title: Routine vaginal examinations for assessing progress of labour to improve outcomes for women and babies at term.
abstract: BACKGROUND
  Vaginal examinations have become a routine intervention in labour as a means of assessing labour progress. Used at regular intervals, either alone or as a component of the partogram (a pre-printed form providing a pictorial overview of the progress of labour), the aim is to assess if labour is progressing physiologically, and to provide an early warning of slow progress. Abnormally slow progress can be a sign of labour dystocia, which is associated with maternal and fetal morbidity and mortality, particularly in low-income countries where appropriate interventions cannot easily be accessed. However, over-diagnosis of dystocia can lead to iatrogenic morbidity from unnecessary intervention (e.g. operative vaginal birth or caesarean section). It is, therefore, important to establish whether or not the routine use of vaginal examinations is an effective intervention, both as a diagnostic tool for true labour dystocia, and as an accurate measure of physiological labour progress.
  
  
  OBJECTIVE
  To compare the effectiveness, acceptability and consequences of digital vaginal examination(s) (alone or within the context of the partogram) with other strategies, or different timings, to assess progress during labour at term.
  
  
  METHODS
  We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 February 2013) and reference lists of identified studies.
  
  
  METHODS
  We included randomised controlled trials (RCTs) of vaginal examinations (including digital assessment of the consistency of the cervix, and the degree of dilation and position of the opening of the uterus (cervical os); and position and station of the fetal presenting part, with or without abdominal palpation) compared with other ways of assessing progress of labour. We also included studies assessing different timings of vaginal examinations. We excluded quasi-RCTs and cross-over trials. We also excluded trials with a primary focus on assessing progress of labour using the partogram (of which vaginal examinations is one component) as this is covered by another Cochrane review. However, studies where vaginal examinations were used within the context of the partogram were included if the studies were randomised according to the vaginal examination component.
  
  
  METHODS
  Three review authors assessed the studies for inclusion in the review. Two authors undertook independent data extraction and assessed the risk of bias of each included study. A third review author also checked data extraction and risk of bias. Data entry was checked.
  
  
  RESULTS
  We found two studies that met our inclusion criteria but they were of unclear quality. One study, involving 307 women, compared vaginal examinations with rectal examinations, and the other study, involving 150 women, compared two-hourly with four-hourly vaginal examinations. Both studies were of unclear quality in terms of risk of selection bias, and the study comparing the timing of the vaginal examinations excluded 27% (two hourly) to 28% (four hourly) of women after randomisation because they no longer met the inclusion criteria.When comparing routine vaginal examinations with routine rectal examinations to assess the progress of labour, we identified no difference in neonatal infections requiring antibiotics (risk ratio (RR) 0.33, 95% confidence interval (CI) 0.01 to 8.07, one study, 307 infants). There were no data on the other primary outcomes of length of labour, maternal infections requiring antibiotics and women's overall views of labour. The study did show that significantly fewer women reported that vaginal examination was very uncomfortable compared with rectal examinations (RR 0.42, 95% CI 0.25 to 0.70, one study, 303 women). We identified no difference in the secondary outcomes of augmentation, caesarean section, spontaneous vaginal birth, operative vaginal birth, perinatal mortality and admission to neonatal intensive care.Comparing two-hourly vaginal examinations with four-hourly vaginal examinations in labour, we found no difference in length of labour (mean difference in minutes (MD) -6.00, 95% CI -88.70 to 76.70, one study, 109 women). There were no data on the other primary outcomes of maternal or neonatal infections requiring antibiotics, and women's overall views of labour. We identified no difference in the secondary outcomes of augmentation, epidural for pain relief, caesarean section, spontaneous vaginal birth and operative vaginal birth.
  
  
  CONCLUSIONS
  On the basis of women's preferences, vaginal examination seems to be preferred to rectal examination. For all other outcomes, we found no evidence to support or reject the use of routine vaginal examinations in labour to improve outcomes for women and babies. The two studies included in the review were both small, and carried out in high-income countries in the 1990s.  It is surprising that there is such a widespread use of this intervention without good evidence of effectiveness, particularly considering the sensitivity of the procedure for the women receiving it, and the potential for adverse consequences in some settings.The effectiveness of the use and timing of routine vaginal examinations in labour, and other ways of assessing progress in labour, including maternal behavioural cues, should be the focus of new research as a matter of urgency. Women's views of ways of assessing labour progress should be given high priority in any future research in this area.
authors.affiliation: Research in Childbirth and Health (ReaCH) unit,University of Central Lancashire, Preston, UK.sdowne@uclan.ac.uk.
authors.forename: Soo
authors.initials: S
authors.lastname: Downe
authors.forename: Gillian M L
authors.initials: GM
authors.lastname: Gyte
authors.forename: Hannah G
authors.initials: HG
authors.lastname: Dahlen
authors.forename: Mandisa
authors.initials: M
authors.lastname: Singata
mesh_terms: D004420:Dystocia / Q000175:diagnosis*; D005260:Female; D058869:Gynecological Examination / Q000379:methods*; D006801:Humans; D007231:Infant, Newborn; D007743:Labor, Obstetric / Q000502:physiology*; D010173:Palpation / Q000379:methods*; D011247:Pregnancy; D011256:Pregnancy Outcome; D047929:Term Birth; D014621:Vagina