Your doctor or midwife may suggest a vaginal exam in the weeks leading up to your due date or during labor. These exams have become routine. However, there are questions about whether they are truly necessary, how useful the results really are, and whether the evidence supports their widespread use. This episode explores what happens during a vaginal exam, what the results can and cannot tell you, and the research on the potential benefits and risks to consider. The goal is not to promote or discourage the procedure, but to empower you with knowledge and choice to make an informed decision you are confident in.

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What is a Vaginal Exam?

A vaginal exam is exactly what it sounds like. Your doctor or midwife examines your vagina to assess your cervix. Before the exam, your provider will ask you to empty your bladder, which can make the exam more comfortable. This is a good habit to adopt before any appointment late in pregnancy as your growing uterus puts additional pressure on your bladder.

You will then remove your clothing from the waist down and lie on an exam table. During the exam, your care provider will insert one or two gloved fingers into your vagina to reach your cervix. They assess whether it has begun to dilate (open) or efface (thin). The exam can also provide information about the position of your cervix and the position and station of your baby. It is common to have some light spotting or increased discharge afterward. Especially if your cervix is already starting to soften or dilate.

It is important to know that as your body prepares for labor, many changes occur that you may not feel or notice. Every part of the process works together to create the right conditions for your baby to be born. To better understand this procedure, let’s explore what your care provider is looking for and what the measurements they take actually mean.

Is a Vaginal Exam an Intervention?

An intervention is defined as the action or process of intervening, or an action taken to improve a situation, especially a medical disorder. When you apply these definitions to your pregnancy or birth, I define an intervention is any action taken to alter the course of your pregnancy or birth. The results of a vaginal exam could influence your decision to induce labor, opt for a cesarean birth, or affect your attitude or expectations about when you will go into labor or how your labor is progressing.

Cervical Changes

The cervix is the lower, narrow part of the uterus that connects to the top of the vagina. Your cervix acts like a doorway between the uterus and the vagina. During your pregnancy, your cervix stays closed, firm, and long to help keep your baby safely inside the uterus. As you get closer to labor, your cervix starts preparing for birth by softening, dilating (opening), and effacing (thinning). These changes allow your baby to pass through the birth canal.

Cervical Dilation

Your doctor or midwife measures cervical dilation in centimeters. The first stage of labor is from the onset of labor until your cervix is dilated to 10 centimeters. To give you a tangible idea of dilation measurements, consider the following:

Early Labor	Active Labor	Transition
1 cm = cheerio	4 cm = oreo	8 cm = apple
2 cm = grape	5 cm = mandarin orange	9 cm = donut
3 cm = quarter	6 cm = soda can	10 cm = bagel
	7 cm = tomato

How Your Provider Measures Cervical Dilation

A doctor or midwife measures cervical dilation by inserting two fingers into your vagina. They place them on either side of the vaginal opening to estimate the distance between their two fingers. One study examined the accuracy of vaginal exams by having a researcher perform an exam immediately after a clinician and comparing the results. The two agreed on the dilation measurement in only 49% of cases. In 51%, their assessments differed. In 11% of cases, the measurements were off by 2 centimeters or more. These discrepancies show that vaginal exams are not an exact science and that the results can vary between providers.

Cervical Effacement

Your provider measures cervical effacement as a percentage from 0-100%. At 0% your cervix is closed and hard and feels like the tip of your nose. At 100% it is paper-thin and feels soft like your lips.

Mucus Plug and Bloody Show

During pregnancy, a thick collection of mucus called the mucus plug seals your cervix. This barrier helps protect your baby by preventing bacteria from entering your uterus. As your cervix begins to soften, thin, and open in preparation for labor, the mucus plug can loosen and come out. When this happens, you may notice a small amount of thick or jelly-like discharge. It can be clear, yellowish, brown, or tinged with blood. This is also known as a bloody show. Losing your mucus plug is a normal sign that your body is preparing for labor. However, not everyone will experience it. If you do lose your mucus plug, it does not necessarily mean labor will start immediately, and your birth could still be days away.

