Clinical/Comm Skills - Week 4 - Intrapartum Vaginal Examination - Vulva/Vagina, Cervix, Membranes, Liquor, Presenting part, Position/Pelvis

Question 1

When do the rupture of the membranes occur? What happens during the 1s stage of labour? What are analgesia chocies for women?

Answer 1

ROM usually occurs at the beginning of labour ie when contractions begin but can slightly precede labour

During the 1st stage of labour the uterine contractions increase in intensity, duration and frequency from mild irregular contractions, to strong frequent rhythmic contractions

Analgesia - paracetamol, diamorphine, entonox, epidural, remi-fentanyl, water immersion, TENS

Question 2

Why are vaginal examinations carried out?

Answer 2

Vaginal examinations are carried out to establish if the woman is in established labour - active phase of 1st stage and to assess the progress of labour

Question 3

What are the basic necessities for carrying out the vaginal examination? Remember the vaginal examination is carried out to establish if a women is in established labour and to assess the progress of labour A gyanecological examiantion is a routine examiantion for women

Answer 3

Basic necessities are 1. Swab 2. Tap water for swab 3. Sterile/unsterile gloves 4. An antisetic vaginal cream

Question 4

When can an ordinary surgical glove be used and the women not require swabbing for a vaginal examination? When is it required that the vaginal examination is a sterile procedure?

Answer 4

If the membranes have not yet ruptured and are not going to be ruptured during the vaginal examintion then an ordinary surgical glove can be used and women does not need to be swabbed A vaginal examination in labour should be sterile if the membranes have ruptured or are going to rupture during the vaginal examintion

Question 5

The woman needs to be prepped during the vaginal examination What are the 4 steps of preparing the woman for the vaginal examination? (explanation, womans position and swabbing)

Answer 5

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Question 6

A vaginal examination in labour is a systematic examination, and what is the systemic order in the assessment during the vaginal examination?

Answer 6

1. Vulva and vagina 2. Cervix 3. Membranes 4. Liquor 5. Presenting part 6. Pelvis

Question 7

During the examaintion of the vulva/vagina, cervix, membranes, liquor, presenting part and pelvis What are the main things assessed?

Answer 7

Assess the length of the cervix - cervical effacement Assess any dilation of the cervix - cervical dilation Assess if the membranes have ruptured Assess for the colour and condition of any liquor if the membranes have ruptured Assess the presenting part part and foetal position Assess the size of the pelvis

Question 8

What should always be performed before performing a vaginal examination in labour?

Answer 8

Always perform an abdominal examination before performing a vaginal examination in labour

Question 9

After explaining the procedure to the woman, (also swabbing with tap water starting at labia majora and groins off both sides before swabbing introits whilst holding labia majora apart with thumb and forefinger) What is examined? What is the vulva?

Answer 9

The vulva and vagina are examined The vulva includes the mons pubis, labia majora, labia minora, clitoris, bulb of vestibule, vulval vestibule, urinary meatus, greater and lesser vestibular glands, and the vaginal opening

Question 10

What is assessed when examining the vulva and vagina? What should be done in a vulva/vaginal examination if it is though the woman has preterm or pre-labour rupture of the membranes?

Answer 10

1 When examining the vulva look for for ulceration, condylmata, varices and perineal scarring or rigidity 2. When examination the vagina - note the presence or absence of the following features - A vaginal discharge - A full rectum - A vaginal stricture or septum - Presentation or prolapse of the umbilical cord

Question 11

What should be carried out if it is thought the women is in pre-term or pre-labour rupture of the membranes?

Answer 11

If it is thought the woman is in preterm or pre-labour rupture of the membranes - speculum examination should be carried out to assess the vagina and not a digital examination

Question 12

What are the two things looked for when examining the vulva/vagina again? How should a speculum be inserted?

Answer 12

VUlva - look for ulceration, condylomata, varices and any pernieal scarring or rigidity VAgina - not the presence or absence of A vaginal discharge A full rectum A vaginal stricture or septum Presentation or prolaspe of the umbilical cord Insert speculum at the 3oclock position and rotate to the twelve oclock position

Question 13

What should be observed when examining the cervix?

Answer 13

Examine the cervix for cervical length and dilatation

Question 14

How is cervical length is measured? What is the normal length of the cervical canal? How is cervical length often measured? (ie Bishop’s score)

Answer 14

Cervical length progressively becomes shorter in labour - cervix shortens and softens in latent and active phase The normal length of the cervical canal is approx 3cm - the length is measured by the distance between the insternal os and cervical os on digital examiantion The length of the cervix is measured in cm The cervical length is often measured as a percentage effaced when its known as cervical effacement

Question 15

How is the cervical dilatation assessed? What is the correct method for measuring the cervical dilatation?

Answer 15

Cervical dilatation is assess in centimetres and is best measured by comparing the degree of two fingers on vaginal examination The correct method is to pace the tips of the fingers on the edges of the cervix

Question 16

It is easy to make two mistakes when measuring the cervical dilatation, what are they?

