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Intrapartum Care: Skills workshop Vaginal examination in labour

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Intrapartum Care was developed for doctors and advanced midwives who care for women who deliver in district hospitals. It contains theory chapters and skills workshops adapted from the labour chapters of Maternal Care. monitoring the mother, fetus, and progress of labour, the second and third stages of labour, managing pain, the puerperium and family planning

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Intrapartum Care: Skills workshop Vaginal examination in labour

  1. 1. 3B Skills workshop: Vaginal examination in labour 4. A suitable instrument for rupturing the Objectives membranes. 5. An antiseptic vaginal cream or sterile lubricant. When you have completed this skills An ordinary surgical glove can be used and workshop you should be able to: the woman does not need to be swabbed if the • Perform a complete vaginal examination membranes have not ruptured yet and are not during labour. going to be ruptured during the examination. • Assess the state of the cervix. • Assess the presenting part. B. Preparation of the woman for • Assess the size of the pelvis. a sterile vaginal examination 1. Explain to the woman what examination is to be done, and why it is going to be done.PREPARATION FOR A 2. The woman needs to know that it will be an uncomfortable examination, andVAGINAL EXAMINATION sometimes even a little painful.IN LABOUR 3. The woman should lie on her back, with her legs flexed and knees apart. Do not expose the woman until you are ready to examineA. Equipment that should be available her. It is sometimes necessary to examinefor a sterile vaginal examination the woman in the lithotomy position. 4. The woman’s vulva and perineum areA vaginal examination in labour is a sterile swabbed with tap water. This is done byprocedure if the membranes have ruptured first swabbing the labia majora and groinor are going to be ruptured during the on both sides and then swabbing theexamination. Therefore, a sterile tray is introitus while keeping the labia majoraneeded. The basic necessities are: apart with your thumb and forefinger.1. Swabs.2. Tap water for swabbing.3. Sterile gloves.
  2. 2. SK ILLS WORKSHOP : VAGINAL EXAMINATION IN LABOUR 55C. Preparation needed by the examiner • Presentation or prolapse of the umbilical cord.1. The person to do the vaginal examination 3. A speculum examination, NOT a digital must have either scrubbed or thoroughly examination, must be done if it is thought washed his/her hands. that the woman has preterm or prelabour2. Sterile gloves must be worn. rupture of the membranes.3. The examiner must think about the findings, and their significance for the woman and the management of her labour. THE CERVIXPROCEDURE OF When you examine the cervix you should observe:EXAMINATION 1. Length. 2. Dilatation.A vaginal examination in labour is asystematic examination, and the followingshould be assessed: E. Measuring cervical length1. Vulva and vagina. The cervix becomes progressively shorter2. Cervix. in early labour. The length of the cervix is3. Membranes. measured by assessing the length of the4. Liquor. endocervical canal. This is the distance5. Presenting part. between the internal os and the external os6. Pelvis. on digital examination. The endocervical canal of an uneffaced cervix is approximatelyAlways examine the abdominal before 3 cm long, but when the cervix is fully effacedperforming a vaginal examination in labour. there will be no endocervical canal, only a ring of thin cervix. The length of the cervix is An abdominal examination should always be measured in centimetres. In the past the term ‘cervical effacement’ was used and this was done before a vaginal examination. measured as a percentage. F. DilatationTHE VULVA AND VAGINA Dilatation must be assessed in centimetres, and is best measured by comparing theD. Important aspects of the degree of separation of the fingers on vaginalexamination of the vulva and vagina examination, with the set of circles in the labour ward. In assessing the dilatation of theThis examination is particularly important cervix, it is easy to make two mistakes:when the woman is first admitted: 1. If the cervix is very thin, it may be difficult1. When you examine the vulva you should to feel, and the woman may be said to be look for ulceration, condylomata, varices fully dilated, when in fact she is not. and any perineal scarring or rigidity. 2. When feeling the rim of the cervix, it2. When you examine the vagina, the is easy to stretch it, or pass the fingers presence or absence of the following through the cervix and feel the rim with features should be noted: the side of the fingers. Both of these • A vaginal discharge. methods cause the recording of dilatation • A full rectum. to be more than it really is. The correct • A vaginal stricture or septum.
