Today I came across an article on Facebook called Alternative Methods for Determining Cervical Dilation.
When we perform a vaginal exam and tell the mother about the progress or lack of progress in labor, it can greatly affect her mental state. So if a mother has been in the latent phase of labor for quite some time and we tell her she’s 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. VE is the leading method for assessing labor progress, but it has both advantages and disadvantages. Also worth mentioning, some women perform vaginal self-exams, and in the past, rectal exams were sometimes performed instead of vaginal ones.
However, there are also “alternative” ways to assess labor progress.
Purple Line
This is a non-invasive method that involves assessing labor progress by observing a line that forms during physiological labor from the rectum upward between the buttocks toward the sacrum. The line is supposed to indicate how many centimeters the cervix is dilated. The line doesn’t appear in all women, and it’s also important whether the woman has spontaneous or induced labor. For the most part, the line was most pronounced in women when they were 7-8 cm dilated and had already faded by complete cervical dilation. It appeared around 3-4 cm.
Sounds of Labor
Those who work with women can tell you that women are very different. Some are vocal throughout labor, others only toward the end. Both are fine and normal.
In the early phase of labor, 0-4 cm, the woman usually talks easily or with little effort between contractions. Between contractions, she feels she doesn’t need much rest and will typically talk normally after each contraction.
From 4-6 or 7 cm, the woman breathes more deeply and may make special sounds during contractions and doesn’t talk during them. Between contractions, she’ll probably need to rest.
In the transition phase from 7-9 cm, the woman typically moans, chants a mantra, etc. In the phase of complete dilation, they can become completely silent. She may not want to talk even during the pause between contractions.
Pushing has its own set of sounds again. These are usually low, open sounds that help the woman open up. The lower jaw must be relaxed.
Smell
A specific “labor smell” 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 Fundus
This involves assessing cervical dilation from the outside. At the end of pregnancy at 40 weeks, when labor hasn’t started yet, there are 5 fingers between the fundus and the 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 xiphoid process and fundus decreases during labor, while the cervix opens approximately two centimeters for each finger; 5 fingers means a completely closed cervical os and 0 fingers means complete cervical dilation. The method is more effective in women who have given birth before. The method must 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. As with sounds, this doesn’t apply to all women. Women are relaxed at the beginning 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 may become frightened. In this phase, they often say they can’t do it, become scared, and want something for the pain. Labor is nearing the end. At this point, they also typically grab onto things.
Bloody Show/Mucus Plug
This is a bloody, sometimes mucus-like discharge from the vagina that we treat as an indicator of the beginning of labor. It indicates that the cervix has started to open. It can come away as early as the beginning 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.
We also notice bloody discharge toward the end of labor when the woman is 6-8 cm dilated, or other authors describe that bloody discharge appears when the woman is almost completely dilated. It can be just bloody, or mucus can also be released.
In Slovenia, there is also a thesis on this topic by Špela Žabar from 2013 titled: Labour Progress Assessment Methods / Špela Žabar; Thesis, University of Ljubljana, Faculty of Health Sciences, Department of Midwifery; COBISS.SI-ID 4620139, which describes other methods:
Mexican Warm Legs Technique
At the beginning of labor, the legs are warm. When labor becomes more intense, blood flow is directed to the uterus and the legs become cooler from the ankles upward. At 5 cm dilation, the legs will be cooler from the ankles to about mid-calf. When the leg also becomes cold above the knees, spontaneous abdominal pressure will appear. If the woman is in a birth pool, she must be dry for at least 20 minutes for this technique.
Physical Changes
As labor approaches, some women feel nauseous and have diarrhea. Others have an urge to clean.
Flushed face and feeling of warmth, shaking. Uncontrollable shaking may be present at the threshold of the second stage of labor. Vomiting itself can be a result of emotions, hormones, or fatigue. Facial flushing, 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 observe several signs together, they are a good indicator of transition. Traditional midwives also describe sweating above the upper lip, which means the woman is 7 cm dilated. So when I’m hot, I’m 7 cm dilated 🙂
Authors also describe thumb flexion, which indicates that the cervix is 6-8 cm dilated. Some authors cite this when the cervix is 7-8 cm dilated. More women also have a greater tendency toward upright positions at this time.
Goosebumps on the back appear before spontaneous pushing, and also on the buttocks and thighs. Many also vomit during this phase. Many complain that they need to go to the toilet for a bowel movement, but this is usually just a sensation because the head is so low.
Sensation of Pressure from the Baby’s Head or Presenting Part
The baby descends during labor and the woman feels pressure on different parts of her back. The pressure moves from the pelvic rim downward to the tailbone. This information usually doesn’t tell us about cervical dilation, but it does tell us the baby’s position. Nevertheless, authors indicate 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, tailbone, and sacroiliac joint. This rhombus rises above the level of the back by several centimeters and increases the pelvic capacity, allowing the baby to descend through the birth canal. The condition is that the woman has her knees lower than her hips (kneeling, squatting, on all fours…), so the sacrum can open because the back of the baby’s head contacts the G-spot. When this happens, the woman will spontaneously grab forward for support, spread her knees and drop her belly, then arch her back and curve the lower part of her body. Michel Odent defined this sequence of events as the Fetus Ejection Reflex.
Drawing a Circle
This is a technique described by Ina May Gaskin, where you give the woman a pen and a sheet of paper and ask her to draw a circle with her eyes closed that represents her current cervical dilation.
For a woman to be able to report her sensations, she must listen to her body and surrender to the feeling. When assessing labor progress, we’re not only interested in cervical dilation. We’re also interested in the descent of the presenting part, the baby’s condition, and the strength/duration of contractions.