Answer 16

Easy to measure wrongly if: If the cervix is very thin it may make it difficult to feel the cervix and the woman be be said to be fully dilated when in fact she is not When feeling the cervix it is easy to stretch it or pass fingers through and feel the rim with sides of the fingers - both methods record an greater dilatation than it accurately is

Question 17

After assesing the vulva/vagina and the cervix, the next part of the examaintion is assess if the membranes have ruptured and assess and colour and condition of the liquor if the membranes have ruptured What is the ideal liquor colour? What colour does the presence of meconium give? What does meconium indicate?

Answer 17

* Rupture of the membranes may be obvious if there is liquor draining * It is important to assess the colour and condition of the liquor * Ideal liquor colour - this is a clear or straw colour * Meconium gives the liquor a greenish colour (meconium is a greenish/black/tar colour) Meconium indicates foetal distress has been and may still be present - transfer to consultant unit and commence foetal heart monitoring

Question 18

The presenting part of the foetus is next examined Why is it important that the abdominal examination is done before vaginal examaintion? if the presenting part of the foetus is the foetal ehad, what must be determined on abdominal examaintion?

Answer 18

It is important that the abdominal examination is carried out before the vaginal examination - will allow the presenting part of the foetus to be determined and will determine the lie of the foetus If the presenting part is the foetal head it is important to determine the number of fifths palpable - if only 2/5ths of the foetal head are palpbale then the foetus is said to be engaged

Question 19

When palpating the presenting part on baginal examiantion, it is important to note four aspects Remember the lie of the foetus and presenting part have already be determined in the abdominal examiantin What are the four aspects to note on examinign the presenting part?

Answer 19

1. Confirm what the presenting part is - head, shoulder or breech 2. If the head is the presenting part, what is the presentation - vertex, brow or face presentation/ 3. What is the position of the presenting part in relation to the mothers pelvis 4. If the presentation is vertex, is moulding present

Question 20

Run through again the four important apsects when palpating the presenting part on vaginal examaintin

Answer 20

1. What is the presenting part - head, breech or shoulder.? 2. If the head is presenting, what is the presentation - vertex, mentum or brow presentation?11 3. What is the position of the presenting part in relation to the mothers pelvis? 4. If the vertex is the presentation, is moulding present?

Question 21

Vulva/vagina Cervix Membranes Liquor Presenting part (and presentation) Finally examine the presentation in relation to the mothers pelvis What is most commonly the presenting part?

Answer 21

Most commonly the presenting part is the head

Question 22

It is important to assess the position of the presenting part in relation to the mothers pelvis What are the features of an occuput presentation on vaginal examination? (pariteal presentation is simply deflexed occiput presentation)

Answer 22

The posterior fontanelle is usually felt The saggital suture is usually felt If the head is well flexed the anterior fontanelle will not be felt but if it is not well flexed (deflexed), the anterior fontanelle will be felt

Question 23

What are the features of a face presentation on vaginal examination? On abdominal examaintion the presenting part is simply the head

Answer 23

Instead of a solid skull, something soft is felt The gum margins distinguish the mouth from anus The cheek bones and moth forma trianles Orbital ridges can be felt and ear may be felt Head is fully extended here

Question 24

What are the features of a brow presentation on vaginal examination?

Answer 24

Can feel the anterior fontanelle, root of the nose and orbital ridges may be felt laterally

Question 25

What are the features of breech presentation on abdominal and vaginal examination?

Answer 25

On abdominal examination 0 the head may be felt high in the abdomen in the fundal part of the uterus On vaginal examination - instead of a firm skull, something soft is felt - the foetal anus may be felt

Question 26

What are the features of a shoulder presentation on vaginal examination? What is the lie of the foetus detected on abdominal examination?

Answer 26

On abdominal examination the foetus may be adopting a transverse lie The features of shoulder presentation on vaginal examination may be an am felt or seen at the vulva

Question 27

Position of the foetus means the relationship of fixed point on the presenting part of the foetus (ie the point of reference or the denominator) to the mothers pelvis What is the point of reference (or denominator) in a vertex presentation? Face presnetation? Breech presentation?

Answer 27

The point of reference (or denominator) In vertex presentation - the posterior fontanelle ie the occiput IN face presentation - the chin ie the mentum In breech presentation - the sacrum of the foetus

Question 28

If the posterior fonetanelle in a vertex presentation points upwars and towards the mothers left side, what is the position of the presenting part called? If the mentum in a face presentation points downwards and towards the mothers right side what is the position of the presenting part?

Answer 28

If the posterior fontanelle in a vertex presentation points upwards and towards the mothers left side - the position is left occipito-anterior If the mentum in a face presentation points downwards and towards the mothers right side - the position is right mento-posterior

Question 29

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Answer 29

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