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CLINICAL GUIDELINES

ASSESSMENT AND PROCEDURE FOR


Register No: 12022
PERFORMING A VAGINAL EXAMINATION
Status: Public

Developed in response to: Intrapartum NICE Guidelines


RCOG Guideline
Contributes to CQC Regulation 9,12

Consulted With Post/Committee/Group Date


Anita Rao/ Clinical Director for Women’s, Children’s and Sexual Health Directorate May 2015
Alison Cuthbertson
Vidya Thakur Consultant for Obstetrics and Gynaecology
Alison Cuthbertson Head of Midwifery/Nursing for Women’s and Children’s Services
Deb Cobie Lead Midwife Labour Ward and Acute Inpatient Services Manager
Chris Berner Maternity Risk Manager
Diane Roberts Lead Midwife Community Services; Named Midwife Safeguarding
Paula Hollis Senior Midwife
Sarah Moon Specialist Midwife Guidelines and Audit
Professionally Approved By
Dr Rao Lead Consultant for Obstetrics and Gynaecology May 2015

Version Number 2.1


Issuing Directorate Obstetrics and Gynaecology
Ratified by Documents Ratification Group
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Ratified on 26 June 2015
Trust Executive Board Date July 2015
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Implementation Date 6 July 2015
Next Review Date May 2018
Author/Contact for information Gemma May, Practice Development Midwife
Policy to be followed by (target staff) Midwives, Obstetricians, Paediatricians
Distribution Method Intranet and Website. Notified on Staff Focus
Related Trust Policies (to be read in 04071 Standard Infection Prevention
conjunction with) 04072 Hand Hygiene
06036 Guideline for Maternity Record Keeping including
Documentation in Handheld Records
08014 Guideline for Fetal Blood Sampling
09042 Guideline for the Antenatal, Intrapartum and Postnatal
Management of Women with Pregnancy Loss
09046 Guideline for the Completion of the Partogram in
Pregnancy
05118 Chaperone Policy
04080 Consent Policy
09127 Interpreting and Translation Policy
07043 Abdominal Palpation
09046 Completion of the Partogram in Pregnancy
04229 Induction of labour with Prostaglandin, Artificial
Rupture of Membranes and Stretch and Sweep
Document History Review:
Version No Authored/Reviewed by Active date
1.0 Linda Anselmi June 2012
1.1 Gemma May – Clarification to point 4.0, 5.3 and 6.0 January 2014
2.0 Gemma May, Practice Development Midwife July 2015
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2.1 Sarah Moon – Clarification to point 4.2 and 11.0 5 July 2016

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INDEX

1. Purpose

2. Aims

3. Equality and Diversity

4. Rationale

5. Obtaining Consent for the Vaginal Examination

6. Use of Chaperones

7. Performing the Vaginal Examination

8. Staffing and Training

9. Infection Prevention

10. Supervisor of Midwives

11. Audit and Monitoring

12. Guideline Management

13. Communication

14. References

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1.0 Purpose

1.1 The purpose of this document is to provide guidelines for the procedures to be
followed when undertaking a vaginal examination (VE).

2.0 Aims

2.1 To provide guidance on vaginal examinations, ensuring privacy and dignity for all
women

2.1 To minimise the risk of professional actions being misinterpreted.

3.0 Equality and Diversity

3.1 Mid Essex Hospital Services NHS Trust is committed to the provision of a service that
is fair, accessible and meets the needs of all individuals.

4.0 Rationale

4.1 VE (vaginal examination) is a tool to assess the cervix’s favourability for induction or to
confirm the progress of labour by assessing the cervical effacement and dilatation; it
should only be carried out if it will benefit the woman’s management and care.

4.2 When conducting a vaginal examination:

• Be sure that the examination is necessary and will add important information to the
decision-making process
• Recognise that a vaginal examination can be distressing for woman, especially if
she is already in pain, highly anxious and in an unfamiliar environment
• Explain the reason for the examination
• Ensure the woman’s informed consent, privacy, dignity and comfort
• Explain sensitively the findings of the examination and any impact on the birth plan
to the woman and her birth companion (s)

4.3 Vaginal examinations are considered in the following scenarios:

• Confirming onset of labour


• Assessing progress in labour
• To identify the presentation and position of the baby
• To perform artificial rupture of membranes
• To apply a fetal scalp electrode
• To perform a fetal blood sample
• To exclude cord prolapse after spontaneous rupture of membranes where there is
an ill-fitting presenting part
• To confirm onset of second stage
• To assess favourability of cervix before induction
• To administer prostin or propess vaginally during induction of labour

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5.0 Obtaining Consent for the Vaginal Examination
(Refer to the policy entitled ‘Consent Policy’; register number 04080)

5.1 Valid informed consent must be obtained from the patient before undertaking a
vaginal examination and a clear rationale for the procedure given.

