Can We Just Leave the Cervix Alone Already?
In labour, all anyone can talk about is your cervix and how dilated you are - but does it really matter?????
I’m going to preface this blog post by saying that I 100% do not think the cervix check is a great way to see how established or progressed your labour is - ESPECIALLY if you are in spontaneous and physiological labour. BUT, if you are birthing in a hospital (or anywhere with a medical professional really) you will be asked if you would like to have a vaginal examination to check your cervix. So firstly I’m going to go through what the cervix is, why and how it dilates, and when you might have it checked.
What is the cervix?
The Cervix is at the bottom of the uterus (womb) and forms a canal that opens into the vagina, which leads to the outside of the body. When you’re pregnant, it is closed firmly with a thick mucous plug. This mucous plug can come away and regenerate throughout pregnancy, sometimes with some pink or brown blood attached. It can mean labour is coming soonish, but not necessarily. The mucous coming away is sometimes called a “show” or a “bloody show”. Anyway, I digress - the cervix is made up of tissue that is sort of like your lips or nose (not cartilage) - firm but squishy? It’s a weird one to try to explain with words - but you can actually usually feel your cervix if you want to, just make sure your hands are clean. It’s about 2cm thick and is like a tiny firm donut cushion. If you want to look at real life pics of cervixes you can check them out here. Then you’ll know they look nothing like donuts!
How does the cervix open?
There are 2 things that happen as you progress to the end of your pregnancy - effacement (thinning) and dilation (opening). Effacement can happen without you even knowing, sometimes during braxton hicks or during practice labour. This is when your uterine muscles are pulling upwards to build an amazingly thick fundus (muscle layer) at the top of your uterus to eventually push your baby out. This fundus grows thicker with every contraction as labour progresses, and as the uterus pulls up, the cervix can’t help but open gradually.
What is a Cervical check?
While on your back with knees up (usually with a modesty drape if in hospital/birth centre), a sterile gloved exam is done to determine the degree of cervical dilation and effacement. The measurement of cervical dilation is made by locating the cervix inside the vagina, spreading one's fingers in a 'V' shape, and estimating the distance in centimetres between the two fingers. This measurement is not always accurate and research has shown that between one care provider and then next there can be up to 50% difference in estimated measurement.
When will you be offered a Cervical check?
Before admission to a maternity ward
Every 2/4 hourly depending on the hospital policy
If asking for medical pain relief
If you request a caesarean section while in labour
If you say you feel “pushy” or pressure in your bottom
The key word here is OFFERED but I use that lightly - as most providers in our maternity system will broach the subject with a statement instead of providing risks and benefits and asking for consent. Things like - “we’re just going to check where you’re at”, or “after this contraction we’ll see if you’ve progressed”, cue glove on and ready.
That being said, you can and should say no if you don’t want a VE - to which you can expect there to be pushback or “you have to”’s in some birthing facilities. This is why I encourage all mums to map out all their decisions during pregnancy so that discussions can be had and everyone is on the same page well before you go into labour.
What risks do cervical checks have?
Cervical checks are always invasive, usually uncomfortable, and sometimes painful - some women even report being traumatised by the experience
They aren’t predictive, therefore they are not a great way to help inform your decisions
They are inconsistent between providers - sometimes by up to 50%!
They can be disempowering and disappointing - sometimes in your heart you know you are further along but if you have a number given to you that you weren’t expecting - you can start to doubt your instincts
Sometimes membranes can be accidentally ruptured when the midwife or OB does a check. This can alter the whole trajectory of a birth, and take a decision that was yours to make. When birthing in a facility, time frames are put around labouring women who have ruptured membranes, and lots of pressure can be applied to have further intervention. If you have made this call yourself knowing these risks, amazing! Many mums don’t realise these risks though, until it’s too late.
Increases the risk of infection, especially if membranes have already released.
When can cervical checks be beneficial?
In a medicalised labour (induction) to ensure that the induction method is working as needed
In a long labour (over 24 hours active labour), to check if all is well or if you want to try any new coping techniques or pain medication
If you as the birthing mum, ask for one - it’s your call mama!
With all of this in mind, you might ask - if a cervix check isn’t accurate for assessing labour progression, then what is? Well, good midwives and OB’s can tell how far you are progressing by watching you labour for even a short amount of time. They watch for the sounds you are making, the things you are saying (or how you are saying them), the positions you are instinctively moving into, the feeling of the top of your fundus and how your lower back is looking (look up Rhombus of Michaelis or “the purple line” during labour). There are so many ways! This is another reason to chat to your care provider in pregnancy if you will be declining VE’s - you might want to know if they have these skills.
The reason VE’s are offered so often is because it’s easier to measure or track a labour of many women at once if you have numbers to work with. Routine VE’s are just another indicator of our medical system trying to mechanise birth unfortunately. But we are unique HUMANS BEINGS, not man made machines - and we can’t be predicated or graphed!
