Script: Painful Cervical Exams During Labor
Original script written 8/2016, slight edits for updated language 10/2021:
There are innumerable times when I’ve received report, or over-heard discussion, about someone having "difficult exams," or someone who is "unable to tolerate exams," or someone having "painful exams" during labor. At my prior hospital, other providers would request my help in "checking" someone during labor, because somehow I was able to complete an exam without pain or "difficulty," or at least minimally less so. At my new hospital, it seems standard to offer people either IV or epidural medication to allow them to better "tolerate" exams. While pain medication or anti-anxiety medication can be helpful and a critical option for some, there can also be gentle approaches, power-transfer strategies, and generalized trauma-informed care that should be normalized for all exams. I discuss consent and trauma-informed care in this open-access article, including some similar scripts to what is written below.
A few notes on this, mostly based on my opinion:
Rarely are cervical exams an emergency. An update on cervical dilation, if not changing a possible management plan (such as need for further cervical ripening, concern for malposition, etc.) is not a necessary activity regularly throughout labor. Only discuss the possible need to assess cervical dilation if it is necessary, as we should only ever enter people's bodies when necessary.
Language like "tolerate" or "difficult" especially in the realm of care of people who are standardly marginalized even before they enter our care (women, queer and trans and gender expansive people, people of color) is rooted in power and demonstrates activity against a person rather than with them. Identifying someone as "difficult" rather than as someone who "experiences painful exams" is essentially an other-ing of that person, rather than a humanizing linguistic and practical understanding. Language matters. "Experiences painful exams” or “Has difficulty with exams” if the person receiving the exam describes it as painful, is appropriate.
Standard of care vis-a-vis trauma-informed care supports an assumption that people have had trauma in their lives. Statistics range from 1 in 3 to 1 in 5 people who’ve experienced sexual trauma, with rates even higher for people of color, higher for queer people, and even higher for queer people of color. Engage in trauma-informed pelvic care regardless of whether someone discloses a sexual assault history.
Vaginismus and vulvodynia are very real diagnoses, and require special care during pregnancy and birth. If someone reports no issues with painful intercourse or previous exams in gynecological care, then likely these diagnoses are not the issue and providers should refrain from assuming pathology when someone experiences a painful exam.
Suggestion from a reader in the post-script in 2016: Minimize any other interventions/interactions happening at the same time (intake questions from the RN, BP cuff inflating, adjusting monitors, family calling others, etc.)
While I greatly dislike disembodied vaginas and legs, and standard white mannequins, the pictures in the original post will hopefully facilitate better visualizations of what I try to describe with the words below. Thanks for your kindness in my using what I have available to me for props. I need to figure out better photos, which is why I haven’t repeated them here.
A final note about my feminist approach to care: I never enter a room and say "It's time to check your cervix!" My approach is always to see how someone is doing, discuss how they are experiencing the labor, how their partner(s) and family are experiencing the labor, how I understand the labor to be going from a midwifery standpoint, and discuss where we might go together next in the plan of care, outlining all options. Sometimes that involves a cervical exam.
Now, the script. I'll set this up as if I am coming on and taking over care for someone who I understand to experience painful exams, and there is an important reason to have updated information on dilation. This script assumes there’s time to have this conversation, but is easy to condense and modify if there isn’t as much time. NB: there is always time for consent before a pelvic exam, even in emergencies.
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Midwife: Hi, I'm Stephanie, I'm the midwife working with you for the next shift. (Meet the patient, introduce self to partner(s), family, doula.) I would love to hear how the labor has been going!...And family, how are you all doing?
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I discussed your care with the midwife who was working with you before, and looked over your record so I can understand more about how your pregnancy has been going up until this point. The nurse and I also discussed how your care and experience have been with from the nursing perspective. Anything that you want to make sure I know about your pregnancy and birth plan?
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Can you tell me how the cervical exams have been for you?
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What exactly has been painful, or caused you discomfort? Is it more a feeling on the outside, inside, or both? Is there a process or position you think would be more comfortable for you?
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Thank you for sharing. I am so sorry those exams have been painful. There are many reasons why that may be the case: depending on baby's position and irritation of nerve endings, or blood flow and swelling in your cervix/vagina/vulva, or where you are experiencing your contractions, or just the approach. I have a few ways that I have found make exams more comfortable. Based on where your labor is currently, it might be important for you and for us to have an idea of changes in your cervix and the baby's position, for the following reasons: (xxx). Continuing with the next steps in the labor process would be complicated by not knowing your cervical exam for the following reasons: (xxx). Like with everything we discuss, offer, and advise while you are here, you can decline or defer at any time, and we will respect and honor that, and be truthful about our recommendations based on that decision. How do you feel about you and I trying a few things to make the exam more comfortable to try and obtain that information?
