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Vaginal Examination

Extracted from Survival Guide to Midwifery, 2nd Edition (2012) Diane M. Fraser and Margaret A. Cooper, Oxford; Churchill Livingstone: 2012. Courtesy Elsevier

Vaginal examination may be carried out to assess progress in labour. Although it is not essential to examine the woman vaginally at frequent intervals, it may be useful to do so when progress is in doubt or another indication arises. Under no circumstances should a midwife make a vaginal examination if there is any frank bleeding, unless the placenta is positively known to be in the upper uterine segment. The features that are indicative of progress are:

 

  • Effacement and dilatation of the cervix
  • Descent, flexion and rotation of the fetal head.

Cervix fully dilated

Progressive dilatation is monitored as labour continues and charted on either the partograph or the cervicograph. The level or station of the presenting part is estimated in relation to the ischial spines; during normal labour the head descends progressively. Moulding or a large caput will give a false impression of the level of the fetal head. In vertex presentations, progress depends partly on increased flexion. Flexion is assessed by the position of the sutures and fontanelles:

  • If the head is fully flexed, the posterior fontanelle becomes almost central
  • If the head is deflexed, both anterior and posterior fontanelles may be palpable.

Rotation is assessed by noting changes in the position of the fetus between one examination and the next. The sutures and fontanelles are palpated in order to determine position. Under no circumstances should a midwife make a vaginal examination if there is any frank bleeding, unless the placenta is positively known to be in the upper uterine segment.

Breech presentation

On vaginal examination, the breech feels soft and irregular with no sutures palpable. The anus may be felt, and fresh meconium on the examining finger is usually diagnostic.

 


Feet felt - complete breech presentation

Brow presentation

On vaginal examination, the presenting part is high. The anterior fontanelle may be felt on one side of the pelvis, and the orbital ridges, and possibly the root of the nose, at the other. A large caput succedaneum may mask these landmarks if the woman has been in labour for some hours.

Face presentation

On vaginal examination, the presenting part is high, soft and irregular. The orbital ridges, eyes, nose and mouth mat be felt. As labour progresses the face becomes oedematous, making it more difficult to distinguish from a breech presentation. Care must be taken not to injure or infect the eyes.

 

Left mentoanterior position: A. the mentim is felt to the left and anteriorly; B. Following increased extension of the head, the mouth may be felt; C. The face has rotated 1/8 circle: orbital ridges in transverse diameter of the pelvis

 

Occipitoposterior positions

Findings on vaginal examination will depend on the degree of flexion of the head; locating the anterior fontanelle in the anterior part of the pelvis is diagnostic of occipitoposterior presentation.

Shoulder presentation

Vaginal examination should not be performed without first excluding placenta praevia.

  • In early labour, the presenting part may not be felt.
  • The membranes usually rupture early.
  • If the labour has been in progress for some time, the shoulder may be felt as a soft irregular mass.
  • It is sometimes possible to palpate the ribs, their characteristic grid-iron pattern being diagnostic.
  • When the shoulder enters the pelvic brim, an arm may prolapse; this should be differentiated from a leg.

     

The Practising Midwife featured article

Introducing educational theory: vaginal examination TPM 2015; 18(8): 27 - 29 Author: Jo Killingly

 

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