I’m going to take a break from the labor induction series and focus today on a question that was asked by a student midwife. While this blog is mostly focused on research recommendations and ways that they affect patient care, I also hope that students and providers can use it as a reference point as well. The midwifery student was asking for suggestions and tips for mastering the vaginal exam.
While cervical checks are frequently overused in obstetrics, and there is no need for routine exams, there are times that they can offer important clinical information. For example, a routine check at 37 weeks “just to see if anything is happening”? Skip it. Unable to assess baby’s position by leopold’s (feeling the baby through the patient’s abdomen)? Sudden decelerations in the baby’s heart rate right after the water breaks in labor? Labor seeming to take much longer than expected? Better get your glove on! As a student, it can take quite a bit of practice before feeling the “mush” gives useful information. Here are some tips for practice that I give to students:
Finding the cervix:
-Always tell the patient what you are doing BEFORE you do it, and ask to make sure it is ok to proceed. If they tell you to stop, EVEN IN THE MIDDLE OF THE EXAM, you stop.
-Vaginal exams can be triggering for people with trauma. Be careful what language you use. Avoid saying “open your legs”, “hold still”, “good girl”, etc. Some people will say “ouch!” or be very tense even at the touch of their thigh or labia. Do not try to start the exam if they are clenching their bottom, even if they say it is ok. It will HURT.
-Have the patient pee before the exam if they need to go. Extra pressure from a full bladder can make the exam more uncomfortable, and the patient will feel like she’s about to pee on your hand and will try to clench down so she doesn’t, making the exam more difficult.
-Sit down on the bed during the exam (or have your hips at the same level as the patient) instead of leaning down over the patient during the exam. This will give you extra depth without having to apply extra pressure.
-My routine is to ask if it’s ok to do a vaginal exam because of X. If they agree, I sit down on the bed and say: Go ahead and bend your knees up. Let your legs fall open all the way open (sometimes if people are nervous, even getting them to relax their legs down takes a minute). You’re going to feel the back of my hand (touch the side of her thigh), then cold fingers (cold gel on the labia), then pressure from my hand (begin the exam).
-Spread the labia from the bottom until you can visualize the POSTERIOR side of the introitus and enter through the posterior side. There are less nerve endings here. If you apply pressure on the anterior side along the urethra as you begin your exam, this makes it more uncomfortable.
-Watch where you put your thumb. The natural spot for it to rest during an exam happens to be right over the clitorus. This is uncomfortable for the patient. Move it a bit off to the side.
-Remind the patient to breathe during the exam (remind yourself, too!).
-If you’re having trouble reaching the cervix, have mom put her fists or a bedpan under her hips. This helps raise her hips up and bring the cervix forward. It is a little awkward for the patient but ultimately makes the exam more comfortable because you don’t have to reach as far, or need to check twice because you couldn’t get it the first time. I default to having everyone do this during an exam.
-If the cervix is posterior and you can only just feel the most anterior edge, use your middle finger to apply anterior (upward) pressure to “hook” it and pull it forward. Then continue to extend your middle finger along the length of the cervix until you feel the baby’s head. Once your middle finger is through, you can leave it in place and add your index finger
-Measure the width of your middle and index fingers so you know how wide they are. Are your two fingers together 2cm? Or 3.5?
-Make sure you are measuring the dilation of the INTERNAL os. Keep your fingers on the baby’s head (or amniotic sac if it’s bulging) to make sure you are all the way through. The internal os and the external os can be two different measurements; clinically, you only care about the internal. A cervix can be 4cm externally, but funnel down to only 2cm internally, or 1cm externally but closed internally. This is particularly true with multips.
-Don’t use how stretchy the cervix is as your measurement. You’ll hear people say “she’s 6cm, but can stretch to 9”. While this is a great sign, she’s still considered 6cm.
-Once you get past 7cm, measure dilation by taking your fingers off of the baby’s head and placing them over the sides of the cervix to feel how much is left. This helps get rid of using the “stretch” as your number. Her cervix might be 10cm “open” finger to finger, but she’s certainly not complete if there’s cervix left. If you feel how much cervix is actually LEFT, this might be a different number and is more important. If you have 1.5 finger’s width of cervix left on either side of the baby’s head, assuming your finger is 1cm wide, she’s 7cm dilated. 1.5cm x 2= 3cm of cervix left.
-It can sometimes be difficult to tell if someone is completely dilated or just very effaced and you’re missing the cervix or os. If this is the case, slide your fingers along the anterior vaginal wall. If they are complete, you will be able to continue on the anterior wall up past the baby’s head.
-If they are not completely dilated, you won’t be able to continue past the baby’s head without hitting at least a ridge of cervix around the head.
-To tell if someone is just a lip, or is 9.5cm, find the ridge of cervix along the anterior wall FIRST, then try to follow it around first one way, then the other. Don’t forget to follow it along the posterior side of the head, too. If the cervix goes all the way around, they are not more than 9.5cm.
-Effacement is fairly subjective. Find landmarks on your own fingers that will give you consistency.
-It is rare to find a true 0% effaced cervix, but once you feel it, you’ll realize just how long the cervix actually can be. For me, a cervix that is 0% effaced goes to the second line on my index finger. 50% goes to the first line. 90% is about 1mm thin. The rest are in between those to scale.
-Sometimes a very thick but soft cervix can “fold over” on itself during the exam and can make it initially seem shorter than it is, especially if the cervix is posterior. This is why it is important to continue until you are touching the baby’s head, so you can be sure you are all the way through the internal os.
-If you can’t touch the baby’s head, either the cervix is funneled to closed, or it’s folded over on itself. Try to make a slight “hooking” motion with your middle finger as you advance to see if you can pull the cervix forward to a better angle and advance your fingers.
-Station is the MOST subjective of the measurements
-Station is supposed to be done based off the ischial spines.
-It can be uncomfortable for the patient when you find the spines. If the mom is thin, you should be able to feel them without much difficulty. If you are able to practice on someone with an epidural, this makes it easier as it’s more comfortable for the patient.
-You won’t feel them at the same time you are assessing the cervix, you’ll take your fingers off the cervix and feel separately for them.
-It is easier to learn if you are able to find the spines at least some of the time so you have a reference point while you figure out “how far am I reaching now?”
-If you are not able to find the spines, then station is done by feel. For my own exam, head ballottable -4. If I have to reeeally reach -3. To my finger base without having to apply pressure 0. To each knuckle I can bring out, +1, +2, +3 at introitus.
-The two most important functions of assessing station are being able to tell 1) is the head well applied to the cervix? and 2) Is decent occurring and progress being made?
-Sometimes, if the baby’s head is low but the cervix is not very dilated, the head can be at a LOWER station than the cervix. Usually, the cervix is posterior when this happens. You have to reach behind the baby’s head to find the os. Make a fist and put your knuckles on a table facing away from you. That’s the baby’s head, knuckles facing the back of the vagina. Instead of the cervix being right underneath in the center of the bottom (your fingers), it’s tilted back, either over the knuckles or even higher on the back of your hand. If you did a vaginal exam (coming straight up from under the table), you’d go in, hit the baby’s head, then have to continue back and up to get to the os. The station is the baby’s head, not where the cervix is.
Be patient with yourself while you’re learning. In the beginning, even FINDING the cervix is a success! At first, have someone more experienced check before you and then tell you what to look for. As you get more comfortable, check first and then use the more experienced person to confirm your exam. Hopefully, this helps you navigate the “mush” that is the cervix!