5.2 Consent may be given in writing, verbally or may be implied by the co-operation of the
patient. The practitioner must ensure the woman is legally competent to consent.

5.3 The person completing the VE must be aware that consent may be withdrawn at any
time during the procedure, and therefore examination must stop immediately.

5.4 VE should not be carried out on non-English speaking patients without an


interpreter/advocate except in an emergency. (Refer to the guideline entitled
‘interpreting and translation policy’; register number 09127)
5.5 Young adults (aged 16 to 18 years) are presumed to be competent to provide consent
(Family Law Reform Act, 1969). However, if they withhold consent this could be
challenged by their parents or the courts (The Fraser Guidelines, 1989)
5.6 No person has the right to provide consent on behalf of another competent adult unless
in an emergency where treatment is intended to preserve life.

6.0 Use of Chaperones


(Refer to the policy entitled ‘Chaperone Policy’; register number 05118)
6.1 The patient shall be given the opportunity to ask for and have a chaperone,
irrespective of organisational constraints or settings.
6.2 The patient may wish the chaperone to be a family member or friend. Alternatively
another care-giver may act as a chaperone. No assumptions should be made as to
who is the most appropriate chaperone.
6.3 The patient’s preference should be documented in her health care record along with the
name/designation of the chaperone.
6.4 Midwives also have the right to request a chaperone and this is good practice in the
provision of a witness should misunderstandings or an allegation of assault occur
(Royal College of Nursing (RCN), 2002)
6.5 When the chaperone is another Midwife he/she can act as an advocate for the patient
and assist with:
• Explaining the VE procedures
• Evaluating the patient’s level of understanding
• Providing a reassuring presence during the VE

7.0 Performing the Vaginal Examination


7.1 The patient should be treated with dignity and respect at all times.
7.2 All vaginal examinations should be preceded by an abdominal palpation (Refer to the
guideline entitled ‘Abdominal palpation’; register number 07043)
7.3 The patient should be advised that the procedure may become uncomfortable and can
request for it to be stopped at any time. The method that will be used by the patient to
request a stop should be agreed in advance, e.g. by the raising of a hand or by a verbal
request.
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7.4 The Midwife must ensure that all equipment required for the VE is to-hand
• Apron
• Sterile gloves
• Tap water can be used for cleansing before the examination
• A lubricant should be ready for use such as aquagel /obstetric cream.

7.5 The patient should be encouraged to empty their bladder to reduce discomfort.
Catheterisation may be necessary.
7.6 The Midwife should ensure that a supply of entonox is available for the patient’s use
should they require it.
7.7 The woman should adopt a semi recumbent position, with her knees bent, ankles
together and knees parted.
7.8 Gently insert the first two fingers of the examining hand into the vagina, in a downward
and backwards direction along the anterior vaginal wall to locate the cervix.
7.9 During the examination:
• Discussion should be relevant and free of unnecessary comments
• The patient’s privacy and dignity should continue to be respected
• Attention should be paid to verbal and non-verbal indications of distress from the
patient

7.10 A full explanation of the results of the VE shall be provided to the patient in a sensitive
manor and documented within the handheld records using a vaginal examination
sticker (Refer to appendix A)
7.11 It is mandatory to comment on each of the following areas during the examination and
must be commented on as follows:
• External genitalia - any abnormalities such as varicosities, oedema, piercings,
warts or signs of infection should be noted
• Vagina - the vagina should feel warm and moist; a full rectum may be felt during
the examination and should be commented upon
• Cervix- Dilatation should be documented in centimetres (cm) and be
documented as one figure i.e. 5cm
• Effacement - is assessed by the length of the cervix and degree to which it
protrudes into the vagina
• Position - should be described as posterior, central or anterior
• Consistency- firm, medium or soft
• Presentation - the identification of landmarks on the presenting part help to
confirm presentation. A pictorial diagram is recommended to evidence the fetal
position. It should be noted how well the presenting part is applied to the cervix
and if the presence of a cord or membranes are felt.
• Station - this is the distance between the presenting part and the ischial spines
in cm. Above the spines will be (–cm) and below the spines should be referred to
as (+cm)
• Vaginal Loss – Show, blood, liquor including amount and colour using the
following definitions ( Intact , clear, thin meconium stained, thick meconium
stained, offensive, absence of liquor
• Caput - This should be circled: Present or not present
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• Molding -These will be circled upon completion of the vaginal examination and
are referenced as follows:
i. 0 = Separated bones, sutures felt easily
ii. + = Bones just touching each other
iii. ++ = Overlapping bones, reducible
iv. +++ = Severely overlapping bones, non-reducible
7.12 The midwife should auscultate the fetal heart with a pinard or sonic-aid and this should
be performed pre and post VE.
7.13 If the patient is in established labour the findings should be charted on the partogram.
(Refer to the guideline entitled ‘Completion of the partogram in pregnancy’; register
number 09046)
7.14 Vaginal examinations should not be carried out in:
• Patients with ruptured membranes who are not in established labour
• Presence of active herpes in a patient with ruptured membranes unless the
patient is in labour
• Unknown placental localisation
• Placenta praevia
• Preterm under 37/52 and midwives

