Cervical Exams and the Psychology of “Making Progress”
Opening, slow and steady.
It happens so often.
I will be at a birth with a client. The 3 R’s (relaxation, rhythm, and ritual) are being tapped into beautifully. The room hums with the sounds of the deep work of labor. There is that special kind of flow happening that says yes, this is how baby will move through.
And then the nurse comes in, turns the light on, and says “Okay, the doctor would like us to do a cervical exam to check on progress. After this contraction, make your way to the bed.”
And I pause. I turn to my client, still deep in her progress but now visibly distracted, and find her eyes. Even the mention of moving here to there, or doing something that is not just being with each contraction, activates my client’s prefrontal cortex and changes the rhythm she is in.
She meets me gaze, speaking through her eyes: do I have to?
The answer is, and always will be, no. Cervical exams are not always necessary, required, or even beneficial. Sometimes, they can be the opposite of that.
Other than disrupting the rhythm of labor, cervical exams also are not an accurate holistic picture of what is happening in labor. They are a snapshot in time of a single moment. I’ve seen a birthing person go from 3 centimeters dilation to 10 in 1 hour. I’ve seen a birthing person be at 9 centimeters for 6 hours. I’ve seen a birthing person be in a very active 6 centimeters for 48 hours, to go on and give birth vaginally with no complications.
Labor is not a curve, not an equation. It does not fit neatly into a box, no matter what Friedman or your OB might say. But the obsession with cervical exams and the psychology of progress can bury that notion deep in the psyche of a pregnant or birthing person. We live in a culture obsessed with constant growth, expansion, “progress for the sake of progress.” That insidious, sometimes Machiavellian, state of mind is hella pervasive. And it does find its way into the birthing space.
If a client of mine has been laboring for a while and decides to get a cervical exam, sometimes they will say “what happens if I haven’t progressed?”, meaning “what if I’m still at 3, 4, 5 centimeters?” First, I’ll often remind them of all the amazing holy work they are already doing. That there is no such thing as “not making progress” in labor. Second, I’ll ask “how will you feel if you are at the same dilation? Will that change how you want to proceed?” and then we will talk about it.
Prenatally, I’ll discuss with families about the nitty-gritty of the stages of labor. Of all the things that have to happen for labor to begin. Before dilation there is effacement of the cervix, before effacement there is softening or ripening, before ripening there is a whole incredible complex cocktail of hormones that tells the body how to start preparing. Baby also must find their way into the pelvis and engage, meaning the bottom of their head is aligned with the ischial spines. So that way, if they opt for a cervical exam, they know there are other factors at play.
It’s all about the language we use. When a nurse comes in and a cervical exam is done, and then they say “Oh, sorry, you’re still at a 5,” with a downcast tone that could be used to say “your dog died,” it doesn’t encourage the birthing person at all. In fact, it may do just the opposite.
Oxytocin, the hormone responsible for labor contractions can also be called “the hormone of love”. What we know about oxytocin is that it is supported by being in an atmosphere that is warm, loving, and generally nurturing and uplifting. In birth, when we remember this, we can actually help things along by being a presence of care, compassion, and love…whatever that may need to look like for the birthing person.
What we also know about oxytocin is that it is counteracted by stress hormones. Now, I’m not here to talk down about stress hormones or fear. I’m not here to say that labor is all love and kisses and bliss. Adrenaline actually serves a very important function in the second stage of labor by fueling the body’s fetal ejection reflex, or “urge to push”. Fear can be a motivator to understanding ourselves deeper and how we birth and parent. What I am here to say is, causing unnecessary stress in a birthing person by saying “Well, you’re only at a 4, that’s not much progress” may just be the thing keeping their cervix closed.
