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1C                                                Skills workshop:                                                Vaginal ...
52    MATERNAL CAREB. Contraindications to a vaginal                    E. Speculum examinationexamination in pregnancy   ...
SK ILLS WORKSHOP : VAGINAL EXAMINATION IN PREGNANC Y        53   slightly open, so that the vaginal walls can          doc...
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Maternal Care: Skills workshop Vaginal examination in pregnancy

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Maternal Care addresses all the common and important problems that occur during pregnancy, labour, delivery and the puerperium. It covers: the antenatal and postnatal care of healthy women with normal pregnancies, monitoring and managing the progress of labour, specific medical problems during pregnancy, labour and the puerperium, family planning, regionalised perinatal care

Publié dans : Formation, Santé & Médecine
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Maternal Care: Skills workshop Vaginal examination in pregnancy

  1. 1. 1C Skills workshop: Vaginal examination in pregnancy A. Indications for a vaginal Objectives examination in pregnancy 1. At the first visit: When you have completed this skills • The diagnosis of pregnancy during the first trimester. workshop you should be able to: • Assessment of the gestational age. • List the indications for a vaginal • Detection of abnormalities in the examination. genital tract. • Insert a bivalve speculum. • Investigation of a vaginal discharge. • Perform a bimanual vaginal • Examination of the cervix. examination. • Taking a cervical (Papanicolaou) smear. 2. At subsequent antenatal visits: • Take a cervical smear. • Investigation of a threatened abortion. • Confirmation of preterm rupture of the membranes with a sterile speculum.INDICATIONS FOR A • To confirm the diagnosis of pretermVAGINAL EXAMINATION labour. • Detection of cervical effacement and/or dilatation in a patient with a risk forA vaginal examination is the most intimate preterm labour e.g. multiple pregnancy,examination a woman is ever subjected to. It a previous midtrimester abortion,must never be performed without: preterm labour or polyhyramnios.1. A careful explanation to the patient about • Assessment of the ripeness of the cervix the examination. prior to induction of labour.2. Asking permission from the patient to • Identification of the presenting part in perform the examination. the pelvis.3. A valid reason for performing the • Performance of a pelvic assessment. examination. 3. Immediately before labour: • Performance of artificial rupture of the membranes to induce labour.
  2. 2. 52 MATERNAL CAREB. Contraindications to a vaginal E. Speculum examinationexamination in pregnancy 1. A speculum examination is always per-1. Antepartum haemorrhage. However, there formed at the first antenatal visit. At sub- are two exceptions to this rule: sequent antenatal visits this examination is • A cephalic presentation with the fetal only done when indicated, e.g. to investigate head palpable 2/5 or less above the a vaginal discharge or in the case of preterm pelvic brim (i.e. engaged), thereby, or prelabour rupture of the membranes. excluding a placenta praevia. 2. The Cusco or bivalve speculum is the one • Obvious signs and symptoms of most commonly used. abruptio placentae.2. Preterm and prelabour rupture of the F. Insertion of a bivalve speculum membranes without contractions (except with a sterile speculum to confirm or 1. The procedure must be explained to the exclude rupture of the membranes). patient. 2. The labia are parted with the fingers of the gloved left hand.METHOD OF VAGINAL 3. The patient is asked to bear down. 4. The closed speculum is gently insertedEXAMINATION posteriorly into the vagina. Great care must be taken to avoid undue contact with the anterior vaginal wall at the introitus as thisC. Preparation for vaginal examination causes great discomfort, or even pain, from1. The bladder must be empty. pressure on the urethra.2. The procedure must be carefully explained 5. As soon as the speculum has passed to the patient. through the vaginal opening, the blades3. The patient is put in the dorsal or must be slightly opened. The speculum is lithotomy position: now inserted deeper into the vagina. When • The dorsal position is more comfortable the cervix is reached, the speculum is fully and less embarrassing than the opened. This method allows for inspection lithotomy position and does not require of the vaginal walls during insertion and any equipment. This is the position ensures that the cervix is found. most often used. 6. Any vaginal discharge must be identified. • The lithotomy position provides better Where needed, a sample is taken with a access to the genital tract than the wooden spatula. dorsal position. Lithotomy poles and 7. The vagina is inspected for congenital abnor- stirrups are required. malities such as a vaginal septum, a vaginal stenosis or a double vagina and cervix. 