My experience with VE’s
I wanted to pop my own experience with VE’s here because well… I don’t have any! After doing a lot of research during my first pregnancy and asking for the support of my private midwives, I asked how they felt about not doing VE’s and they said they absolutely didn’t need to do them. They knew they would be with me in the room for hours as I progressed through labour, and would know if labour wasn’t progressing as “normal”. I am so grateful to my first pair of lovely midwives Peta and Vanessa for teaching me about how women should be cared for in labour - they were truly “with woman” and that was the best and safest care I could have asked for. Obviously for my next 3 babies it wasn’t even a question! Even when my last baby decided to turn sunny side up while in labour - still no need for any checks! They trusted me, and I trusted myself. I think it totally would have interrupted my labour focus and had me in my thinking brain instead of my labour brain. I was so glad that once I declined in pregnancy, it wasn’t even offered - allowing me to ask if I ever felt the need.
Some extra homework for you guys is to look into cervical recoil (yep, that’s right - your cervix can recoil if you don’t feel safe!) and to listen to any of the Podcasts below… they will educate you on so much more than I can fit into a blog post
The Midwives’ Cauldon “Vaginal Examinations”
The Midwives’ Cauldron “Dr Clare Davison Interview”
The Midwives’ Cauldron “Pushing & Cervixes”
Much cervical love to you all!!!!
Britt xx
Resources & References:
https://www.sarawickham.com/topic-resources/cervical-wisdom-resources/
https://teachmeanatomy.info/pelvis/female-reproductive-tract/uterus/
https://www.sarawickham.com/original-articles/exploring-cervical-recoil/
https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/1471-2393-10-54
https://midwifethinking.com/2017/02/03/understanding-and-assessing-labour-progress/
https://www.ingentaconnect.com/content/springer/ijc/2013/00000003/00000003/art00001
The Placenta: Part II
Actively manage or support physiological placenta delivery… that is the question.
So it feels like I’m banging on about the Placenta right? Well, yes I am - but with good reason! Did you know that the majority of women in Australia go through their whole pregnancy not discussing options for the third stage of labour? If it is brushed over in a quick talk, care providers can also make statements of “hospital policy” instead of going through your options. So here we are… let’s fill some gaps in information, shall we?
Physiological delivery - what happens for mum & bub
When a mother and baby are uninterrupted and given time after birth, the baby can start to bond with mum in skin to skin and starts to breathe air. As the baby’s oxygen levels increase, its lungs are activated and the placenta gets the message that its job is nearly done. Blood vessels in the baby’s lungs open up and are filled with blood from the placenta. The two arteries that send blood back to the placenta now start to constrict so that the blood is on a one way track directly to your baby. With patience, and a safe and calm environment, the baby will begin to attempt breastfeeding and this will trigger hormones that start a natural detaching of the placenta from the wall of the womb with a clot forming behind it. The mother’s body might have contractions or urges to push, and the placenta will come sliding out like a slab of jelly, sometimes with the help of a cough or standing up (gravity!). Research shows that the best prevention of a postpartum haemorrhage in a physiological birth is having the baby on the mother’s skin to keep the hormones flowing. It can take up to an hour or more for the placenta to detach, so asking for extra time would be pretty vital in choosing this option.
Active Management (usually hospital preferrence)
Active management is when a uterotonic (a synthetic version of oxytocin usually) called syntocinon is injected into the mother so that contractions start to release the placenta. Unless there is an immediate need to control a haemorrhage, this can be done at any time after the baby’s birth, meaning that you can wait for the full volume of blood to reach bub before it’s administered. This is the same drug that is given for a chemical induction, in which case another drug may need to be administered called ergometrine. This one can make mum feel a little worse for wear, so it’s important to ask which one will be administered if you choose this route.
Postpartum Haemorrhage, Breastfeeding & other things to consider
Even though the World Health Organisation recommends uterotonic management of the placenta in all births worldwide, there is research emerging that in a physiological birth (intervention & induction free) in low risk women, PPH is more common if the uterotonic is administered. Research is also well established that breastfeeding rates are affected if syntocinon is administered to mums at ANY point during labour and birth. Of course, hormonal gaps can always be filled with skin-to-skin - and it’s important to have this knowledge before you go into labour so that you can plan ahead for the outcome you want.
I want a physiological placental birth, now what?
The first thing to do is chat with your care provider during pregnancy. While most will be fine with it, or at the very least, having a “wait and see” approach, some OB’s (while not ethical) may choose to discontinue treatment if you choose a physiological placental birth, so it’s important to have this conversation during pregnancy if it’s something you really want. It’s really important to also have your birth space protected during the golden moments after birth, as it will be the safest way for you to birth your placenta. Keeping the room dark, quiet and relaxed, keeping your baby on you, and keeping everyone unnecessary out of the room (including phone calls to the outside world!) will allow your hormones to continue on their natural trajectory and work efficiently. There is plenty of time to announce your baby’s birth, and detaching from the bubble of hormones can stop your hormones from working. The birth is not “done” until the placenta is out - so take that time to soak up your new baby’s smells and sounds. If your birth team know that you want a physiological third stage they will ensure that your space is held until after you birth your placenta - one of the perks of having a doula in the hospital!