In her book Birth Matters, Ina May Gaskin compares the cervix with a sphincter. “Sphincters…are the ring shaped muscles that surround the opening to various organs, such as the stomach, the bladder, and the anus. The cervix, although not strictly speaking a sphincter, behaves like one. Basically, sphincters are shy, and they open better in privacy. They don’t obey orders, because they are part of the autonomic (involuntary) nervous system. Once they begin to open, they can suddenly slam shut if their owner is embarrassed or frightened.” (Gaskin)
Most of us are familiar with that experience in the context of peeing. It can be hard to pee when you know someone is watching, especially if you’re not fully comfortable around them. A laboring cervix will often mimic that same behavior. Ina May goes on to write, “...it’s possible to find films…of mammalian mothers in the wild whose babies are on the point of emerging when they are involuntarily sucked back inside in case of sudden danger. The same evolutionary behaviors take over in us humans when we go into labor, without our necessarily understanding the evolutionary wisdom of our own behavior…so when dilation is stalled or reversed, the woman is usually told that she has ‘uterine dysfunction,’ ‘inadequate contractions,’ or a mysterious condition called ‘failure to progress.’”
In the context of cervical exams, they may be exactly what is keeping further opening to happen.
And of course, I can’t talk about cervical exams without also talking about consent, medical coercion, and sexual trauma.
To circle back to the narrative in the first paragraph, I want to call attention to the language the nurse uses there. “The doctor wants us to do an exam, so that’s what’s going to happen.” Where is the choice in that? The informed consent? This often leaves birthing people to feel that they have no say in the matter. That it must be done. Or, that it’s even imperative to their or their baby’s health.
For those of us that identify as survivors, this may not be a small happening. It may be the night-and-day difference of being open, safe, and coping, to being deep in the recesses of our trauma bodies. Cervical exams themselves may be off the table altogether to honor a survivor’s need to not be touched.
Exams don’t have to be this way. They don’t have to be with the birthing person on their back, vulnerable, not fully consenting. They don’t have to be checked by anyone they don’t want to (yes, I’m looking at you, residents and student nurses). And they don’t need to be aggressive, hasty, or performed at all.
I have seen a cervical check that brought me to tears because of how careful and respectful the midwife was of the client’s need to be in control and aware of what was happening. For those providers that do not know the art of such an exam, or the art of hearing “no” and being more than okay with it, it’s time to evolve.
It’s time to grow past the limiting mindset and language of dilation=progress, and the dangerous places one can go from there.
For those providers that do not know the art of such an exam, or the art of hearing “no” and being more than okay with it, it’s time to evolve. It’s time to grow past the limiting mindset and language of dilation = progress, and the dangerous places one can go from there.
If you’re pregnant and asking yourself if you want to utilize the tool of cervical exams, talk with your doula about it. Get all of the information you need to know your rights and what may be best for you.
Talk with your provider about it. How often will they want to check? In what circumstances does it become more important to check? How will you honor me if I want to be checked in whatever position I feel comfortable in? How can I be assured I will have only female providers? If your provider doesn’t give you very reassuring answers, know that you still have options, including changing your provider!
You may not want a cervical exam if:
Your waters have released. CE’s increase the risk of infection after membrane rupture.
You want to stay in your rhythm and not be bothered by them.
You don’t want to know your dilation.
You have a history of sexual abuse.
You don’t want the extra discomfort.
You just don’t want one.
You may want a cervical exam if:
You want to know what dilation you are at.
You are about to get an epidural, but are hoping to be at a certain dilation before having it placed.
You are feeling like pushing.
You want to know in another way if baby is head down.
You just want one!
All of these things are just fine. Birth is not a race, not a contest, not a show of how fast, how strong, or how dilated.
There are so many other ways to gauge what is happening in labor. What kind of sounds is the laboring person making? How close together are contractions? Are they still talking through them? Are they shaking? Vomiting? Having more bloody show? Are they themselves feeling like labor is going well? Is baby getting lower in the pelvis? All of these are valid ways of assessing how labor is going, if one is wanting to know.
Looking at dilation as the only determinant of labor progress is symptomatic of the greater issue within our industrialized medical system. It looks at one part, and then makes an assumption about the whole picture. To be truly holistic, to be truly centered around best practices, we must embrace nuance and treat each person as a unique ecosystem, rather than a piece of information run through an algorithm.
And then, we may begin to see what I would call progress.
