Healthy Pregnancy Series: Internal Exams

admin September 8, 2010

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Welcome to the next post in the Healthy Pregnancy Series!  If you haven’t read the older posts, you may want to go back and do that now!

Next week, on the off chance that you’re still in the pre-conception phase, we’ll be taking a journey back to talk about healthy conception, so don’t miss that!  (There will be some healthy ideas to use throughout pregnancy for those of you who are already pregnant, too.)

But now we’re going to talk about everyone’s favorite topic, internal exams.  That is, vaginal or cervical exams.  Do you need them?  When?  Why?  How many?

In a typical obstetrician (or nurse-midwife who is overseen by an OB)’s office, you would likely receive vaginal exams at your initial appointment (around 8 weeks), at 37 weeks (to test for Group B strep and likely dialation), possibly weekly after 37 weeks and almost certainly after 40 weeks; and any time you experience anything unusual, such as spotting or bleeding. You would also be checked several times during labor, beginning when you enter triage and about hourly thereafter.

In a certified midwife’s practice, you would often not receive any at all until you are in labor, and then only upon request or once it is clear you are in or near transition.  Some midwives will perform one early on, and/or if you experience any spotting or other concerns, but this is much less common.

The reason vaginal exams are typically performed are 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.  Many women do too.

However, vaginal exams before labor are generally useless unless there is bleeding or another serious concern.  Here is why:

1) They don’t tell you much more than could be ascertained by external palpations.  Practitioners can feel the size of the uterus externally in most cases; they don’t need to do so internally (especially after 12 weeks).

2) The information they provide is often unnecessary.  Do you need to know how far you are dialated?  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.

3) There is a risk of infection every time an exam is performed, even with sterile gloves.

4) Exams can cause the cervix to bleed, as it is extra sensitive in pregnancy.  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 in this case.

5) They can give you false security or hope.  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 dialated 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.  There are other ways to get the necessary information to ensure your pregnancy is progressing normally.  With that said, I would at least consider an exam under the following circumstances:

1) Bleeding or spotting that lasts more than a few hours, even with resting

2) Uterus can’t be measured accurately from outside palpations past 16 weeks (this would likely lead to further testing, like an ultrasound, as the uterus should be only a couple inches below the belly button at this point, easily felt, so if it’s not, it could mean something is wrong)

3) Fluid is leaking from the vagina and you are not full term (this could be amniotic fluid and could mean that your water has broken, or is leaking, and could be a sign of pre-term labor)

Do you need vaginal exams leading up to labor, or during labor?

Not really.  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 dialated 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 Daniel’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.  No, it is not predictive and checking myself was not particularly helpful, although it made me feel a little better…sometimes, lol.)

During labor, vaginal exams aren’t really necessary either.  Early in labor they don’t tell you anything.  You may or may not be dialated, 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.  There is 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.  Your practitioner will likely want to check too to make sure things are going well.  There’s a big difference between a 6 and a 10!  Of course, you don’t really have to have an exam even then.  You can continue to check yourself (which should be easy because your baby will drop very low in preparation for birth) and when it’s time to push, assuming you haven’t had an epidural, you will know!  If you have had an epidural, you will need someone else to check you during labor to let you know when you are fully dialated and it’s time to push, because you won’t be able to feel that.

(Another note: during transition I was constantly reaching for Daniel’s head.  It was right there!  I could tell about how dialated I was and easily feel what was going on.  I didn’t let them check me again until they said I was bleeding and I had to be checked, at which point I was an 8, and very quickly got to 10.)

The upshot?  Minimize vaginal exams.  Have a couple if it gives you peace of mind, especially once you are in labor.  Sometimes it helps you to cope to know that something’s happening down there, and you’re not laboring for nothing (ask me how I know…I was in real labor for about 11 hours with no progress, then went from 4 – 10 in an hour!).  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.

How do you feel about internal exams?

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  1. 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.


  2. 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.


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I’m Kate, mama to 5 and wife to Ben.  I love meeting new people and hearing their stories.  I’m also a big fan of “fancy” drinks (anything but plain water counts as ‘fancy’ in my world!) and I can’t stop myself from DIY-ing everything.  I sure hope you’ll stick around so I can get to know you better!

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