(Important: If they decline a cervical exam, respect that. Have another plan for how you will move forward with the labor based on that discussion. Do not coerce.)
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Something I have found helpful with other people who have experienced painful exams is to use the following two words: "Stop" and "Out." "Stop" means that I will keep my hand where it is, but I will stop moving until you tell me it is okay to continue. "Out" means that I will immediately and gently take out my hand. Are those words that would work for you? If you find that you can't find those words, if you raise your hand or close your legs I will stop and check-in.
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It is very important for me to respect both your words and your body. Know that I will listen to you the moment you say anything, and if I feel your body respond I will stop and wait so that we can discuss relaxation techniques
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Some people like to be talked through each part of the exam, and others prefer to talk about something else. Which would work for you?
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(Wear the smallest glove appropriate for your hand, to avoid baggy material pulling on tissue unnecessarily. Apply copious amounts of lube from the base to the tips of the fingers, to ensure that the dry glove does not pull on the labia at the base of the finger once the tips of the fingers are inserted.)
Whenever you are ready, bend your knees and put your feet close to your pelvis. Drop your knees out to the sides like an open book. Once you are in this position* I’ll check back in to know if you’re ready. Take as much time as you need. *or whatever position they said would be most comfortable for them
(Never move someone's legs for them. Never. If they are having a hard time understanding your description, place your hands outside of their knees and have them meet your hands with their knees as they relax them open.)
This is my hand on your thigh.
And then just on the outside of your vagina.
Next I will separate the labia. (When caring for anyone, and especially trans, nonbinary, and gender expansive folks, be sure to have already checked-in on what their language is for their anatomy. Also, some providers ask patients if they’d prefer to separate their own labia, particularly if they experience pain mostly externally during exams.)
Now you will feel pressure pushing downward and toward the back of your pelvis.
This is the muscle that if you are able to soften or release it, it might decrease some of the discomfort during the exam. For some people it makes sense to think about "dropping" your pelvis downward.
Let me know at any time if I should slow down or change something.
(Wait for the muscle to drop - you will see and feel it. This is an essential part of a gentle and consensual vaginal exam.)
(Note: If you feel a tight "ring" pressing upward against your fingers, that is the hymenal ring and will cause them pain when you press there. Move the fingers internally about 1cm and place pressure again to have them drop the muscle.)
A little bit more pressure here.
(While still pressing posterior, rotate your hand supine, and gently and slowly continue downward pressure while seeking the cervix, beginning by going as far posterior as possible. Assuming you will find the cervix toward the "top" of the vagina or in the "middle" will likely cause discomfort as you bump into the cervix covering the fetal head, the urethra, the meatus, or the pubic bone.)
Now here's the really, really important part: do not give false pretenses. Do exactly as you said you would, regarding both the person's verbal and bodily responses. If they say STOP, STOP. Wait for them to say they are ready, discuss possible ways to again drop the perineal muscle or find a more comfortable position, and get consent before starting again. If they say OUT, get OUT gently and immediately.
(Intermission: Things never to do. Again, NEVER.
Never search for the introitus by taking two fingers and pushing/searching up and down in between the labia. This will bump into the urethra and suprapubic bone, pull on the hair and labia, and start the exam from a painful place.Your thumb should be nowhere near someone's clitoris. For new learners to the cervical exam, this is often the hardest hand skill to develop. See the pictures above to not how for lateral the thumb is, on purpose. Again, the picture below is NEVER to be done.
Intermission over.)
(For someone with a very posterior cervix, changing the examiner's position can greatly facilitate the exam. Let the person know you will be moving your body but not your hand. Keep your hand in the same place, and move your arm and elbow in front of their knee. Sometimes just this change in position can allow a more easy exam into the posterior fornix. At times, very slight fundal pressure to push the presenting part against the cervix can help, but this should only be done after asking the laborer if it is okay to press gently on their belly during the exam. Do not assume that just because your hand is inside someone's body that you have access to the touching any other part without their prior consent.)
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Okay, now I will remove my hand. Your cervix is (xxx) / baby’s position is (xxx).
How was that exam? Anything I could do differently next time? Were there things that worked well?
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Readers: looking forward to your comments!
- Stephanie
