Recently, on a busy, understaffed NHS labour ward, I experienced significant pressure from a senior colleague to conduct a vaginal examination on a woman who had declined one after a balanced discussion and for whom it was not clinically indicated. For approximately 2 hours until the shift ended, I faced repeated requests to do the vaginal examination and exasperated looks when I reiterated the woman's wishes and lack of clinical indication for an examination.
I ended that shift feeling proud to have been a true advocate for that woman, but paradoxically demoralised at what I feel to be the state of midwifery in the NHS now. When did ‘offering’ (National Institute for Health and Care Excellence, 2017) a vaginal examination come to mean ‘coercing’? Or is it that women are not truly being offered vaginal examinations in labour and given the opportunity to accept or decline, but instead are being coerced or guided into having them to meet the needs of institutions and clinicians? The cynic in me, after 8 years in clinical practice, suspects it is the latter.
Since the research of Friedman (1954) in the 1950s, intrapartum care has been built around notions of labour being ‘on time’ in the name of safety, and being on time means there are regular cervical assessments to monitor the progression of labour. The practice of routine vaginal examinations was solidified by the almost universal adoption of O'Driscoll et al's (1974) ‘active management in labour protocol’. Recent evidence has robustly challenged the idea that all women will dilate at a standardised, linear rate and shown no difference in perinatal outcomes for women with longer labours (Oladapo et al, 2017). The Peel Report in the 1970s (Ministry of Health, 1970) advised a 100% hospital birth rate (albeit not based on strong supporting evidence and it was challenged robustly by Tew (1985)), which has further cemented the routine 4 hourly vaginal examination in UK intrapartum care. Most women in the UK give birth in a hospital on obstetric-led units (National Maternity and Perinatal Audit Project Project Team, 2019), in a system that is fragmented and chronically understaffed, resulting in women needing to be moved through the many different parts.
During the COVID-19 pandemic, some women were being coerced into having vaginal examinations in order to be admitted to labour wards and have their birthing partner present with them (Nelson, 2021), because of hastily written clinical policies that seemed to forget a person's right to bodily autonomy. Even before the pandemic, can we say that women were truly being offered a vaginal examination or can we speculate that perhaps they were being guided or coerced into having one?
The issue is not with vaginal examinations per se. When truly clinically indicated and when a woman has given her consent for the procedure to happen after a balanced discussion, there is no problem (providing the clinician also respects any request from the woman for the examination to stop). What is unacceptable, and unethical, is coercing women into having vaginal examinations and this makes a mockery of the notions of informed choice and consent. Midwives frequently observe women in labour and therefore, can develop skills to assess labour progress in alternative ways – relying on vaginal examinations and not truly giving women the choice to accept or decline one sees these alternative skills devalued.
Finally, ‘midwife’ means ‘with woman’; midwives have a duty to be an advocate for women and uphold their rights during pregnancy and childbirth, even when it may feel uncomfortable for midwives as clinicians.