WOMEN AND NEWBORN HEALTH SERVICE

King Edward Memorial Hospital

CLINICAL GUIDELINES
OBSTETRICS AND MIDWIFERY
ANTENATAL CARE
ANTENATAL PROCEDURES

VAGINAL EXAMINATIONS: PERFORMING

Keywords: chaperone, vaginal procedure, vaginal examination, VE, pelvic
examination, intimate examination, assess labour progress

PRE-PROCEDURE:
1. Explain procedure & answer questions
2. Gain consent & offer a chaperone. Inform and gain consent for the presence of
students & further consent if student is examining the patient for training / education.
3. Prepare: Empty bladder, provide privacy & attend hand hygiene
4. Abdominal palpation
5. Attend hand hygiene, apply gloves, and eye protection if risk of splash.
PROCEDURE:
6. If intrapartum, attend examination between contractions
7. Inspect external genitalia- labia, perineum, scars &note any discharge/liquor/blood
8. Gently insert lubricated fingers into vagina- avoid contact with clitoris
Quick Reference Guide

9. Assess:
 Vagina: Muscle tone / dryness / excess heat
 Cervix: Length/effacement, dilation, position, consistency, application (& if
membranes intact / bulging / smooth)
 Fetus: Presentation, position, station, caput, moulding, fontanelles, sutures
 Any abnormal features (e.g. vasa praevia, pulsating umbilical cord)
 Pelvis: Ischial spines (any undue prominence) & angle of suprapubic arch as
withdraw fingers
POST-PROCEDURE:
10. Remove gloves & attend hand hygiene
11. Provide privacy for redressing, sanitary pad if required, remove soiled linen & make
comfortable.
12. Auscultate fetal heart rate
13. Discuss findings with the woman
14. Document: Procedure, consent, persons attending examination (e.g. chaperone,
family), justification for examination, findings & plan.

Note: This QRG represents minimum care & should be read in conjunction with the full guideline.
Additional care should be individualised.

AIMS
 To guide vaginal examinations, ensuring dignity and privacy for all patients.
 To minimise the risk of professional actions being misinterpreted.
(B1.6.4) All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 1 of 6
 BACKGROUND
A vaginal examination (VE) can be used to assess gynaecological symptoms,1 membrane
sweep, assess cervical ripening before induction of labour, for performing labour induction
methods, and during labour.2 The use of routine preterm (<37 weeks) cervical screening
has not been shown to reduce the risk of preterm birth and is not suggested.3
There is limited research determining the timing and effectiveness of routine
intrapartum VE’s.4 Currently accepted reasons for an intrapartum VE include
assessing progress, confirming full dilatation, presentation or engagement, artificial
rupture of membranes or to determine if already ruptured, exclude cord prolapse after
membrane rupture (particularly if fetal heart rate variation or ill-fitting presenting part)
and for multiple birth assessment.5

KEY POINTS
1. A vaginal examination shall only be carried out if it will benefit the woman’s
management and care.5
2. The woman shall be informed of the need for the examination and be offered an
explanation as to the procedure that is involved in a way that she can understand
and communicate.5-7
3. All vaginal examinations shall be preceded by an abdominal palpation. 1, 5
4. Vaginal examinations shall not be carried out if:
 Ruptured membranes in women who are not in labour (including if
presence of active Herpes Simplex Virus (HSV) lesions in a woman with
ruptured membranes, unless the woman is in labour).
 Unknown placental localisation, or placenta praevia8
 Frank bleeding8 (unless placenta is known to be in the upper uterine segment)5
 The woman does not consent7, 9.
5. Consent: Verbal consent shall always be obtained from the woman before an
examination.1, 5-7, 9, 10
 If required, an interpreter should be used to ensure valid consent to
examination.11 Vaginal examinations should not be carried out on non-English
speaking women without an interpreter / advocate, except in an emergency.
 Any emergency situation and the circumstances that make the woman unable
to consent should be documented in the medical record 11.
6. Chaperone:
 The woman shall be given the opportunity to ask for and have a chaperone. 6
The woman’s personal preference shall be documented in the clinical record.
 Health care providers also have the right to request a chaperone. 7
 The person who is the chaperone shall be agreed to by the woman.7 No
assumptions should be made as to who is the most appropriate chaperone. It
Vaginal Examination: Performing King Edward Memorial Hospital
Clinical Guidelines: Obstetric and Midwifery Perth Western Australia

(B1.6.4) All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 2 of 6
 may not be acceptable to the woman for relatives to remain present during the
examination. If the woman is not comfortable with a particular chaperone,
another chaperone should be offered if the VE can be delayed. The woman
should not feel pressure to proceed if a suitable chaperone is not available.7
 Document the chaperone’s name & designation in the medical notes.7
7. Refer to WNHS W040- Patient Interview and Examination Policy & NMHS
COC13- Chaperone Policy as required.
8. During the examination7:
 Keep discussion relevant and avoid inappropriate verbal / non-verbal gestures
 Avoid interruptions and unnecessary discussion with other staff members
 At all times, treat the woman with privacy and dignity,5-7, 9 minimising the
amount of the woman’s body that is exposed and time spent undressed
Remain alert to verbal and non-verbal indications of distress from the
woman
 Any requests to discontinue the examination should be respected and
documented in the medical record.7
9. Hand hygiene shall be performed before and after the examination. 9
10. Where possible, intrapartum VE’s should ideally be attended by the same person
to identify any changes.5