Cervical and Fetal Position

In addition to measuring dilation and effacement, your provider assesses both the position of your cervix and the position and descent of your baby.

The Position of the Cervix

During pregnancy, your cervix is posterior and points towards your tailbone. Near or during labor, your cervix moves forward to an anterior position, toward your pelvic bone, to give your baby an easier path through the birth canal. Your provider will take note of whether your cervix is posterior, mid-position, or anterior.

Station of Your Baby

In the weeks or hours leading up to birth, your baby will settle deeper into your pelvis. This is referred to as lightning or your baby dropping. The position of your baby’s head in relation to your pelvis is described in terms of station. This is measured on a scale from -5 to +5. At -5, your baby’s head is still high and not yet engaged in the pelvis. A zero station means the head is level with your pelvic bones, and your baby is considered engaged. A +5 station means your baby’s head is crowning and visible at the vaginal opening.

Like cervical measurements, measuring the station of your baby is not an exact science. One study used a specially designed birth simulator to examine how accurately doctors could determine a baby’s station. The results found that determining fetal station by touch alone is not very reliable. Residents were inaccurate in 50–88% of cases, and even experienced physicians made errors 36–80% of the time.

Position of Your Baby

Your doctor or midwife will also assess the position of your baby. They may be able to tell this by feeling your belly. They can also determine which way your baby is facing by feeling their skull during a vaginal exam. Prior to birth, the bones in your baby’s skull are not yet fused. This allows the head to mold and pass more easily through the birth canal. This is why some babies born vaginally have a slightly cone-shaped head. Don’t worry, this is completely normal and temporary. The soft spots, or fontanelles, where the skull bones meet, help your provider identify your baby’s position.

Bishop Score

Your doctor or midwife can use all of these measurements to calculate a Bishop score. The Bishop’s score is a scale from one to ten that was originally developed to predict the likelihood of going into labor. A score of one indicated labor was about 3 weeks away. A score of ten indicated labor would start within a few days.

Recall that all of these measurements are estimates and are subject to a margin of error. Today, we know that a Bishop score may not be the best predictor of when you go into labor. However, it may be relevant if you are considering inducing labor. A Bishop score is the most commonly used method to rate the readiness of the cervix for labor induction. There is evidence that inductions tend to be more successful with higher Bishop scores. An unfavorable Bishop score, of 5 or lower, was the main factor linked to a failed induction and a higher chance of cesarean birth.

Clinical Guidelines

The American College of Obstetricians and Gynecologists states that “Cervical examinations are indicated to determine labor progress, but there is insufficient evidence to provide guidance on the frequency of cervical examinations in labor to assist with labor progress or dystocia.” ACOG goes on to state, “It is reasonable to perform cervical examinations as often as needed when clinically indicated.” Essentially, it is up to your doctor to determine when they deem a vaginal exam necessary. Then, the decision of whether to perform a vaginal exam would employ shared decision-making and informed consent.

Internationally, the consensus on vaginal exams during labor is to offer them every four hours during labor. The National Institute for Health and Clinical Excellence (NICE) in the UK recommends providers offer expecting mothers a vaginal examination when they enter a hospital in suspected established labor and every 4 hours as labor progresses. The World Health Organization recommends vaginal examination at intervals of four hours for routine assessment of the active first stage of labor in low-risk women.

The Evidence on Routine Exams

A Cochrane review examined routine vaginal examinations compared with other methods, or different timings, to assess labor progress. The researchers found no strong evidence that frequent or routine exams improve outcomes for mothers or babies compared to less invasive or less frequent alternatives. Ultimately, they conclude that further large‐scale RCT trials are required. This suggests that while providers widely use vaginal exams, their benefit in improving outcomes is not firmly supported by high-quality evidence.