  3. 3. 56 INTRAPAR TUM CARE Correct IncorrectFigure 3B-1: The correct method of measuring cervical dilatation method is to place the tips of the fingers on cord may prolapse. However, it is better the edges of the cervix. for the cord to prolapse while the hand of the examiner is in the vagina, when it can be detected immediately,THE MEMBRANES than to have the cord prolapse withAND LIQUOR spontaneous rupture of the membranes while the woman is unattended. • HIV positive patients should not haveG. Assessment of the membranes their membranes ruptured unless there is poor progress of labour.Rupture of the membranes may be obvious if 2. What is the condition of the liquor whenthere is liquor draining. However, one should the membranes rupture?always feel for the presence of membranesoverlying the presenting part. If the presenting The presence of meconium may change thepart is high, it is usually quite easy to feel management of the patient as it indicates thatintact membranes. It may be difficult to feel fetal distress has been and may still be present.them if the presenting part is well applied tothe cervix. In this case, one should wait for acontraction, when some liquor often comes THE PRESENTING PARTin front of the presenting part, allowing themembranes to be felt. Sometimes the umbilical An abdominal examination must havecord can be felt in front of the presenting part been done before the vaginal examination(a cord presentation). to determine the lie of the fetus and theIf the membranes are intact, the following two presenting part. If the presenting part is thequestions should be asked: fetal head, the number of fifths palpable above the pelvic brim must first be determined.1. Should the membranes be ruptured? • In most instances, if the woman is When palpating the presenting part on in the active phase of labour, the vaginal examination, there are four important membranes should be ruptured. questions that you must ask yourself: • When the presenting part is high, there is always the danger that the umbilical
  4. 4. SK ILLS WORKSHOP : VAGINAL EXAMINATION IN LABOUR 571. What is the presenting part, e.g. head, part is the head. However, on vaginal breech or shoulder? examination:2. If the head is presenting, what is the • Instead of a firm skull, something soft presentation, e.g. vertex, brow or face is felt. presentation? • The gum margins distinguish the3. What is the position of the presenting part mouth from the anus. in relation to the mother’s pelvis? • The cheek bones and the mouth form a4. If the presentation is vertex, is moulding triangle. present? • The orbital ridges above the eyes can be felt.H. Assessing the presenting part • The ears may be felt. 3. Features of a brow presentation. TheThe presenting part is usually the head but presenting part is high. The anteriormay be the breech, the arm, or the shoulder. fontanelle felt is on one side of the pelvis,1. Features of an occiput presentation. The the root of the nose on the other side, andFigure 3B-2: Features of an occiput presentation Figure 3B-4: Features of a brow presentation posterior fontanelle is normally felt. It is the orbital ridges may be felt laterally. a small triangular space. In contrast, the If the presenting part is not the head, it could anterior fontanelle is diamond shaped. If the be either a breech or a shoulder. head is well flexed, the anterior fontanelle will not be felt. If the anterior fontanelle can 4. Features of a breech presentation. On be easily felt, the head is deflexed. abdominal examination the presenting2. Features of a face presentation. On part is the breech (soft and triangular). On abdominal examination the presenting vaginal examination:Figure 3B-3: Features of a face presentation Figure 3B-5: Features of a breech presentation
  5. 5. 58 INTRAPAR TUM CARE Left occipito-anterior (LOA) Right occipito-posterior (ROP) Left mento-anterior (LMA) Left sacro-posterior (LSP)Figure 3B-6: Examples of the position of the presenting part with the patient lying on her back • Instead of a firm skull, something soft I. Determining the position is felt. of the presenting part • The anus does not have gum margins. Position means the relationship of a fixed • The anus and the ischial tuberosities point on the presenting part (i.e. the point of form a straight line. reference or the denominator) to the mother’s5. Features of a shoulder presentation. On pelvis. The position is determined on vaginal abdominal examination the lie will examination. be transverse or oblique. Features of a shoulder presentation on vaginal The point of reference (or denominator) is: examination will be quite easy if the arm 1. In a vertex presentation the point of has prolapsed. The shoulder is not always reference is the posterior fontanelle (i.e. the that easy to identify, unless the arm can be occiput). felt. The presenting part is usually high. 2. In a face presentation the point of reference is the chin (i.e. the mentum).
