- by Barbara E. Herrera, Navelgazing Midwife

Interestingly, women who want no one else to check their cervices (plural for cervix), invariably ask me how to check their own. I have described it for years, but finally wrote the process out for one of my on-line groups and it was well-received and understood for something that is 100% tactile as opposed to intellectual. I hope the information is helpful to those that want to know.

Note #1: I utilize several food analogies below that might offend some who feel I am not seeing the woman for her Self. Please know that isn't so at all, but I am trying to find common items we can touch and experience. I am not objectifying the woman. I promise.

Note #2: When I speak of "we" throughout, I am speaking as a midwife. As a mom, I never did self vaginal exams because I was too fat to reach, so reading over this, it sounds like midwives have exclusive domain over these learned skills. I don't imply that at all and am actually writing this so folks not only know what we are doing (when they are done), but so they can do them themselves if they want to.

Learning to do vaginal exams 101/201/301. No test given, ask any questions when they come up!

IMPORTANT NOTE FOR PARTNERS: When putting fingers inside the vagina, washing hands is a given, but we have found that the index and middle finger are easiest to maneuver inside a vagina. Just watch that thumb! It, all too often, finds the clitoris... please be aware of your thumb and keep it to the side.

DILATION:

            We (midwives, I can't speak for docs) start by measuring our forefingers and middle fingers as they are stretched apart. Mine are 8 centimeters (cm) apart. Then, we begin guess-timating objects: drinking glasses, soda cans, salt shaker's bottoms; anything in a circle, small and large. We guess, then measure; first with the tape measure, then our fingers to verify, then, when we are guessing correctly more than not, we switch that order... fingers, guess, then measure.

            When I first went into a vagina to find a cervix, it was mush. I was lost in the terrain. Mind you, I had been lesbian for many years and had assisted Certified Nurse-Midwives and Labor & Delivery nurses for a long time so knew what cervices looked like with speculums, but finding one with my fingers was a whole 'nother story! Non-pregnant cervices feel like the tip of your nose. Pregnant cervices feel like your soft, gooshy lips. Being slow and gentle and patient helps you or your partner find your cervix (and can be foreplay for some).
           
            I can tell when someone looking for a cervix finds it. They get an Ah-HA lightbulb over their head because, even in the gooshy terrain, there is a distinct difference once the cervix is felt.
           
            Many descriptions abound: a soft, full donut is the most common... the "hole" of the donut (the "os" of the cervix) closed and tight when not dilated... warm and open and varying in size as dilation begins and progresses.

EFFACEMENT:

            The length of the cervix is now actually measured when women are having pre-term labor issues... their finding that the length of the cervix can be indicative of early labor (along with the fetal fibronectin test, but that is another story).

From http://www.babycentre.co.uk/expert/557301.html:

A vaginal scan is the best way to measure your cervix because it can be seen much more clearly this way. The cervix looks like a tube on the scan, between 3 and 5 cms in length, with one end at the top of the vagina (the external os), and the other end inside the womb (the internal os). It is the internal os that can begin to open first, and this will look like a V shape on the scan. As the os opens further it becomes U shaped. This is called funneling. (2) If the closed part of the cervix measures less than 2.5 cms, a stitch will be put in to stop the cervix opening further. <my note: that is cerclage>

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            But, in normal labors, cervical effacement (as the shortening is called) can occur weeks ahead (not uncommon) or not until labor begins (not usual). Judging effacement again begins with measuring your (or your partner's) middle finger and finding where 4 cm is... touch that... feel where that is on your finger. 4 cm is a bit long to me, especially as we move closer to birth, so maybe finding where 4 cm and below would be better.

           
            What is measured during that early ultrasound (if one is performed) is the distance from external os to internal os. Measuring with fingers is different since we aren’t putting a finger inside the os, so instead, we feel the cervix from the outside... feeling the os, and then running our finger up the outer portion… up to the upper vaginal wall and guess there. And it is a guess.

            Of course, to make things more confusing, we don't guess in centimeters, we guess in percentages effaced (gone/shortened).  