The Value of a Vaginal Exam for Your Care Provider vs. the Value to You

So much of what happens during birth occurs internally. It can be difficult for a doctor or midwife to know exactly how your labor is progressing. Vaginal exams and the measurements they provide are appealing because they give your provider measurable signs of progress. Vaginal exams primarily offer two key pieces of information: how your labor is progressing and whether your cervix is fully dilated to 10 centimeters before pushing begins. For you, the value of a vaginal exam depends on what you hope to gain from the information. Understanding how the results may or may not affect your care can help you decide whether the potential benefits outweigh the possible risks or discomfort.

Measuring Progress

Your doctor or midwife wants to know that labor is progressing. In the past, doctors expected cervical dilation to progress by one centimeter per hour. Research has shown that the one centimeter per hour guideline is not realistic and that cervical dilation patterns are not linear. The rate of dilation typically accelerates after 5 or 6 centimeters, during the active phase of labor. Plus, the rate at which the cervix dilates and effaces varies greatly from one expecting mother to the next.

For example, if your doctor measures your cervix and you are dilated to 2 cm, and four hours later you are at 7 cm, that is tangible evidence that your labor is moving forward. However, this is not a steady linear measurement. You could take three hours to go from two to three centimeters, then progress to 6 centimeters in under an hour.

Reaching Full Dilation Before Pushing

It is widely accepted in the medical community that you should be fully dilated to 10 centimeters before pushing. The reasoning is that if your cervix is not completely open, pushing will not effectively help your baby move down, since there is not enough space for them to pass through the birth canal. In an unmedicated birth, the urge to push usually occurs naturally once you reach full dilation. With an epidural, you may not feel these same sensations or the natural urge to push. ACOG recommends that pushing commence when complete cervical dilation is achieved. The only way for your care provider to confirm full dilation is by performing a vaginal exam.

Don’t Focus Solely on the Numbers

Your cervix has a lot of work to do before your baby is born. The measurements of dilation or effacement only tell part of the story. While these numbers can be helpful for your care provider, they do not capture everything that is happening in your body. How you feel and the changes you sense can be just as meaningful as any measurement. You have the unique advantage of experiencing your labor from the inside, and that gives you valuable insight into your own progress.

What a Vaginal Exam Tells You

The results of a vaginal exam can provide useful information, but they cannot accurately predict when labor will start or how much longer it will last. You could dilate to 2 centimeters for weeks before labor begins and still go past your due date. During labor, progress is rarely linear. You may progress from 2 to 3 centimeters in an hour, but there is no guarantee that in another hour you will be at 4 centimeters. You may still be at 3 centimeters, or you could advance to 6 centimeters. Your body is constantly making changes to prepare for birth, many of which are not visible or measurable during an exam.

Some expecting mothers want to know the status of their cervix simply out of curiosity, and that is completely valid. If you are considering an induction, knowing whether your cervix has started to dilate and efface may indicate that you have a higher probability of a successful induction.

Risks of Vaginal Exams

Vaginal exams do come with some risks. As with any procedure, your doctor or midwife should discuss all of the risks and benefits with you and only proceed with your informed consent. This conversation is part of shared decision-making, where you and your care provider work together to decide what is best for you and your baby. You have the right to ask questions, understand your options, and opt out of any procedure you are not comfortable with.

Physical Discomfort

Vaginal exams can be physically uncomfortable. A study based on interviews with women after birth found that 82% reported pain or severe pain, and 68% reported discomfort during the exam. This discomfort can happen for several reasons. The exam involves inserting fingers into a sensitive area, and your cervix and vaginal tissues may already be tender or swollen late in pregnancy or during labor. Feeling anxious or tense can also make the muscles around the vagina tighten, which can increase discomfort.

Infection Risks

There is a risk of infection if your provider pushes bacteria from the vagina up into the cervix. A large study of over 22,000 births examined whether the number of vaginal exams during labor affects the risk of infection. The study found a clear pattern that the more vaginal exams performed, the higher the risk of infection. Women who had five or more exams were significantly more likely to develop fever, chorioamnionitis (a uterine infection during labor), or postpartum infections like endometritis. The authors concluded that performing five or more vaginal exams independently increases the risk of developing a fever related to infection, and the risk rises as the number of exams increases.

