The Dreaded Pelvic Exam

Last week I provided some jumping-off points for selecting the right prenatal testing for your own situation.

This week, I’m going to discuss a prenatal test that many of us submit to without even considering it a prenatal test at all: the pelvic examination.

There are several points in pregnancy when pelvic exams may be offered or suggested. They used to be performed as a routine part of a pregnancy diagnosis, though this is not common anymore. If you are behind schedule on Pap smears (which test for cancer of the cervix; current guidelines recommend one every third year to most healthy childbearing-aged women), your provider may encourage you to have one early in pregnancy. Pelvic exams may also be indicated to diagnose or manage any of a wide range of disorders, from STIs to yeast infections to unexpected bleeding.

Finally, there are the pelvic exams that are often part of routine care in the last month of gestation. At this point in pregnancy, you’re visiting your doctor or midwife every week (more, if your pregnancy is complicated or you go more than a few days past your due date). And you, your provider, your mother-in-law, and the guy who bags your groceries all desperately want to know one thing:

When will this baby get born?!

You have doubtless heard friends, or characters in movies, talk about their late-pregnancy cervical checks. “Oh, the doctor said I’m 3.” “I’m closed tight, and my due date is tomorrow; help!” “I was 1 cm last week; I wonder what I’ll be tomorrow?” And there you are, at the office and the nurse is handing you a hospital gown and a drape for your lap. Surely you want checked, right?

Well, maybe not.

Plenty of women have been “shut up tight” at a prenatal appointment only to be holding their baby less than 24 hours later. Others walk around for days or weeks–really: weeks!!–dilated 3 centimeters or more. Either finding, then, can set some moms up for unnecessary stress (“Oh no! I’ll never have this baby”)  or disappointment (“Great, I’m almost done!”). Because of course you will have this baby, and you are almost done–but maybe not that almost done.

Furthermore, there is some reason for concern that a pelvic exam, even when performed with sterile gloves, can introduce germs to the cervix and uterus by pushing up critters that are perfectly normal and healthy residents of the vulva but do not belong higher in the vagina or uterus. These germs can lead to premature rupture of membranes (particularly risky when baby’s not ready to be born; but even at term if the waters break before labor contractions start, this puts you at an increased risk of additional unnecessary interventions) and increased risk of infection in both mom and baby.

Then there is the separate, but related, intervention of membrane sweeping or stripping. This is when, during a pelvic exam, a provider inserts her or his finger through the partially dilated cervix and rotates it to detach any places where the bag of waters may be stuck to the cervix. Membrane sweeping is a valid way to attempt to bring on labor without (or before) resorting to hospital admission for a medical induction. It is particularly common in the UK, where it is routinely offered to first-time moms at 40 weeks and to all moms at 41 weeks. It has some demonstrated success at triggering labor within 48 hours, though it is not a sure thing. Membrane sweeps are generally regarded as extremely uncomfortable, and they carry a risk of artificially rupturing the membranes. Some providers have been known to perform membrane sweeps without actually offering: it’s just something they do “while they’re in there,” whether the mom wants it done or not. So if you don’t want it done, declining late-pregnancy pelvic exams is one way to be sure. (As is, one would hope, telling your provider beforehand whether or not you are interested in a sweep.)

One time you definitely should have a late-pregnancy cervical check is if you are considering scheduling an induction. An induction is not (any nerds in the audience will get this reference) a magic missile: it is not guaranteed to hit the target every time without fail. If you are deciding between a medical induction, a planned cesarian, and just plain waiting (which options are available will, of course, depend on your and baby’s health status), your decision-making will be aided by discussing your Bishop Score with your provider. This is a cumulative assessment of four qualities of your cervix (dilation, effacement, consistency, and position), plus the height of your baby’s head in your pelvis. A Bishop Score of 9 or higher usually indicates that either induction or waiting for baby to choose a birthday should be quick and easy; a score of 5 or less means baby is unlikely to appear on his own within 48-72 hours and an induction is only moderately likely to succeed.

The long and short of pelvic exams in pregnancy is that they can give important information for your care, but they don’t always and are widely overused, largely out of the mistaken belief that they always give important information, which they don’t. So, next time the nurse offers you a gown and a drape, think carefully before you don it. Will you and your provider learn something meaningful from this exam, or might you want to keep your pants on?

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