‘Repeated VEs are an invasive intervention, of, as yet, unproven value. Those who advocate their use thus have the responsibility to test their belief in an appropriately controlled trial’ (RCM, 2005 citing Enkin, 1992).

• VEs are relied upon to assess labour progress, and as such they do appear to be a useful guide; however, studies have found that VEs can be an imprecise measure of labour progress particularly when performed by different examiners (Crowther et al., 2000). Where possible, therefore, they should be carried out by the same clinician (RCM, 2005).
  
• In multiparous women, cervical dilatation does not always correlate to their true labour progress, which is sometimes more accurately reflected in their typical labour behaviour and vocalisation.
  
• Simkin and Ancheta (2005) describe the importance of additional measures of progress including cervical consistency, thinning and effacement, movement from posterior to anterior and the importance of good cervical application to the presenting part.

VEs are the main focus for assessing progress of labour; Warren (1999) suggests midwives ask themselves, ‘What decision has to be made at this time which requires information that can only be obtained from a VE?’

• The timing and accuracy of VEs varies:

It is recommended that the timing of VEs in labour should be relevant to each individual woman in order to permit adequate assessment of her progress (and not be performed too frequently or for the sake of ‘routine’) (Crowther et al., 2000).

Conversely, National Institute for Clinical Excellence (NICE) (2007) advocates VEs at routine, fixed 4-hourly time intervals in the first stage of labour.

• Definitions of progress vary (Crowther et al., 2000) but a cervical dilatation of 0.5 cm/hour is advised in the NICE (2007) intrapartum guidelines.
  Labour progress issues are discussed further in Chapter 8.

A study of women’s experiences of VE and information giving in labour found that two thirds of midwives provided good or very good information at this time. The equivalent for doctors was just a third (Lewin et al., 2005).

• Discuss the indication for the examination.
  
• Check if this is the woman’s first VE (often it is).
  
• Explain what it may feel like and typically how long it may last.
  
• Offer a chaperone irrespective of the clinician’s gender ( Royal College of Obstetricians and Gynaecologists (RCOG), 1997).
  
• In non-English speaking women, ensure an interpreter/advocate is available (RCOG, 1997).

Implied consent (including written consent) may not be sufficient evidence that someone has given express consent (GMC, 1998). Many women conform or comply with suggestions for which, when they later reflect, their informed and express consent had not actually been sought. Performing a vaginal examination without express consent may constitute assault and has medico-legal implications (RCM, 2005).

If consent is withheld:

• Remain sensitive, open and accept her decision. (You may have to protect the woman from pressure to comply from particular colleagues.)
  
• Seek alternative methods of assessing progress in labour as discussed in Chapter 1 under the heading ‘Assessing progress in labour’.
  
• Consider that many women, including survivors of sexual abuse, may not be able to cope with invasive, intimate procedures in labour (see later in this chapter).

Stewart (2006) found that midwives sanitise their terminology, using abbreviations (a VE) and euphemisms (an ‘internal’) to distance themselves from intimacy and embarrassment. She comments that some midwives ceremonially prepare a sterile trolley, opening packets and performing a ritualised washing down of the woman’s external genitalia as an overt statement of power and an attempt to sanitise the woman’s bodily fluids perceived as ‘dirty’. Since women are capable of cleaning themselves, this practice, which exposes them to high levels of genital touching and embarrassment, has little basis in necessity. In contrast to this, other midwives use an informal, speedier approach, while maintaining asepsis, by squeezing lubricant inside the opened packet of sterile gloves and donning them discreetly.

Despite VEs being undertaken frequently, the procedure lacks good evidence to guide best practice.

VE procedure

• Ensure the woman’s bladder is empty.
  
• Provide privacy: directly ask any unnecessary people present to leave the room. Never underestimate someone’s potential embarrassement or vulnerability even if attending a birth at home. Ensure doors are closed, curtains drawn and in hospital display a ‘please knock and wait’ sign on the door.
  
• Cover up the woman’s lower half with a sheet/dressing gown.
  
• Abdominal palpation first! This is a good habit to get into.
  
• In the absence of useful evidence, it seems prudent if the membranes are not intact, the labour is preterm or prolonged or infection is a possibility, that sterile gloves should be worn.
  
• Evidence suggests a douche or wash down, even using chlorhexidine is of no benefit in reducing ascending infection (Lumbiganon et al., 2004).
  
• Tell the woman that if she wants you to stop at any point or the VE ‘hurts’ she can trust that you will respond appropriately.
  
• Sit next to the woman and encourage her to relax her thighs and bottom before commencing the VE. Use plenty of lubricant and gently advance two fingers inside the vagina.
  
• Never start a VE during a contraction: it is unnecessary and painful. If the woman has a contraction during the VE (commonly triggered by you touching the cervix), keep fingers still and talk her through or remove them.
  
• Explain what you are doing, particularly when moving your fingers anteriorly (usually the most uncomfortable and sensitive area) and be aware of the woman’s body language; actually ask her if she is okay.
  
• Be aware of your own body language when performing a VE. Avoid looking disapproving, worried, disappointed or disconnected from what is happening.