Psychological Effects

The psychological impact of a vaginal exam is often overlooked, but it can be significant. The results can shape your emotions and expectations. You might be excited if it sounds like labor is starting soon, or disappointed if it seems like progress is slow. If you expect labor to begin right away and it does not, that can lead to frustration or anxiety that your body is not progressing as quickly as you or your care provider hoped. It is important to understand what the results of a vaginal exam truly mean, and what they do not. If anything is unclear, ask your doctor or midwife to explain the findings and what they indicate for your unique situation.

Transperineal Ultrasound

In the future, there may be greater access to alternative ways of assessing cervical dilation and your baby’s position using ultrasound instead of a manual vaginal exam. The main advantage of this approach is that it is less invasive, which could help reduce discomfort and some of the risks associated with traditional vaginal exams.

One study found that transperineal ultrasound (an ultrasound placed on the perineum) was effective at diagnosing active labor (4 centimeters dilated or more). However, it was less reliable when dilation reached 8 centimeters or more, or after the membranes had ruptured. Another study compared a vaginal examination to a transperineal ultrasound during labor to look at outcomes on pain and anxiety. This randomized controlled trial found that pain levels were significantly lower during ultrasound exams, though anxiety levels were similar between the two groups. A third study found that ultrasound was more accurate for assessing fetal head position and station, but less accurate for measuring cervical dilation than traditional vaginal exams.

As technology advances, transperineal ultrasound could become a more widely available option for assessing labor progress. If this approach interests you, ask your doctor or midwife whether it is an available option in your birth setting.

Your Options

As with any procedure, you have choices when it comes to vaginal exams. You can decline an exam altogether, limit the frequency, or request one if you want to know your measurements. You can also postpone the exam. If your provider offers an exam at 38 weeks and you prefer to wait until closer to your due date, you can opt to do that as well. If your doctor offers an exam during labor you can also ask to hold off until later.

Talking to Your Doctor or Midwife

Unfortunately, not all interventions come with full informed consent. Especially in cases when providers view an intervention as a simple routine procedure. After reading this article, you know the potential benefits, risks, and limitations of vaginal exams to help you have an informed conversation with your doctor or midwife. You have an opportunity to discuss this procedure before your birth to better understand your care provider’s practice in using this during labor and to express your preferences.

Potential Questions to Ask Yourself or Your Care Provider

The BRAIN acronym is a fantastic framework for evaluating interventions and a vaginal exam. Each letter represents a question you can ask to determine whether any intervention is the right choice for you and your baby.

• Benefits – What are the benefits?
• Risks – What are the risks?
• Alternatives – What are the alternatives? Is a transperineal ultrasound an option?
• Intuition – What does your intuition tell you?
• Nothing – What happens if you do nothing? If you decline a vaginal exam, how will that affect your care?

The goal is for you to make an informed choice you feel confident in, not simply avoidance or acceptance of the procedure.

Including Vaginal Exams in Your Birth Plan

This is a procedure you may want to include in your birth plan. Writing a birth plan is a valuable way to start meaningful conversations with your care provider and clarify your preferences. Simply handing over a typed sheet during labor will not guarantee the birth experience you want. The real value lies in the preparation and discussing your wishes with your partner and care provider ahead of time so everyone is on the same page.

The Pregnancy Podcast has many resources to help you craft a birth plan:

• Guide to Creating Your Birth Plan
• Get a copy of Vanessa’s birth plan
• Your Birth Plan book
• Become a Premium Member for a FREE copy of the Your Birth Plan book and access to every single episode ad-free

Making the Best Decision for You and Your Baby

Vaginal exams can provide useful information, but they are not the only way to understand how your body is preparing for birth or progressing during labor. The most important thing is that any procedure aligns with your preferences and comes with informed consent. When you understand the evidence, ask questions, and make decisions that feel right for you, you are empowered to have the birth experience that best supports you and your baby.

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