Ep 306: Tracking Labor Progress: Vaginal Exams Decoded

Nicole Rankins (00:00.222)

Vaginal exams are one of the most common parts of labor and one of the least understood. They can empower you or they can leave you feeling powerless. And the difference comes down to one thing, knowledge. Let's talk about what those exams really mean and how to make them work for you.

Nicole Rankins (00:26.53)

Welcome to the Birth with Power podcast where knowledge is power and power transforms birth. I'm Dr. Nicole Callaway-Rankins, mom of two and practicing board certified OB-GYN with over 20 years of experience and nearly 2000 births attended. I've seen firsthand how the hospital system can leave women feeling unheard and uncertain, but that doesn't have to be your story. Here, you'll get the knowledge, support,

and strategies to take charge of your birth experience so you can walk into the hospital feeling calm, confident, and empowered. Note this podcast is for educational purposes only and it's not a substitute for medical advice. See the full disclaimer at drnaclomeragins.com forward slash disclaimer. Now let's get to it.

Well, hello there. Welcome to another episode of the podcast. This is episode number 306. Whether it is your first time being here or you've been here before, you know, I'm glad you're spending some time with me today. This episode is special because I'm giving you a sneak peek into my forthcoming updated childbirth education class, the Birth with Power Pathway.

Inside the pathway, I walk you step by step through everything you need to feel calm, confident, and empowered for your hospital birth. And today I'm letting you in on one specific lesson tracking progress with vaginal exams. Now, vaginal exams are one of the most common things you'll encounter during labor. They're also one of the most misunderstood.

What do the numbers mean? How often should they be done? Do you really have to have them? And most importantly, how do you make sure they're done in a way that respects you? That's exactly what we're digging into today. But before we dive into the details, let me set the stage with a quick story. So I will never forget the time I walked into a hospital room and it smelled amazing.

Nicole Rankins (02:33.516)

I'm talking lavender, vanilla, like spa day vibes. The lights were dim. There were candles flickering softly. I pulled up a stool. I sat down. I just started chatting with my patient and her husband. The vibe was just absolutely immaculate. Then the nurse, and we'll call her Carrie, she walks in and she gives me this look and I'm like, girl, what, why are you looking at me like that? So she leans in and she whispers, Dr. Rankins, those are real.

candles. So I had not even noticed that's how good the energy was in the room. Now, yes, real candles in a hospital, definitely a fire hazard. So they had to be blown out. But what really stuck with me wasn't the fire hazard. It was how that woman had claimed her space like a boss. Yes, she was in a hospital.

but she had taken the time to make this space hers to make it feel safe, sacred and soothing. And that matters a lot more than you think. Now you're probably listening to this podcast because you're planning to give birth in the hospital. And here's what I want you to know about that, because I'm telling you all this connects. When you know your birth environment, you can own your birth experience. When you know

your birth environment, you can own your birth experience. So how do you make that happen? Well, you're going to do that with the birth blueprint. The birth blueprint is my guide I created to help you know what typically happens in the hospital. It's about helping you avoid those wait. Nobody told me that would happen moments or create that wonderful blissful space.

like the patient created even, okay, we can do the real candles, but we could have done electric candles, work with me here. But the point is that this blueprint helps you know what happens again, so you can avoid those, I didn't know that, what am I doing, how are things going here? So it breaks down like this. B stands for begin at arrival.

Nicole Rankins (04:44.642)

That is what happens from check-in to triage to moving into your labor room, how to make your labor room yours. I is IV fluids and monitoring, how IV fluids and fetal monitoring are usually handled in the hospital. R is for refuel, how hospitals approach eating and drinking and labor. T is for track progress.

How we check to see where you are in labor with vaginal exams and then H is for hustle or hold still. How movement and positioning can help your baby get into the best position. Each piece of the blueprint gives you clarity over chaos and confidence over confusion about what happens in the hospital. And today in this episode, you're getting a sneak peek on the T track.

progress with vaginal exams. You will learn what we check during a vaginal exam, why it matters for tracking labor progress, what the numbers actually mean, what makes exams vary between doctors and midwives or between different doctors or a doctor and a midwife, basically between different providers, and then how to make the experience more comfortable and more respectful. So let's get into it.

All right, vaginal exams are done to help us figure out how your labor is progressing. And they can be done by your labor nurse, your doctor, your midwife. And I want you to know upfront, the truth is that most doctors rely pretty exclusively on vaginal exams to assess labor progress. That is how we are trained.

Now, midwives may be more in tune to physical and behavioral cues, especially if you don't have an epidural. For example, without an epidural, it's easier to tell if someone is in transition or ready to push based on her breathing, her sounds, her body language. That's not always obvious though, and especially not when someone has an epidural. So I'm saying all that to say that at some point,

Nicole Rankins (07:01.772)

you are almost certainly going to be approached about having a vaginal exam during your labor. So let's walk through exactly what that means so you feel informed when that time comes. All right, now during a vaginal exam, also called a cervical exam or a cervical check, we check for three things. That is dilation, effacement,

and fetal station. And you'll typically hear us say them in that order, although some doctors change the order a little bit, but typically it's dilation, effacement and fetal station. And let me break down each one. And I'm going to start with dilation. So dilation is how open your cervix is. And that's going to range from zero centimeters, which means your cervix is completely closed.

to 10 centimeters, which means fully dilated and ready to push. We use centimeters, not inches here in the US, like actually everywhere. Pretty much people use centimeters and not inches in order to describe how open your cervix is. Now, if you're a visual person, maybe it can help you to picture it like this. At one centimeter, your cervix is open to about the size of a blueberry.

