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Analysis

How to… perform a vaginal examination

15 April, 2011

How to… perform a vaginal examination

University of Chester's deputy head of midwifery and reproductive health Jane Harris outlines the key practice points of this intimate procedure. University of Chester’s deputy head of midwifery and reproductive health Jane Harris outlines the key practice points of this intimate procedure.


Midwives magazine: Issue 3 :: 2011


A vaginal examination is an intimate procedure that should only be performed when it is absolutely necessary and will provide information that will aid in the decision-making process (NICE, 2007). The examination should always be approached in a sensitive manner that maintains the dignity of the client at all times. The midwife should ensure that the woman is in a comfortable position, she has emptied her bladder and that the examination is explained in full. Informed consent must be obtained before the procedure is carried out (NMC, 2008).

Indications for vaginal examination are to:
✲ Confirm the onset of labour
✲ Identify the presentation and position of the fetus
✲ Assess progress or delay in labour
✲ Ascertain the presence of forewaters (carry out rupture of membranes if indicated)
✲ Assess prior to administering analgesia
✲ Apply a fetal scalp electrode
(carry out fetal blood sampling
if indicated)
✲ Exclude cord prolapse following spontaneous rupture of the forewaters, especially if there is an ill-fitting presenting part
✲ Confirm full dilatation of the cervix especially in a breech presentation (McCormick, 2009).

An examination should not be carried out if there is any history of vaginal bleeding, placenta praevia, early rupture of forewaters or preterm labour (Johnson and Taylor, 2010). Prior to the procedure, an abdominal assessment and auscultation of the fetal heart should be undertaken. The method used to carry out the examination is classified as a clean technique if the membranes are intact and an aseptic technique if there is liquor draining (McCormick, 2009).

The procedure
You should:
✲ Communicate with the woman, while undertaking the examination
✲ Ensure that she is in a comfortable position and her dignity is maintained at all times
✲ Wash hands
✲ Set up the trolley and open the vaginal examination pack
✲ Put on gloves
✲ Swab vulva from front to back
✲ Use individual sterile lubricating gel
✲ Use ‘dirty’ hand to hold labia apart
✲ Then gently insert ‘clean’ fingers downwards and backwards into the vagina.

Findings
Inspect external genitalia for signs of:
✲ Varicosities
✲ Oedema
✲ Warts
✲ Previous scarring
✲ Mutilation and type
✲ Discharge or bleeding.

The condition of the vagina should always be warm and moist in a normal labour, but it can feel hot and dry in a prolonged or obstructed labour. Once the examining fingers reach the end of the vagina, the sensitive pads are turned upwards towards the cervix. The os is located by gently sweeping the fingers from side to side. The normal location is a central one, but sometimes in early labour it can be in a posterior position (McCormick, 2009).

You are assessing for:
✲ Effacement
✲ Consistency of the cervix
✲ Dilatation, which is measured in centimetres from one to ten
✲ Presence of membranes – if ruptured, the liquor should be clear and non-offensive
✲ Position and station of presenting part (identify any moulding or caput that may be present).

Following the procedure, the fetal heart should be auscultated, the woman should be left in a comfortable position and the findings should be discussed with her and documented (NMC, 2009).

References

Johnson R, Taylor W. (2010) Skills for midwifery practice (third edition). Churchill Livingstone Elsevier, Edinburgh.

McCormick C. (2009) The first stage of labour: physiology and early care: In: Fraser D, Cooper MA. (Eds.). Myles' textbook for midwives (15th edition). Churchill Livingstone Elsevier, Edinburgh.

NICE. (2007) Intrapartum care: care of healthy women and their babies during childbirth. Clinical guideline 55. NICE: London.

NMC. (2008) The code: standards of conduct, performance and ethics for nurses and midwives. NMC: London. See: www.nmc-uk.org/Nurses-and-midwives/The-code/The-code-in-full (accessed 18 April 2011).

NMC. (2009) Record-keeping: guidance for nurses and midwives. See: www.nmc-uk.org/Documents/Guidance/nmcGuidanceRecordKeepingGuidanceforNursesandMidwives.pdf (accessed 18 April 2011).







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