8.0 Staffing and Training


8.1 All midwifery and obstetric staff must attend yearly mandatory training which includes
skills and drills training. (Refer to ‘Mandatory training policy for Maternity Services
(incorporating training needs analysis.)’; register number 09062)
8.2 All midwifery and obstetric staff are to ensure that their knowledge and skills are up-to-
date in order to complete their portfolio for appraisal.
9.0 Infection Prevention
9.1 All staff should follow Trust guidelines on infection prevention by ensuring that they
effectively ‘decontaminate their hands’ before and after each procedure.
10.0 Supervisor of Midwives
10.1 The supervision of midwives is a statutory responsibility that provides a mechanism for
support and guidance to every midwife practising in the UK. The purpose of supervision
is to protect women and babies, while supporting midwives to be fit for practice'. This
role is carried out on our behalf by local supervising authorities. Advice should be
sought from the supervisors of midwives are experienced practising midwives who have
undertaken further education in order to supervise midwifery services. A 24 hour on call
rota operates to ensure that a Supervisor of Midwives is available to advise and support
midwives and women in their care choices

11.0 Audit and Monitoring

11.1 Audit of compliance with this guideline will be considered on an annual audit basis in
accordance with the Clinical Audit Strategy and Policy (register number 08076), the
Corporate Clinical Audit and Quality Improvement Project Plan and the Maternity
annual audit work plan; to encompass national and local audit and clinical governance
identifying key harm themes. The Women’s and Children’s Clinical Audit Group will
identify a lead for the audit.

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11.2 The findings of the audit will be reported to and approved by the Multi-disciplinary Risk
Management Group (MRMG) and an action plan with named leads and timescales will
be developed to address any identified deficiencies. Performance against the action
plan will be monitored by this group at subsequent meetings.

11.3 The audit report will be reported to the monthly Directorate Governance
Meeting (DGM) and significant concerns relating to compliance will be entered on the
local Risk Assurance Framework.

11.4 Key findings and learning points from the audit will be submitted to the Clinical
Governance Group within the integrated learning report.

11.5 Key findings and learning points will be disseminated to relevant staff.

12.0 Guideline Management

12.1 As an integral part of the knowledge, skills framework, staff are appraised annually to
ensure competency in computer skills and the ability to access the current approved
guidelines via the Trust’s intranet site.
12.2 Quarterly memos are sent to line managers to disseminate to their staff the most
currently approved guidelines available via the intranet and clinical guideline folders,
located in each designated clinical area.

12.3 Guideline monitors have been nominated to each clinical area to ensure a system
whereby obsolete guidelines are archived and newly approved guidelines are now
downloaded from the intranet and filed appropriately in the guideline folders. ‘Spot
checks’ are performed on all clinical guidelines quarterly.

12.4 Quarterly Clinical Practices group meetings are held to discuss ‘guidelines’. During this
meeting the practice development midwife can highlight any areas for future training
needs will be met using methods such as ‘workshops’ or to be included in future ‘skills
and drills’ mandatory training sessions.

13.0 Communication

13.1 A quarterly ‘maternity newsletter’ is issued to all staff to highlight key changes in clinical
practice, to include a list of newly approved guidelines for staff to acknowledge and
familiarise themselves with and practice accordingly. Midwives that are on maternity
leave or ‘bank’ staff have letters sent to their home address update them on current
clinical changes.

13.2 Approved guidelines are published monthly in the Trust’s Staff Focus that is sent via
email to all staff.

13.3 Approved guidelines will be disseminated to appropriate staff quarterly via email.

13.4 Regular memos are posted on the guideline and audit notice boards in each clinical
area to notify staff of the latest revised guidelines and how to access guidelines via the
intranet or clinical guideline folders.

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14.0 References

Department of Health Website www.dh.gov.uk

National Institute for Health and Clinical Excellence (2008) Antenatal care.
Routine care for the healthy pregnant woman. NICE: London

National Institute of Health and Clinical Excellence (2014) Intrapartum Care:.Care of


healthy women and their babies during childbirth. NICE: London. December.

Nursing Midwifery Council (2004) Midwives Rules and Code of Professional


Conduct . NMC. www.nmc-uk.org

Royal College of Nursing, 2002


Available at: http://www.rcn.org.uk/

The Family Law Reform Act, 1969:


Available at: http://www.legislation.gov.uk/ukpga/1969/46

The Fraser Guidelines. 1985. Gillick v West Norfolk & Wisbech Area Health
Authority (1985)
Available at : http://www.bailii.org/uk/cases/UKHL/1985/7.html