At five centimeters, your cervix is open about to the width of a lemon, I would say. And at 10 centimeters, it's open about as wide as a bagel. 10 centimeters is what we mean when we say you're complete or you're completely dilated. That's when your cervix is open enough for your baby to pass through and be born. Now,

If you're a numbers person like me and you kind of want to know like what centimeters is based on inches, then one inch is 2.54 centimeters. So when we say 10 centimeters, that's just about under four inches open that your cervix is. And yes, I know that inches to centimeters conversion off the top of my head. I majored in math and mechanical engineering before going to med school. So numbers are

Nicole Rankins (09:22.806)

actually kind of my thing. Okay, so let's talk about effacement. Effacement is how thin or short your cervix is. We describe this as a percentage. So at 0 % efface, your cervix is its normal length, which is typically going to be about three to four centimeters long. At 50 % efface, it's halfway thinned out and at

100 % effaced, it's paper thin with no length at all. It really feels really, really thin and it just has no length to it at all. And then the last number is fetal station. So we talked about dilation, effacement, and now fetal station. Station tells us where your baby's head is in relation to your pelvis.

specifically the ischial spines, which are bony landmarks inside of your pelvis. When your baby's head is at the level of the spines, the fetal station is zero. If the head is higher up above the ischial spines, the numbers are negative, like negative three, negative two, and so on. And then as your baby moves down, the numbers go up.

So positive one, positive two, all the way to plus five. Typically we say, so plus one, plus two, plus five. That's when your baby's head is visible at the vaginal opening and crowning. Now we may also comment on two other things, the consistency of your cervix and the position of your cervix in your vagina. Your cervix may feel soft or firm. That's the consistency.

and it may be anterior, meaning it's rotated forward in the vagina or posterior, meaning it's tilted further back or it may be mid position. And as labor progresses, your cervix gets softer and it rotates forward. So when we say that it's anterior, then that means labor is moving along. If it's softer, that means labor is moving along.

Nicole Rankins (11:46.126)

It also makes it easier as your cervix rotates more forward, it makes the exams more comfortable. They're less painful that way. So when you hear a doctor say or a nurse or a midwife say something like, okay, her cervix is 580 minus one soft and anterior, we write it as five and then a slash, then an 80 slash minus one. And that means your cervix is

five centimeters dilated, 80 % effaced. Your baby is just above the ischial spines and your cervix is soft and in a forward position. So let's talk about next, how often do we do vaginal exams? So vaginal exams are typically about four to six hours apart once you're in active labor.

And active labor is when you're five to six centimeters or more. If there is concern about your baby or if you feel something new, like suddenly you have pressure or you have the urge to push, then we may check sooner. But four to six hours is completely reasonable during active labor. Now during early labor before five centimeters, it is not uncommon to wait at least six hours or even longer between exams. That's perfectly

appropriate. Now here's something important that I really, really want you to know, really, really want you to take in because this trips up people a lot. Vaginal exams are estimates. They are estimates. Not one of us is putting a actual ruler inside your vagina. So there's always going to be some variation from doctor to nurse to midwife between different people who do different exams.

One person might say that you are three centimeters dilated, and then another person might say that you are two centimeters dilated. The same goes for a faceman and station. Someone may say you're 50 % a face. Someone may say you're 70 % a face. And I totally get it that that can be very confusing, but it is not a sign of trouble at all. It's just a difference in examiners.

Nicole Rankins (14:06.84)

We each develop our own internal reference points for how we do vaginal exams. For example, here's how I do it. If I can fit one finger in your cervix, I will call that one centimeter. If I can comfortably fit two fingers in your cervix, then that is about three centimeters. If I can spread my fingers a bit, that's four centimeters. So we each develop our own internal reference points for

cervical exam and those differences are not a big deal. It's just a difference in examiners. Okay now let's talk about comfort because this is really important also. For some women, vaginal exams can be very uncomfortable. The vagina has a lot more blood flow and it can be more sensitive during pregnancy.

Even if you usually have no problems with pelvic exams or speculum exams, this might feel different in pregnancy. Vaginal exams can also be more uncomfortable early in labor when the cervix is still tilted back in the vagina. So they can be more uncomfortable then. But the good news is as labor progress, as I mentioned earlier, exams usually get less uncomfortable.

as that cervix moves forward and your baby's head comes down. Now there are some things that you can do to make exams easier. First, and I almost hesitate to say this because I know it can be annoying to hear this, but try your best to relax as best you can. I know that that's easier said than done and there's a lot of things going on, but tension in your pelvic muscles

can make the exam more painful. So you want to try and really soften your whole body. You want to let your legs go loose like spaghetti noodles. You want to melt into the bed as much as you can. So try your best to just relax all of your muscles and let things go loose. I'm actually sitting here in my chair, like relaxing all my muscles while I'm saying this.

