should birth workers!), but the woman will naturally start to moan and groan through those surges; those noises come from deep within her and she has little control over them.

The 'purple' line
If you google this term you will find lots of excellent blogs reflecting on this phenomena, pictures on what you may see and so forth.  My favourite post is in Birth Without Fear which is beautifully written: just read that for a great explanation on the purple line.  I love the purple line; once you recognise it you can't fail to notice it.  Just wish bottoms came with a little gauge - you know, when it's this height the cervix is x-cms etc!

This is a woman who smiled
most of the way through her labour!
Sense of humour failure
When the woman is no longer smiling, then we are in serious business (except for those women who are having serene, orgasmic births - they smile a lot).  Humour can really help a woman in labour as it can ease tension.  If you follow her guide however, the more serious she becomes the less she may appreciate wise-crack jokes from her supporters, and the more likely her labour is advancing well.

It's all a bit sticky down here
Around 8-9 cms, women will discharge a sticky, blood-stained mucousy plug as the cervix really opens. Yay!  Even better still, as the cervix becomes fully open, the waters will spontaneously release if they have not done so already.  There is NO NEED to do an ARM if a women is 9 cms and membranes are intact (and yes I have seen midwives do this, because otherwise how will the baby get out?).

Cold Feet
As the uterus continues to work beautifully, the blood circulation will move more and more towards to uterus: this is why women get cold feet as labour progresses.  A German midwife (when I was a student) also taught me that the heat will move 'up the woman's' legs.  At around 5 cms, the heat will start from just above her knees, 8 cms the thighs feel cold, at 9cms, only a small amount of heat is left at the top of her thighs.  We used to have guessing games by gently placing a hand on the woman's thighs to see 'where she was'.  It doesn't always work, but is gentle and non-invasive.  Use the back of your hand to gently asses the coolness of the legs.

Pushing on through
Why, oh why, oh why on earth do some midwives feel the need to 'confirm' the onset of second stage with a VE?  Really?  As a woman moves into second stage, she will start to make grunting / expulsive noises.  These will intensify as the baby moves further down, triggering further expulsive urges.  The woman's body will start to 'open' as the rhombus lifts.  The purple line will be highly visible and prominent.  She will probably poop.  All of this will happen either quickly (as with the foetal ejection reflex), or for the vast majority of women, s-l-o-w-l-y!  Women can tell when they are 'moving' their baby and will often remark they can feel the baby moving down.  If after a period of time of strong expulsive urges, there are no external signs of descent, then a VE may be appropriate.  That time depends on the whole clinical picture.  And No, 10 minutes is not long enough.

There are many other ways of recognising progress in labour without the use of VEs (and please do share them); these are the ones I use to help me recognise that labour is progressing without needing me to 'do' anything other then keep the mother and baby safe and hold the space for the birth.  Observing the woman in a non-invasive way (i.e. not staring at her and 'drinking tea intelligently') normally enables the midwife to sense if something is not 'quite' right and provide the appropriate care to help the mother birth her baby as she needs to.  And this is usually herself.

Midwife angela 

“There is no other organ quite like the uterus. If men had such an organ they would brag about it. So should we” ― Ina May Gaskin


  1. Excellent, thank you Angela :-)

  2. This is SO interesting, thank you for sharing this! I am a midwife student near to graduation and I reallly appreciate this! I've always found VE invasive and I'll defo search and go into the topic :)
    (sorry for my bad english but i'm italian :D)

  3. Thanks for your feedback. Do remember to share other skills you learn so that we can all learn from each other. angela x

  4. Thank you for the mention! I agree we need to share these skills and help others become confident in trusting them. I often feel there is a difference between the little grunty pushes that rotate a baby and the really big irresistible ones that help the baby descend.

  5. Ohh yes - how right you are! Noticed that very audibly last week at a very long birth. Baby needed to do lots of rotations ;-)

  6. Hi Angela - great article :) I am from in Australia...I have been trying to contact you via the email address on the North Surrey Midwives site, and it bounced…is there another email I can contact you on? I am wanting to find out if I can get permission to use an extract of a story on your site, for a book we are writing about healing from traumatic birth. I hope that's ok. You can contact me at that's easier :) Thanks for all you are doing to support women and families in their birthing years. From Melissa at :)

    1. Hi there Melissa; I replied to you via email confirming consent for the story. Not sure where our emails are disappearing to :-( Please try again at but 'yes' I give permission. Best wishes angela x

  7. Thanks for writing this, I really enjoyed it. It's so easy to forget the basics, I remember my first VE like it was yesterday (felt like warm mud!) but until now I hadn't considered writing about it. I've subscribed, please keep writing! x

    1. Thanks so much for reading; planning writing again very soon!