            And, with practice, we needn’t have felt a woman’s cervix at all in pregnancy to know what the effacement is in labor; either... it is an intuition... a "feeling" of where that cervix was/is.
           
            So, remembering that the cervix is the uterus can help with visualizing what you are feeling. The uterus uses her muscles to pull up in preparation for pushing down of second stage. The cervix (the actual donut part if we go back to that analogy) thins as the uterus pulls those muscles up. From thick like rigatoni (10% effaced)... gooshier than rigatoni... like rigatoni filled with jello or pudding, maybe... to thin like over-cooked fettuccini (80% effaced), but wider... not as wide as lasagna noodles, though, and no more pudding... just flat and soft.

            When the cervix is 100% effaced, then it is unable to be felt at all... called "paper thin" because the cervix is flush with the baby's head... barely a perception of change between vaginal wall and baby's head... a fraction of an elevation... like when you put your hand on a sheet of paper lying on your desk and slide your finger off the paper onto the desk with your eyes closed... like that.

            The rigatoni to fettuccini stages are subjective since they are done in percentages... and I don't put too much stock in effacement since it happens with dilation anyway. If the cervix is 1-2 cm long, that's about 50% effaced. Less than that, 75%-100%... not usually 100% until 10 cm (and without a cervical lip!). However, women do have 100% effacement pre-labor. I know to run to their home (or have them run to the birth center/hospital if that is where they are delivering) when labor begins... 100% effacement is a pretty darn good gauge of a quick labor in the making.

STATION:

             Station is measured in -4, -3, -2, -1, 0, +1, +2, +3, +4. Minus 4 is high, high (some texts discuss minus 5 and plus 5, but not all)... the head floating... ballotable (bounce-able... pronounced buh-LOT-able). Even a minus 2 or 1 is generally ballotable. Once the baby gets down deeper in the pelvis, it can no longer ballot (buh-lot).

            How do we make the baby ballot? With fingers inside the vagina, we can actually touch the baby's head, even with a closed cervix... alongside the upper vaginal wall... we can feel a head about minus 2 (longer fingers can reach minus 3s and 4s). Touching the baby's head, we put pressure there and if it bounces out of the pelvis, it is ballotable. It’s best not to ballot too hard lest the umbilical cord fall below the head. A gentle tap to feel ballotability is sufficient when wanting/needing that information. It is possible to ballot externally, but they (those that judge) wouldn't consider that accurate. When there is a question about head/pelvic compatibility, docs and midwives have been known to push the baby into the pelvis to see if the baby fits. We can actually feel the head above the pelvic bone (pubic symphasis) if it does not go into the pelvis.

            Of course, for goodness sake, that is zero indication of being able to fit through the pelvis and is nearly absurd to even put a mom emotionally through the experience. The baby's head isn't in the position of its own choosing, the woman is lying down, the pelvis isn't open to its full capacity, the baby's head hasn't molded... la la la.

            What does a baby's ballotability mean for me? It gives me warning about cord prolapse... that is about it. While I share about cord prolapse with each client, if I find a baby high during prenatals (even externally), I have the woman look me in the eye so she understands what to do if her water breaks before I see her again to see where that baby is. (A midwife is the product of the sum of her experiences... and I have had 2 cord prolapses in my hands.) The head being high is an avenue for a cord to slip around the head as the membranes release, the head possibly following, compressing the cord – a life-threatening emergency for the baby.

            So, what does it feel like when your fingers are in the vagina and you touch the baby’s head? Hard compared to the soft and gooshy vagina and cervix... even through the vagina as opposed to inside and through an open cervix, the head can be felt. If you are able to reach in and feel the baby easily without reaching far, the baby could be at zero station or less. If the baby feels really close (5-6 cm in) to the introitus of your vagina, s/he could be at a plus 1 or 2 station (what you might find in good active labor). The baby’s head able to be seen with pushes, and not in-between contractions/surges? Plus 3. Able to be seen between contractions and continues birthing? Plus 4. Plus 5 is crowning if a plus 5 is used.