8. The cervix is inspected for any laceration A vaginal examination must always be preceded or tumour. A smooth red area surrounding by an abdominal examination. the external os that retains the normal smooth surface is normal during the reproductive years and is called ectopy.D. Examination of the vulva 9. If there is a history of rupture of theThe vulva must be carefully inspected for any membranes, the presence of liquor is notedabnormalities, such as scars, warts, varicosities, and tested for.congenital abnormalities, ulcers or discharge. 10. A cervical (Papanicolaou) smear must be taken if a smear has not been taken recently. 11. At the end of the examination the speculum is gently withdrawn, keeping it
  3. 3. SK ILLS WORKSHOP : VAGINAL EXAMINATION IN PREGNANC Y 53 slightly open, so that the vaginal walls can doctor to decide whether delivery will be again be inspected all the way out. interfered with. 3. The cervix is palpated and the followingG. Taking a cervical smear are noted: • Any dilatation.1. A cervical (Papanicolaou) smear is taken • The length of the cervix in cm, i.e. to detect abnormalities of the cervix, e.g. whether the cervix is effaced or not. human papilloma virus infection, cervical • The surface should be smooth and intra-epithelial neoplasia or carcinoma of regular. the cervix. • The consistency, which will become2. Ideally the first cervical smear should be softer during pregnancy. taken when the patient becomes sexually 4. Special care must be taken, when active. In practice the first smear is usually performing a bimanual examination late taken when the patient first attends a in pregnancy and in the presence of a high family planning or antenatal clinic. presenting part, not to damage a low-lying3. If the cervical smear is normal, it should be placenta. If the latter is suspected, a finger repeated at 30, 40 and 50 years of age. must not be inserted into the cervical4. The technique of taking a cervical smear is canal. Instead, the presenting part is gently as follows: palpated through all the fornices. If any • The name, folder number and date must bogginess is noted between the fingers of be written on the slide with a pencil the examining hand and the presenting beforehand. Also make sure that a spray part, the examination must be immediately can is close at hand to fix the slide. abandoned and the patient must be • A vaginal speculum is inserted. referred urgently for ultrasonography. • The cervix must be clearly seen and is 5. Where possible the presenting part is carefully inspected. identified. • A suitable spatula is inserted into 6. A most important part of the bimanual the cervix and rotated through 360 examination is the determination of the degrees, making sure that the whole gestational age, by estimating the size of the circumference is gently scraped. It uterus and comparing it with the period of is important that the smear is taken amenorrhoea. This is only really accurate from the inside of the cervical canal in the first trimester. Thereafter, the fundal as well as from the surface of the height and the size of the fetus must be cervix. An Ayres (Aylesbury) or tongue determined by abdominal examination. spatula must be used and not a brush 7. The uterine wall is palpated for any with sharp or long points such as a irregularity, suggesting the presence of a Cervibrush or Cytobrush. congenital abnormality (e.g. bicornuate • The material obtained is smeared onto uterus) or myomata (fibroids). a glass slide and immediately sprayed 8. Lastly, the fornices are palpated to exclude with Papanicolaou’s fixative. any masses, the commonest of which is an • When the slide is dry, it is sent to the ovarian cyst or tumour. laboratory for examination. I. Explanation to the patientH. Performing a bimanual examination Do not forget to explain to the patient, after the1. First one and then, where possible, two examination is completed, what you have found. gloved and lubricated fingers are gently It is especially important to tell her how far inserted into the vagina. pregnant she is, if that can be determined, and to2. If a vaginal septum or stenosis is present, reassure her, if everything appears to be normal. the patient should be referred to a