Nicole Rankins (16:24.374)

And then the second thing that I want you to do is breathe. All right. And I mean, really breathe. We completely underestimate the power of breath and making things less uncomfortable. So you really want to take slow, deep breaths during the exam. So inhale for three counts.

Nicole Rankins (16:53.406)

Exhale for three counts.

Nicole Rankins (16:59.01)

This will help your body relax. And it's actually harder, much harder to stay tense if you're focusing on your breath. We really, really, really underestimate the power of our own breath and helping us feel more comfortable in challenging situations. And then the final thing you can do is you can try and tilt your pelvis forward.

So what we do with that is lifting your hips up a bit by balling up your fist and you'll place them under your hips. Like you literally ball up your fist, place them under your hips and that will gently tilt your pelvis forward. That can make things easier, especially if your cervix is further back in your vagina. Now, the final thing I want you to know, if at any point that the cervical exam is too much, tell your doctor.

to stop, tell your doctor to stop, tell your midwife to stop, tell the nurse to stop. That is always your right and they absolutely should stop because consent during a vaginal exam is non-negotiable. Not just consent once it's going on, but actually backing it up, consent before we even start. Your doctor, your nurse, your midwife should always ask,

your explicit permission before doing a vaginal exam and continuing a vaginal exam. Now, unfortunately, we do not always get this right. So it often goes something like this, the scenario of doing a vaginal exam. Hey, it's Dr. Rankins. I'm just here to do a cervical check and check your labor progress. Go ahead and just put your ankles together, let your knees fall out to the side.

You're going to feel my two fingers, lots of pressure. Now, in that little blurb there, I may have sounded nice and friendly, but at no point did I ever ask for explicit consent to do the vaginal exam. This is something that happens far too often, something we absolutely need to change. It's just a relic of how we have been.

Nicole Rankins (19:16.716)

trained. So here is how it should actually go. Hey, it's Dr. Rankins. I'm just checking in to see how things are going. If it's okay with you, I'd like to do a cervical exam to check and see your progress in labor. Is that okay? And then actually wait for your affirmative yes before proceeding with the exam and even better.

even ask if like, hey, do you need to use the bathroom first before the exam? Because it can be uncomfortable to have a vaginal exam when you have to go to the bathroom. All right. Now, just because we ask for an affirmative, yes, I want you to hear me. That doesn't mean you have to give it. You always have the right to say no to a vaginal exam or to anything in labor. But if you choose to decline, it's really helpful for you to be prepared.

to share your reasons and talk it through. Because remember, again, as doctors, we are trained to assess labor based on cervical exams. And if we don't have that information, we don't really know how else to gauge your progress. And I'm gonna be honest, some doctors may even get frustrated.

if you say you don't want an exam. So to keep that relationship grounded and trust in a shared decision-making and keep it where you're working together, it's helpful to have a dialogue and not just a flat no. So in those situations, if you're not ready for a bachelor exam, try saying something like this, I'm not ready to be checked right now.

And as long as my baby looks okay, I'd like to wait another couple hours to get checked. So that keeps the conversation open while protecting your boundaries and maintaining a positive relationship with your doctor.

Nicole Rankins (21:29.634)

Now do keep in mind that your doctor may not be able to come back in exactly two hours. They may be in the office seeing patients or may even be leaving the hospital. In those moments, you can ask your nurse to check when you are ready. And on the flip side, if there's a time that you want a vaginal exam to see what your progress is,

then you can ask for one also. think sometimes, especially on social media, there's like this whole, get a VASAL exam. Don't let your doctor do that. And I get it that it should absolutely, and I agree 1000 % never be forced, but on the flip side, if it's information that you want to know, you can also ask to have a VASAL exam. Totally, totally appropriate. The point is that in both circumstances, we are centering what

is most valuable and important to you. So let's recap. Vaginal exams are a tool. They are not the whole story. They measure dilation, effacement, and station, but they do not predict timing. They should never be done without your consent. And they only give us a snapshot of what is happening in that

moment, okay? Doesn't tell us when labor is going to happen. It's just a snapshot picture of what's going on. You can make the experience easier with relaxation, that breathing and positioning of tilting your pelvis forward. And you always have the right to say no or to say not right now or say, yes, actually I do want an exam right now.

When you understand what these exams can and cannot tell you, you are going to move from feeling like things are happening to you, to feeling involved, informed, and empowered in your birth. So that is it for this sneak peek episode. If it was helpful, imagine how much calmer and more confident you'll feel with the entire pathway guiding you through every part of your hospital birth.

Nicole Rankins (23:47.404)

The Birth with Power Pathway is coming soon. I'd love for you to be the first to know when it launches. Head to drnicholrenkens.com forward slash email and join my email list. That's where I share updates, behind the scenes insights, resources I don't share anywhere else. And if we're not connected yet on the socials, come follow me on Instagram at drnicholrenkens. My DMs are open and I truly, truly love hearing from you. Now do me one more favor.

Come on back next week and remember to trust your power and take charge of your birth.