The Vaginal Exam in Labor

A vaginal exam is the surest way to know if a labor is progressing normally. You will learn this skill best from an experienced birth attendant and with lots of practice. This video will show the steps to doing this exam and the key information to gather.

Vaginal exams increase the risk of infection. Do one initially and then not more often than every 4 hours, unless necessary. Never do a vaginal exam if there is bleeding from the vagina. This could be a sign of placenta previa. You should then transfer the woman to a hospital that can do Caesarean deliveries.

It’s important that this exam be done with sensitivity and gentleness. Explain how it will be done and why. Ask for the woman’s consent. Then ask her to urinate before the exam. To begin, wash your hands with soap and water and use gloves. Have the woman bend her knees and open her legs. Do not force them open; be patient and talk to her if she is afraid or reluctant. If the woman hasn’t already washed her genital area, gently wash from front to back with clean water. There is no need to shave the area. Notice if there are any conditions, such as infections or scars from genital cutting that could affect the delivery.

Next check the woman internally. Put on a sterile glove. Wait until she has finished a contraction. Then suggest she take deep slow breaths to relax. This will help reduce the discomfort of the exam.

Now separate the labia and gently insert your first 2 fingers. Even before labor begins the cervix may start to change: it can soften, thin, and dilate a little; especially in mothers who have already had babies.

First check the position of the cervix. Early in labor the cervix may be positioned towards the back of the vagina. As labor progresses the cervix will move towards the front and be easy to reach. Feel the consistency of the cervix: is it firm – like your nose? – or soft? As labor progresses it will become very soft.

Next check the thickness – or effacement – of the cervix. In early labor it may be thick, like a tube, a few centimeters long. The tube shortens as the cervix effaces, eventually becoming a thin band around your fingers. Now the cervix is fully effaced.

Next check the dilation. You will learn with practice how many centimeters the cervix is dilated by how far apart your fingers are as you gently stretch the cervix open. The dilation is always determined by the inner cervical opening next to the baby’s head. At the beginning the cervix will fit a fingertip. 1 centimeter fits one finger tightly. 2 centimeters fits one finger loosely. 3 centimeters fits 2 fingers tightly. 4 centimeters is 2 loose fingers. 5 centimeters is a little more open than 2 loose fingers. The fingers start to open further and further at 6, 7, 8 and 9 centimeters. At 10 centimeters, the cervix is completely open, fully dilated. You will not be able to feel any cervix in front of the baby’s head. Sweep your fingers around the head to be sure you feel no cervix at all. At 10 centimeters, with no cervix in the way, the woman can safely push the baby out without risking a tear of the cervix.

Check what part of the baby is coming first. You will usually feel the hard, smooth head but sometimes you’ll feel the softer buttocks of the baby. Check how close the baby is: is the head high? Unable to be easily touched by your fingers. Is it midway? There, at the end of your fingers. Or low? Coming into the vagina.

Check if you feel the bag of waters. They will feel like a fluid-filled bulge at the cervical opening. The membranes usually break late in labor – but can break anytime, even before labor begins. Notice the color of the water. If they are clear or light yellow and the baby’s heart rate is normal, the baby is probably ok. Green waters mean there is meconium – the baby’s feces – in the waters. If they are dark green and thick the baby may be in trouble. If the birth is not soon, it’s best to transfer the woman to a higher-level facility.

It’s normal to have a little blood mixed with mucus on your glove after a vaginal exam. Check for a foul odor that could indicate an infection that should be treated.

This woman’s cervix is 6 centimeters dilated and fully effaced, the head of her baby is easily touched by your fingers, and her bag of waters is intact. Encourage her to walk to help her labor progress.

Remember, do the vaginal exam with sensitivity and gentleness. Learn this skill through practice with an experienced birth attendant. Find out: the position of the cervix, whether it’s firm or soft, how thin it is, how wide it opens, if the baby is head down, how close the baby is to your fingers, whether the bag of waters are intact, and whether the waters are clear, or green.