VAGINAL EXAMINATION FOR THE WOMAN IN LABOR

A vaginal examination must follow an abdominal examination

so that the midwife can combine the external and internal findings to arrive at a
clearer picture of the progress of labor.

Purposes

A vaginal examination for the client in labor will help to: Make a positive
diagnosis of labor

◆ Make a positive identification of the presentation Determine if the

presenting part is engaged

Ascertain if the forewaters have ruptured or rupture them Exclude cord

prolapsed after rupture of the forewaters

artificially

◆ Assess progress or delay in labor

Apply feral scalp electrode

Under no circumstances should a midwife make a vaginal examination if there

is any frank bleeding.
Procedure

explanation. This would enable her to relax and cooperate Prepare the client
folder be huo hyving adega during the examination:

The bladder must be empty so that disconfort during the procedure will be
minimized.

2. Assemble sterile articles such as a vaginal examination pack containing

sterile swabs and bowls along wit sterile disposable gloves. This is important to
avoi Introducing microorganisms into the vagina.

Position the woman on her back with thighs separate and knees bent, taking
care to avoid unnecessary exposure
Be sure that the woman's arms are down by her sides or across her abdomen to
aid relaxation of her abdomina

muscles.

5. Wash hands thoroughly and put on sterile gloves. 6. Swab the client's vagina.

7. Dip the first two fingers of the dominant hand in the antiseptic cream to get
them lubricated.

8. Holding the labia apart with the thumb and index fingers

of the other hand, insert the lubricated fingers into the vaginu palm side down,
pressing downwards. Direct the fingers along the anterior vaginal wall and
should not be withdrawn until the required information has been obtained. With
the fingers inside, explore the vagina for required data, taking care not to touch
the clitoris where it may cause great discomfort or the anus where it may

be contaminated.

Findings

External genitalia: Before cleansing the vulva, observe and

note the following: 1. Any signs of varicositics, edema, vulval warts or sores.

Scar from previous episiotomy or tear.

3.

Any discharge or bleeding from the vaginal orifice. Color and odor of amniotic
fluid if the membranes have

4.

ruptured. Offensive liquor suggests infection and green

fluid indicates the presence of meconium, which may be a sign of fetal distress.
Condition of the Vagina

The vagina should feel warm and moist, and the walls soft and distensible. A
hot dry vagina is a sign of obstructed labor. If the woman has raised
temperature, the vagina

will feel hot, but not dry.

Firm and rigid wall may suggest a longer labor.

Presence of scars from previous perineal wound may cause

delay in the second stage.

4.

In a multiparous woman, a cystocele may be found through the anterior wall.

A loaded rectum may be felt through the posterior wall. Cervix

As the examining fingers reach the end of the vagina, they are turned so that the
sensitive pads face upwards and they are contact with the cervix:

Palpate around the fornices and sense the proximity of the presenting part of the
fetus to the examining finger. A spongy feeling between the fingers and
presenting part may indicate the possibility of a placenta previa.

The cervical os is located by sweeping the fingers from side to side. It will
normally be situated centrally, but sometimes in early labor, it will be posterior.
3. Length of the cervical canal must be assessed.

A long tightly closed cervix indicates that labor has not yet started. The cervical
canal may be obliterated (without margins), partially or completely depending
on the degree of effacement. In a primigravida, the cervix may be completely
effaced, but still closed. As it will be closely applied to the presenting part, the
os may be felt as a small depression in the center.

The consistency of the cervix is then noted. It should be soft, elastic and applied
closely to the presenting part. If it is tight, rigid or unyielding, labor may be
prolonged or it may be poor application associated with an ill-fitting presenting
part.

Uterine os: Dilatation of the cervix that is the distance across the opening is
estimated in centimeters. About 10 cm dilata- tion equates to full dilatation. At
the point where the maxi- mum diameters of the fetal head have passed through
the os, the cervix can no longer be felt. It is important that the midwife feel for
the cervix in every direction as a lip of cervix frequently remains in one quarter
only, usually anteriorly.

Forewaters: Intact membranes can be felt through the di- Tating os. Between
contractions, they feel slack, but will be- come tense when the uterus contracts.
The consistency of the membranes will be similar to thin plastic film. When
forewaters are very shallow, it may be difficult to feel the membranes.

If the presenting part does not fit well, some of the fluid from the hindwaters
escape into the forewaters, causing the membranes to protrude through the
cervix. This will be more exaggerated in obstructed labor. Bulging membranes
are more likely to rupture early and in such case they will not be felt at all.
Following rupture of membranes, there is possibility that the cord may prolapse
and the midwife must feel for any cord. Following leakage of amniotic fluid, if
forewaters are felt, it may be supposed that the hindwaters have ruptured.

Level or Station of the Presenting Part

In order to assess descend of the fetus in labor, the level of the presenting part is
estimated in relation to the maternal ischial spines. The distance of the
presenting part above or

below the ischial spines is expressed in centimeters. As a caput succedaneum

may form over the presenting part, care must be taken to relate the bony part of
the spines and not the edematous swelling. Molding of the fetal skull can also
result in the presenting part becoming lower without any

appreciable advance of the head as a whole. It is not possibleto make an

accurate judgment of the station vaginally. The purpose of making this estimate
is to assess progress and it is therefore valuable for the same person to make all
the vaginal examinations on any particular mother.

Identity of the Presentation

In 96% of cases, the vertex presents and is recognized by feeling the hard bones
of the vault of the skull, fontanels and sutures. For details of finding in other
presentations.

Position

By feeling the features of the presenting part, the position of the presentation
can be derived. In vertex presentations the first feature to be felt even in early
labor, is the sagittal suture. It may be felt in the right or left oblique diameter of
the pelvis or it may be transverse. Later, as further descent occurs, it rotates to
the anteroposterior diameter of the pelvis.

The sagittal suture is to be followed with the finger until a fontanel is reached.
If the head is well-flexed, the posterior fontanel will be felt. The location of the
fontanel(s) in relation to the pelvis, give information as to the whereabouts of
the occiput.

Molding

Molding can be judged by feeling the amount of overlapping of the skull bones
and can give additional information as to position. The parietal bones override
the occipital bone.

Completion of the Examination

As the midwife withdraws her fingers from the vagina, she should note any
blood or amniotic fluid and compare this with the observations made earlier.
Finally, she should remove her gloves and auscultate the fetal heart prior to
assisting the mother to find a comfortable position.

The woman must be kept informed of her progress in labor.. Findings of

examination must be recorded accurately after each examination.