3.3 Vaginal Examination

This is one of the essential diagnostic actions in the assessment of the start and the progress of labour. It should only be conducted by trained birth attendants, with clean hands, covered by sterile gloves. The number of vaginal examinations should be limited to the strictly necessary; during the first stage of labour usually once every 4 hours is enough, as prescribed in the manual for the use of the partograph (WHO 1993). If labour passes off smoothly, experienced birth attendants can sometimes limit the number of examinations to one. Ideally, that would be the one examination necessary to establish active labour, i.e. to confirm the fact that there is dilatation of the cervix (the most objective criterion of active labour). Another practice in the management of labour is to only perform a vaginal examination when there is an indication for the need, for example when the intensity and frequency of the contractions decrease or at signs of heavy show or the urge to push, or before the administration of analgesia.

Something can be said for each of the above-mentioned approaches, but considering our theorem: “In normal childbirth there should be a valid reason to interfere with the natural process” maybe the latter two policies outweigh the former. Yet many questions remain, as there is no clear evidence to support any specific policy. Perhaps more strict guidelines are necessary in those countries where birth attendants have a limited training and are isolated, with great distances to the referral centres. These guidelines would then be country-specific.

In institutions where caregivers are trained a vaginal examination by a student sometimes will have to be repeated and checked by the supervisor. This may only be done after the woman has consented. Under no circumstances should women be compelled to undergo repeated or frequent vaginal examinations by a number of caregivers or students.

In the past rectal examination has been advised to avoid contamination of the vagina. This practice is not recommended. Studies comparing vaginal and rectal examinations showed a similar incidence of puerperal infection whether rectal or vaginal examinations were employed during labour (Crowther et al 1989). Women’s preference for vaginal over rectal examinations was clearly demonstrated in a randomized clinical trial (Murphy et al 1986).