Today I came across an article on Facebook called Alternative methods for determining cervical dilation.
When we perform a vaginal exam and tell a mother about the progress or lack thereof, it can greatly affect her mental state. So, if a mother is no longer in the latent phase of labor, but we tell her she is only 1-2 cm dilated, this can have a very negative effect on her. To assess whether labor is progressing, whether it’s time for the woman to notify her partner/family, or whether it’s time for an epidural… the first thought that comes to mind is a vaginal exam. The VE is the leading way to assess labor progress, but it has its pros and cons. Also, some women examine themselves vaginally—self-examination—and in the past, rectal exams were sometimes performed instead of vaginal ones.
However, there are also “alternative” ways to assess the progress of labor.
The purple line
This is a non-invasive method that involves assessing labor progress by observing a line that, in physiological births, forms from the rectum upwards between the buttocks toward the sacrum. The line is supposed to tell us how many centimeters the cervix is dilated. The line does not appear in all women, and it also matters whether the woman has a spontaneous or induced labor. For the most part, the line was most prominent in women when they were 7-8 cm dilated and had already faded by the time of full cervical dilation. It appeared somewhere around 3.4 cm.
The sound of labor
Those who work with women can tell you that women are very different. Some are vocal throughout the entire labor, others only toward the end. Both are fine and normal.
In the early stage of labor (0-4 cm), a woman can usually talk easily or with a little effort during contractions. During contractions, she feels she doesn’t need much rest and will usually talk and converse normally after each contraction.
From 4-6 or 7 cm, the woman is already breathing more deeply and may make specific sounds during contractions and does not talk during them. She will likely need to rest between contractions.
In the transition phase from 7-9 cm, the woman usually groans, performs a mantra, etc. In the phase of full dilation, they may become completely quiet. She may not want to talk even during the break between contractions.
Pushing again has its own set of sounds. These are usually low, open sounds that help the woman expand. The lower jaw must be relaxed.
birth
A specific “smell of labor” appears when the woman is 6-8 cm dilated or in the transition phase. The smell is specific and everyone describes it differently. Through experience, we sharpen our sense of this smell.
Height of the top of the uterus – the fundus
This involves assessing cervical dilation from the outside. At the end of pregnancy in the 40th week, when labor has not yet started, there are 5 fingers between the fundus of the uterus and the sternum (xiphoid process) and the cervix is closed. As the uterus contracts, the fundus moves upward, consequently pulling the cervix upward and causing it to open more. The distance between the sternum and the fundus decreases during labor, while the cervix opens about two centimeters for every finger; 5 fingers thus mean a completely closed cervix and 0 fingers means full cervical dilation. The method is more effective for those who have already given birth once. The method should be performed at the peak of a contraction, and the woman must be lying on her back.
Emotions
When a woman becomes more serious, labor is progressing. Just like with sound, this doesn’t apply to all women. Women are relaxed at the start of labor. As labor progresses, they become more serious and may ignore their surroundings. This is a very effective sign of transition, which is usually the last phase of dilation and is typically the most intense. A woman in this phase acts irrationally and can become frightened. In this phase, they often say they won’t be able to make it, they become afraid, and they want something for the pain. Labor is coming to an end. At that time, they also usually hold onto or grab things.
Bloody show/mucus plug
This is a blood-tinged, sometimes also mucousy discharge from the vagina, which we treat as an indicator of the start of labor. It indicates that the cervix has begun to open. It can come away as early as the start of the last week of pregnancy and a few days before active labor. We call it the “mucus plug”. Not all women necessarily notice it.
Bloody show is also observed toward the end of labor when the woman is 6-8 cm dilated, or other authors describe the bloody show appearing when the woman is almost fully dilated. It can be just blood, or mucus can also be expelled.
In Slovenia, a thesis was also written on this topic by author Špela Žabar in 2013, titled: Načini ocenjevanja napredovanja poroda = Labour progress assessment methods / Špela Žabar; Thesis, Univ. of Ljubljana, Faculty of Health Sciences, Department of Midwifery; COBISS.SI-ID 4620139, where other methods are also described:
Mexican warm feet technique
At the start of labor, the feet are warm; as labor becomes more intense, blood flow is directed to the uterus, and so the feet become colder from the ankles up. At 5 cm dilation, the feet will be colder from the ankles to about the middle of the calves. When the leg also becomes colder from the knees up, spontaneous abdominal pressure will appear. If the woman is in a birth pool, she must be on dry land for at least 20 minutes for this technique.
Physical changes
When labor is approaching, some women feel nauseous and have diarrhea. Others have an urge to clean.
Flushing in the face and a feeling of heat, shaking. Uncontrolled shaking can be present on the threshold of the second stage of labor. Vomiting itself can be a result of emotions, hormones, or fatigue. Flushing on the face, in the absence of the mentioned signs, is a good indicator of cervical dilation of 6 to 7 cm. Many women shake from fatigue at the end of labor. If we notice several signs together, they are a good indicator of transition. Traditional midwives also describe sweating above the upper lip, which means the laboring woman is 7 cm dilated. So when I’m hot, I’m 7 cm dilated 🙂
Authors also describe the curling of the big toe, which indicates that the cervix is 6-8 cm dilated. Some authors state this when the cervix is 7-8 cm dilated. More women also have a greater tendency toward upright positions during this time.
Goosebumps on the back appear before spontaneous pushing, as well as on the buttocks and thighs. They may also vomit in this phase. Many complain that they need to go to the toilet to poop, but this is usually just a sensation because the head is so low.
Sensation of pressure from the head or the presenting part
The baby descends during labor, and so the laboring woman feels pressure on different parts of her back. The pressure moves from the rim of the pelvis down to the tailbone. This information usually doesn’t tell us about cervical dilation, but it does tell us the baby’s position. Nevertheless, authors suggest that if a woman feels pressure between her legs, the cervix may be 7-8 cm dilated.
Rhombus of Michaelis
It appears on the lower part of the spine, with points between the waist, the tailbone, and the sacroiliac joint. This rhombus rises above the level of the back by several centimeters and increases the volume of the pelvis, thereby allowing the fetus to descend through the birth canal. The condition is that the woman has her knees lower than her hips (knees on a stool, on all fours…), as the sacrum can then open because the back of the fetal head and the G-spot meet. When this happens, the laboring woman will spontaneously grab forward for support, widen her knees, and drop her belly, then flex her back and arch the lower part of her body. This sequence of events was defined by Michel Odent as the Fetus Ejection Reflex.
Drawing a circle
This is a technique described by Ina May Gaskin, where you give a woman a pen and a piece of paper and tell her to draw a circle with her eyes closed that represents her current cervical dilation.
In order for a woman to report her feelings, she must listen to her body and surrender to the sensation. When assessing labor progress, we aren’t just interested in cervical dilation. We are also interested in the descent of the presenting part, the baby’s condition, and the strength/length of the contractions.
