To VE or not to VE?

I wanted to chat a little bit about VE's or Vaginal Examinations.

Firstly, what is a VE in pregnancy? This is generally an examination of the vagina to ascertain cervical dilation and consistency, to assess if the waters have broken* and the station (how low the baby is)/position of the presenting part (baby's head/bottom/whatever is heading first!). They sound very helpful right? Well, yes they can be a useful tool in identifying progress in labour or diagnosing any problems however they are many other ways to identify labour/problems without doing a VE.

*you do not need to have a VE to confirm this but this is just another finding a HCP would look for when performing an examination

Observe Wait Listen... a year ago I came up with the acronym O W L . During a physiological birth there really is no need to offer a VE unless the woman requests one. They are so subjective and only give us a moment in time example of what is going on, so really why do we do them so much? I could tell story after story of women I have examined who's cervixes have been dilated 1cm and then given birth 10 minutes later. Labour is not linear and we need to start realising this.

I've been thinking for a long time why there is so much emphasis on performing VE's every 4 hours (or so) in established labour when we educate women that VE's can introduce infection and are an uncomfortable examination. I think the reason they are so common is that as a species we are so focussed on TIME. We want everything and we want it now. I know not everyone feels like this but the majority of modern society is always looking for more, as much as we think we don't... we really do. We want to get as much out of our hours/days as possible. We want to know when our baby will arrive, what date, how many hours left of labour.... and when they are born... how much do they weigh? What's their name? Are they feeding well? Are they sleeping well? Why isn't the baby sleeping through the night?... I could go on. We need to get back to the roots of being okay with not knowing everything. Due dates are correct less than 5% of the time... because why would ANYONE really know the date your baby is going to arrive? I get asked daily as a Midwife by the couples I care for how long their labour or induction will take... I wish I knew!

Anyway back to the topic.....

So, sometimes there really is a place for VE's. They can identify if there is a problem or complication (eg cord prolapse, bleeding, a limb presenting first instead of a head or bottom) and therefore when performed with consent can absolutely be a life-saving tool. They can also be helpful when labour is delayed to identify a baby that is malpositioned and then working with the mother and her birth partner to use techniques to resolve this (if needed).

So what other things can we see instead of performing a VE to help us know labour is progressing?

1. Behaviour change: a transitioning women in labour will feel increasing pressure and the need to bear down. The baby’s head presses past the back passage as it descends and it can cause the “fetal ejection reflex” when the body completely takes over and births the baby spontaneously. Watching for changes in behaviour will tell you if the labour is progressing with no need to offer an examination. Quite often (nearly every time in fact) a woman requesting a VE or exclaiming "I can't do this!" or "I need a poo!" means a baby is on the way!

2. The purple line: The line may arise because of vasocongestion at the base of the sacrum. This congestion possibly occurs because of increasing intrapelvic pressure as the fetal head descends, which would account for the correlation between station of the fetal head and line length (Byrne & Edwards 1990). The higher the line, the further along labour may be! * it is easier to visualise in some women than others but research has shown that it can be seen in up to 89% of women.

3. The Rhomboid of Michaelis is a kite-shaped area that includes the three lower lumber vertebrae, the sacrum and that long ligament which reaches down from the base of the scull to the sacrum. This wedge-shaped area of bone moves backwards during the second stage of labour and as it moves back it pushes the wings of the ilea out, increasing the diameters of the pelvis (Sutton & Wickham 2002). This can be visible as labour enters the final stages and is an excellent indicator that a baby is descending low.

In conclusion, VE's can be a helpful tool but there are lots of other things to consider before offering/accepting this examination. My final tip, which is one I always tell my clients, if you do decide to have a VE ask the Midwife not to tell you how many centimetres dilated your cervix is. Stay with me here... Ask whether you are in early labour or active labour. You don't need to know the centimetres it won't help your mindset (if you're not as far along as you hoped) and will upset your hormone balance - if you know you're in earlier labour then you know there's time to rest and hydrate, and if you're in active labour then you know you're well on your way to meeting your baby.

Thanks for reading! As always I'd love to hear your birth story or any other themes you would like me to cover on this blog/instagram. Just drop me an email at katie@birthandbreathe.co.uk