            Now, I know that stations typically are described as the widest diameter of the baby's head being aligned with the ischial spines of the mom (zero station if it is even with the spines). That is an obscure description for many people and I hope that how I described it is easier to be “seen.”

             Stations, like effacement, mean virtually nothing in the grand scheme of things unless progress is an issue during active labor. Station can give us a heads up on what might be happening with a baby's head position... with inability to mold easily... or if mom has pelvic issues (a former accident or severe anorexia as a teen). Otherwise, it is just another measurement midwives are taught to do as a matter of course.

CERVICAL LIP:

            Since I mentioned this above, I feel I should talk about it for a moment. Lips can be anywhere, but almost always called “anterior lips" mostly because when a head is entering the vagina during 8-10 cm dilation, feeling behind to find a posterior lip is nearly impossible. We usually will mention/chart where it is... the most common locations are between 11:00 and 2:00.

            What might cause a cervical lip? After talking to hundreds of folks who have felt and know cervices, there seems to be an agreement that cervices do not dilate in a symmetrical manner. It probably doesn’t dilate in an oval path, either, but most likely, in a fluid pattern whereby some parts are more dilated and effaced than others, yet those same parts could seem to lag behind another portion of the cervix ten minutes later. I believe that if there were a way to accurately and continuously measure the diameter of cervices during labor, it would be shown how asymmetrical dilation really is (and I do not advocate creating or utilizing such a tool!). Therefore, I believe that a cervical lip is nothing more than the asymmetrical cervix finishing her job dilating and that so many women have cervical lips because so many people put their fingers in to find them. I believe that if there was a realization (or acknowledgement) of this asymmetry surrounding the entire dilation process, amazing amounts of hysteria from the medical establishment could result – and, conversely, women could use the information towards their own empowerment and refusal to allow the arbitrariness of a cervical exam affect the emotional and spiritual progress of their labors.

             However, most don’t acknowledge or accept this theory and feel they need to do something with a cervical lip. There is a lot of discussion in midwifery and medical communities about what to do and this is certainly a case of experience dictating what the care provider does, but I have really come to believe if your hands aren’t in your vagina (or someone else’s hands in your vagina), you won’t know you have a lip! But, for those that really do want to know what is taught and done during lips in labor, here goes.

            Most midwives agree to not put pressure on the swollen lip... rest it by lying on the opposite side of the lip (unless it is truly anterior, then switching sides can be beneficial). If the lip is more on one side than the other, after resting, flip sides to put pressure on the cervix and see if that helps. Some midwives use ice to take the swelling down, putting the ice in a sterile glove if possible. Some midwives lift the floppy cervix over the babe's head. Some midwives shove "stubborn" (thick) lips out of the way. Some midwives manually dilate their client's cervices (for a number of reasons including selfishness [being tired], or when a baby needs to get out fast). It helps to let a woman do what feels right and if it hurts, don’t push! If it feels good, then push.

            The common belief is if a woman pushes before she is fully dilated (the excuse for vaginal exams to see if it is “time to push”), she will tear her cervix. In 23 years and over 800 births, I have seen a torn cervix one time (with a non-instrumental [forceps] birth) and the woman delivered her 6th baby so fast that baby just fell out, no exams at all. All those women pushing on lips, pushing before they were ready, pushing when told not to... no tears at all. I have felt cervices swell closed (a couple three centimeters more closed) with pushing, but not torn. Listening to the body cannot be stressed enough and, when upright, the body rarely forgets what to do.

            I hope this information has helped those that want or need this information for themselves. Even women who have care providers and allow those providers to do vaginal exams have found the descriptions helpful as they visualize what is happening inside their own bodies.

            Remembering that vaginal exams, even by the same midwife, doctor, partner, or yourself is subjective and what might be felt by one caregiver would register a totally different description by another a few minutes later. Our bodies are fluids, not solids. Change is normal. Being with our bodies during those changes can be delightful!

Barbara E. Herrera strives to be a low-profile midwife and share as much information with women as she is asked, believing the information belongs to the women, not only in the proprietary hands of doctors, nurses, or midwives.