  6. 6. SK ILLS WORKSHOP : VAGINAL EXAMINATION IN LABOUR 59Figure 3B-7: Lateral view of the pelvis, showing the examining fingers just reaching the sacral promontory Normal pelvis Abnormal pelvisFigure 3B-8: The brim of the pelvis.3. In a breech presentation the point of J. Determining the descent and reference is the sacrum of the fetus. engagement of the headFor example, if the posterior fontanelle (i.e. the Descent and engagement of the head isfetal occiput) in a vertex presentation points assessed on abdominal and not on vaginalupwards (anterior) and towards the mother’s examination.left side the position of the presenting part iscalled a left occipito-anterior position.
  7. 7. 60 INTRAPAR TUM CARE Symphysis pubis Sacrum Ischeal tuberosity Coccyx – not palpableFigure 3B-9: The pelvic outletMOULDING L. Grading the degree of moulding The sagittal suture is palpated and theMoulding is the overlapping of the fetal skull relationship or closeness of the two adjacentbones at a suture which may occur during patietal bones assessed. The amount oflabour due to the head being compressed as it moulding recorded on the partogram shouldpasses through the pelvis of the mother. be the most severe degree found in any of the sutures palpated.K. The diagnosis of moulding The degree of moulding is assessed accordingIn a cephalic (head) presentation, moulding is to the following scale:diagnosed by feeling overlapping of the sagittal 0 = Normal separation of the bones with opensuture of the skull on vaginal examination, sutures.and assessing whether or not the overlap canbe reduced (corrected) by pressing gently with 1+ = Bones touching each other.the examining finger. 2+ = Bones overlapping, but can be separatedThe presence of caput succedaneum can also with gentle digital pressure.be felt as a soft, boggy swelling, which may 3+ = Bones overlapping, but cannot bemake it difficult to identify the presenting part separated with gentle digital pressure.of the fetal head clearly. With severe caput thesutures may be impossible to feel. 3+ is regarded as severe moulding. M. Assessing the pelvis When assessing the pelvis on vaginal examination, the size and shape of the pelvic
  8. 8. SK ILLS WORKSHOP : VAGINAL EXAMINATION IN LABOUR 61inlet, the mid-pelvis and the pelvic outlet must they are 3 cm or longer) and the spines arebe determined. small and round. 2. A small pelvis: The ligaments allow less1. To assess the size of the pelvic inlet, the than two fingers long and the spines are sacral promontory and the retropubic area prominent and sharp. are palpated.2. To assess the size of the mid-pelvis, the Step 3. Retropubic area curve of the sacrum, the sacrospinous Put two examining fingers, with the palm ligaments and the ischial spines are of the hand facing upwards, behind the palpated. symphysis pubis and then move them laterally3. To assess the size of the pelvic outlet, the to both sides: subpubic angle, intertuberous diameter and mobility of the coccyx are determined. 1. An adequate pelvis: The retropubic area is flat.It is important to use a step-by-step method to 2. A small pelvis: The retropubic area isassess the pelvis. angulated.Step 1. The sacrum Step 4. The subpubic angle and intertuberousStart with the sacral promontory and follow diameterthe curve of the sacrum down the midline. To measure the subpubic angle, the examining1. An adequate pelvis: The promontory fingers are turned so that the palm of the cannot be easily palpated, the sacrum is hand faces upward, a third finger is held at the well curved and the coccyx cannot be felt. entrance of the vagina (introitus) and the angle2. A small pelvis: The promontory is easily under the pubis felt. The intertuberous diameter palpated and prominent, the sacrum is is measured with the knuckles of a closed fist straight and the coccyx is prominent and/ placed between the ischial tuberosities. or fixed. 1. An adequate pelvis: The subpubic angleStep 2. The ischial spines and sacrospinous allows three fingers (i.e. an angle of aboutligaments 90 degrees) and the intertuberous diameter allows four knuckles.Lateral to the midsacrum, the sacrospinous 2. A small pelvis: The subpubic angle allowsligaments can be felt. If these ligaments are only two fingers (i.e. an angle of aboutfollowed laterally, the ischial spines can be 60 degrees) and the intertuberous diameterpalpated. allows only three knuckles.1. An adequate pelvis: Two fingers can be placed on the sacrospinous ligaments (i.e.