Tuesday, November 20, 2012

How Dilated Am I? Estimating Dilation in Labor WITHOUT a Vaginal Exam

In 2008 I visited Israel and lectured to a wonderful group of doulas on the topic of alternatives to using vaginal exams (VEs) in labor, and that is when I met Sarah Vine.  Sarah later wrote a post about this topic on her blog, which I've reprinted below.  When I published my book, my favorite chapter was titled "Labor is Not About Dilation," where I explain that although vaginal exams in labor are widely and heavily used, scientific studies have not proven routine VEs in childbirth to be beneficial or medically necessary.  VEs have their downsides, including an increased risk of serious infection such as Group B Strep, as well as potentially disturbing a mother's comfort and concentration in labor (imagine how other mammals would respond to this intervention?).  Click here to visit Sarah Vine's blog, and continue reading below to see what she has written about estimating dilation without a VE.

It’s the magic question weighing on most laboring mothers’ minds (as well as the minds of her partner or birth attendants):  How much longer?  Is there any way to tell how far along I am in the birthing process?  I’ve seen mothers beg for an internal exam and then be gutted about the answer (what? only 4 centimeters still?) and suddenly she looses her resolve.  It’s akin to having a test and finding out you’ve failed it, in front of your loved ones as well as complete strangers.  This feeling is not conducive to labor – suddenly doubt and fear slide in and the laboring mother feels tense.  Happily, there are a number of external cues that can help you and your birth partners get clued in to how much labor is advancing. Some are more subtle than others, but if you are ignoring the clock and keeping focused on staying in tune with your body, you will see them.  Listen, embrace, wait.  Enjoy the way it responds!  It is amazing what it can do, this body that God gave you.

1. Sound. The way you talk changes from stage to stage in labor. With the first contractions, you can speak during them if you try, or if something surprises you, or if someone says something you strongly disagree with. You may be getting into breathing and moving and ignoring people – but if you really want to you can raise your head and speak in a normal voice. When the contraction disappears you can chat and laugh at people’s jokes and move about getting preparations done. However, during established labor, there is very little you can do to speak during a contraction. You feel like resting in between, you are not bothered by what people are doing around you. As you near transition and birth, you seem to go to another level of awareness – it’s almost like a spiritual hideaway. You may share this with someone else, staring into their eyes with each surge, or you may close them and go into yourself. In between surges you stay in this place. It is imperative for birth assistants and partners to stay quiet and support the sanctity of this space: there are no more jokes, and should be as little small talk as possible. Suddenly, the sounds start to change involuntarily: you may have been vocalizing before (moaning, talking and expressing your discomfort, singing, etc.) or you may have been silent. Listen – there are deep gutteral sounds along with everything you have heard before, just slipping in there. You are about to start pushing.

2. Smell. There is a smell to birth, that hits towards the end of dilation, during intense labor, just before birth. It is a cross between mown hay and semen and dampness. It has a fresh, yet enclosed quality, and is pervasive. The Navelgazing Midwife has also observed this scent and writes about it here.

3. Irrationality. I love this clue – it often is a sign of transition. It always makes me smile, and I always warn women about this phenomenon so that when we hit it during labor I can remind them that what they’ve just said is irrational, and that I told her this would happen, and here it is! Relax, it means we’re nearing the end. Sometimes a mother will say she wants to go home, she is done now, she’ll come back and do this later, she wants to put on her trousers and coat and go out the door. A mother who wants a natural birth and has been coping brilliantly will suddenly say she was crazy and needs pain killers right now, or that she didn’t want another baby anyways, who said they wanted a baby? Some will just curl up and say they’re going to sleep now. If she does this, that’s okay. The contractions may die down, get farther apart, and maybe she (and the baby) will get a few minutes of sleep. This slowed-down transition sometimes freaks out doctors or hospital midwives and pitocin is offered – try to see if you can put them off for half an hour. Send every one out, lie on your left side propped up by pillows and have a little nap before pushing; it is such a wonderful gift.