After looking at the benefits and risks of both medical management and physiological birth of your placenta or the “third stage”, you can now make an informed decision. Having these conversations with your partner and birth team during pregnancy is not only empowering for you but can help everyone feel involved and invested in the outcomes of your birth. So go ahead and keep researching and resolving all of your birth choices, mapping out a plan that you feel comfortable with. What else should you be discussing with your care provider before employing them? Stay tuned for the next blog!
Resources & further research:
Midwife Thinking - An Actively Managed Placental Birth Might Be the Best Option for Most Women
Sara Wickham - Can I have a Natural Placental Birth After Induction
My name is Brittney Blakeney and I am a Pregnancy, Childbirth and Postpartum Doula, with an emphasis on education and preparation for your birth experience as a woman and mother.
My job is to give you the most up to date research so that you can make decisions with confidence, and to give you the tools, techniques and encouragement to feel calm, safe and supported during your pregnancy, birth and postpartum journey. I aim to create villages around women to ensure they feel strong, supported and listened to as they transition to their new role.
If you don’t want to miss out on any new morsels of info, subscribe to my newsletter to be notified of the latest blogs. I am based NOR in Perth, and can be contacted by email at doula@brittneyblakeney.com.au or head to my Insta to send a direct message.
Click here for some more bloggy goodness.
Cord Clamping: The evidence & your options
Why the timing of cord clamping is so important and what options you have, no matter where or how you birth.
I really want to delve into the WHOLE third stage of labour, but I feel like I need to separate it. So here we are looking at cord clamping first. It is really so vital to know this info - especially if you have a baby pre term (before 37 weeks) and even in a caesarian birth - there are more options than you think - and care providers are not always forthcoming with their “policies”.
There are three sets of timing that are used by care providers
Early Cord Clamping
Clamping within a minute of birth. This is pretty old school, and yet it is what we see in movies and probably imagine what happens in birth. When a cord is clamped within a minute of birth, you have the potential to leave up to half of the baby’s blood volume in the placenta. It’s well known and should be common practice to wait at least 1 minute before clamping and cutting the cord, even in an emergency. If the baby is attached to the pulsing placenta they are still getting oxygen from mum - so even in resuscitation situations, this is beneficial. Adding to that, a good care provider can provide resuscitation to babies wherever they are in the small chance that this is required.
Delayed Cord Clamping:
Clamping within 1-3 minutes of birth. This is what the World Health Organisation recommends in their guidelines - stating that it should be standard in all births, even caesarean birth and preterm birth. Some benefits include: 61% reduction in severe anaemia, 59% reduction in the rate of intraventricular haemorrhage in preterm infants, 62% reduction in the rate of necrotizing enterocolitis among preterm babies, 29% reduction in the rate of neonatal sepsis for preterm infants, 52% reduction in the rate of blood transfusions for low blood pressure among preterm babies.
Wow. Just wow! Something so simple as waiting a couple of minutes can have this amazing effect on a baby - care providers should be discussing this with women!
Optimal Cord Clamping:
Clamping and cutting the cord after the cord is white and clear of blood means that your baby has gotten all of the blood from the placenta. This means your baby will have all the benefits of delayed cord clamping, plus more. Babies that receive their full blood benefit also receive their full quota of stem cells, which are the building blocks for the future well-being of the infant. Cords can be clamped and cut after the placenta is delivered, or not at all. Some mothers like to have a Lotus Birth, where the placenta is birthed and kept until the cord naturally falls away from the baby. This can take up to 15 days to happen.
There is often no reason to cut the cord immediately even if you have a medically managed placenta delivery - though it is usually offered as a package. The discussion of cord clamping definitely needs to happen with your care provider during pregnancy, and make sure your birth partners know your choice as well. That way while you are busy bonding and getting to know your new baby, they can all advocate for your choices and know your reasons why. Stay tuned for the next blog: I’ll dive into your options for supporting physiology or medically managing the birth of your placenta.
Britt xx
Resources and further research:
The Midwives’ Cauldron Podcast S03 E05: Placentas & Cord Blood
https://midwifethinking.com/2016/04/13/the-placenta-essential-resuscitation-equipment/
My name is Brittney Blakeney and I am a Pregnancy, Childbirth and Postpartum Doula, with an emphasis on education and preparation for your birth experience as a woman and mother.
My job is to give you the most up to date research so that you can make decisions with confidence, and to give you the tools, techniques and encouragement to feel calm, safe and supported during your pregnancy, birth and postpartum journey. I aim to create villages around women to ensure they feel strong, supported and listened to as they transition to their new role.
If you don’t want to miss out on any new morsels of info, subscribe to my newsletter to be notified of the latest blogs. I am based NOR in Perth, and can be contacted by email at doula@brittneyblakeney.com.au or head to my Insta to send a direct message.
Click here for some more bloggy goodness.