4. Feel. Here come some of the more fun tools that you might not have heard of before! Think about the shape of the uterus. Before labor, the muscle of the uterus is thick evenly around all sides, above, below, behind. As the cervix starts thinning and dilating, all that muscle has to go somewhere – it bunches up at the top. The top of the uterus thickens dramatically the more the cervix opens. During a contraction, at the beginning of labor, check how many fingers you can fit between the fundus (top of your bump) and the bra line – you will be able to fit 5 fingers. As the top of the fundus rises higher during labor, you will fit fewer and fewer fingers. When you can fit 3 fingers, I usually tell mothers they can think about going into hospital as they will find they are around 5 centimeters dilated. At 1 finger, you are fully dilated. (Awesome, huh! Here is a blog post by a woman who describes in great detail checking her own cervix just before she went into labor.)

5. Look. There is something called the ‘bottom line’, which is a shadow that extends from the anus up towards the back along the crease of the buttocks. It begins as 1cm and lengthens to 10cm, and its length correlates with cervical dilation. Why not look down there before inviting a stranger to put their fingers up inside you? It makes sense to me. Here is current research verifying the existence of the bottom line, and in their trial it was measurable and had acceptable accuracy for 76% of women checked.

6. Gooey Stuff. Also known as bloody show; there is usually one at around 2-3 cm dilation, and it can happen during the beginning of labor or a few days beforehand. Sometimes it’s hard to know what is or isn’t a show, since during the days before labor the amount of vaginal mucus increases in preparation and this can be confusing. A show is up to a couple of tablespoons in quantity, so quite a lot. It can be clear, but is usually streaked with pink, brown, or bright blood. If there is more than a couple of tablespoons of blood then you do need to go into the hospital to make sure the placenta is not detaching, but if there is just a bit and then it stops, then it is just show. There is a SECOND show at around 8 cm dilation. This second show means that birth is near.

7. Opening of the Back. This is at the spot where your birth partner has been doing lower back massage, at the area above the tailbone. It is a smaller than palm-sized, rather kite-shaped area that bulges out during pushing. At this point you’ve waited too long to go into hospital, and you need to refer to my other post, 4 rules of what to do when delivering a baby!

8. Check yourself. Okay, so technically this one is an internal check, but it done by YOU. You don’t have to announce the results or write them down: it is not an exam. To me it’s obvious that as the owner of your body, you have more of a right than anyone else to feel comfortable with it and understand how it works. It helps to get to know what your own cervix feels like from early on in your pregnancy, if not before, and then to keep a regular check on what feels normal. If you do this through out your pregnancy you will keep your flexibility into the 9th month. Check out the Web site My Beautiful Cervix to see photos and descriptions of what a cervix should feel like. At 1 cm you can fit the tip of one finger inside. Use a ruler to practice discerning how many centimeters dilation feels like, measuring with your pointer and middle finger.  NOTE: Always, always, always wash your hands thoroughly beforehand, up to the elbows, for 4 minutes at least. Do not assess your own dilation after your waters have broken.


  1. Love these ideas and so grateful for the info!

  2. As always I am so grateful for the wisdom you share.


  3. What an amazing post! Thank you so much for sharing this.

  4. Lovely post! Makes me smile. I find home birth midwives use these techniques because we are with mamma throughout her process; we take the time to listen to her sound, smell the air in the room, see her uterus and bottom change, listen to what mamma is saying, etc. (I love writing down some of the words moms say - this past weekend mom said "that one was kind of orgasmic in a painful kind of way" :) I think vaginal exams are used more frequently in the hospital because providers don't have the time to watch and listen. Lovely post!

  5. What a great list. Thank you for posting it. It refreshed some of the things I had learned already and taught me even more.

  6. I learned another great technique from a doula in Baltimore, who learned it from midwife Ina May Gaskin: ask the laboring mother to close her eyes, take a pen and paper, and draw a circle representing the current dilation of her cervix. I have used this technique numerous times -- it is usually accurate!

  7. Loved meeting you, and treasure the wealth of knowledge you've gained and share so succinctly! x

  8. Another great post for my tool bag! Thanks!

  9. hi carol,
    I'm an Israeli midwife, we met you were at Nataf a few years ago. I love this post and will print it out and show it to my baby midwives. Will give you the credit. Hope this is OK.

  10. Yes as an L&D nurse for 15 years I can definitely attest to the fact that we do not have time to "smell" complete dilation.