PROCEDURE

PRIOR TO THE EXAMINATION

1. Check the woman understands the purpose of the examination and explain
the procedure.5, 7, 9 Inform the woman that the examination should not be
painful but may be uncomfortable.
 If the woman does not want information about the examination, and
prefers the treatment decision be left with the health professional, the
health professional should encourage the woman to reconsider, however
should not coerce her.11
 If the woman continues to decline receiving information, the health
professional should determine the reason for the woman not wanting
disclosure of information and if the woman expresses inability to manage
receiving the information, the health professional should ensure the
woman broadly understands what is involved.11
2. Respond sensitively to any questions and concerns.6 Respect cultural and
religious considerations.7, 9 Ask if she has had a vaginal examination before,
and discuss any concerns regarding her previous experience. The VE can be

Vaginal Examination: Performing King Edward Memorial Hospital

Clinical Guidelines: Obstetric and Midwifery Perth Western Australia

(B1.6.4) All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 3 of 6
 particularly distressing to women who have survived sexual / physical abuse
or FGM, or women who are very anxious.5
3. Obtain consent1, 5-7, 9, 10 for the procedure and for other people (including
students) to be present during the examination, and record anyone attending
the examination (e.g. family, chaperone, medical students).7
 The woman may decline the examination .6 If declined, explain procedure
importance, offer a chaperone for support, and if still declined, defer to
another time or another practitioner and document plan.7
 If the patient is unable to provide consent, refer to the Consent to
Treatment Policy for the Western Australian Health System 2011. In some
situations (e.g. child), providing a surrogate decision maker to consent to
the examination and a familiar individual (such as a family member or
carer) to accompany the patient, may be appropriate.7
 If initial consent is withdrawn during the procedure, cease the examination,
discuss concerns, defer to another time / practitioner and document plan.7
4. If relevant, see also Vaginal Examination in Children and Young Women
5. Chaperone: Irrespective of the gender of the examiner, offer a chaperone,1, 6 and
document their name and qualifications.7 See also NMHS Chaperone Policy.
 A chaperone should be a qualified (e.g. nurse or appropriate training),
impartial observer who is approved by the woman, maintains
confidentiality and provides security for the woman and practitioner.7
 If the practitioner would like a chaperone but the woman does not consent,
the practitioner does not have to perform the procedure, and may refer to
another practitioner or defer to another time, where appropriate. 7
6. Students: The woman should be informed in advance if students will be in
attendance and of the right to decline students. Additional consent is required if a
student or junior doctor is to perform the examination for training / education.1, 7
7. The woman should empty her bladder.1, 9 This increases her comfort and
reduces any displacement of the fetal head by a full bladder.5
8. The woman shall be given privacy to undress and dress. 1, 6, 7 Provide a cover
during the examination e.g. sheet.1, 6, 7 Do not assist the woman in removing
clothes unless it has been clarified with them or their carer that assistance is
required.7
9. Position the woman comfortably.9 Perform an abdominal palpation before VE.1, 5, 9
10. If using a speculum – see KEMH Clinical Guideline, O&G, Vaginal
Procedures: Speculum Examination. Explain how the speculum is inserted,
offer to demonstrate the speculum, and select an appropriate sized speculum
and warm the speculum if required.

PROCEDURE
Vaginal Examination: Performing King Edward Memorial Hospital
Clinical Guidelines: Obstetric and Midwifery Perth Western Australia

(B1.6.4) All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 4 of 6
 1. Perform hand hygiene, put on gloves7 (both hands), and eye protection if risk
of splash.10
2. If intrapartum VE- wait to assess between contractions9
3. Inspect the external genitalia9 and note any:
 Amniotic fluid / Blood loss / Vaginal discharge - amount, colour, odour, ‘show’5
 Perineum: Lesions / scars (previous tears / episiotomy)5
 Labial: Oedema / varicosities / lesions5, 9
 Scarring5 or evidence of Female Genital Mutilation (FGM). Record the
type of FGM if present. See KEMH Clinical Guideline, O&M, Antepartum
Care: Female Genital Mutilation
4. While separating the labia with the non-examining hand, gently insert
lubricated fingers into the vagina.9 Avoid digital contact with the clitoris as this
may be painful.
5. Assess vaginal muscle tone, dryness& excess heat.9 Dryness may indicate pyrexia9
6. Locate the cervix and determine5, 9:
 Length / effacement  Consistency
 Position  Dilatation
 Application (& feel for membranes- intact, bulging or smooth)
 Presentation (& feel for fontanelles, sutures, moulding, caput & station)
 Any abnormal features (e.g. vasa praevia, umbilical cord pulsation).9
7. Assess the pelvis by palpating the ischial spines9 and assessing for undue
prominence.5 Note angle of the suprapubic arch while withdrawing the fingers.

POST-PROCEDURE
8. Remove gloves and perform hand hygiene.9
9. Give the woman a sanitary pad if necessary, change any soiled linen and
assist her to become comfortable.
10. Auscultate the fetal heart.9
11. Discuss the examination findings with the woman.7, 9
For intrapartum VE, see also Clinical Guidelines, O&M, Intrapartum Care:
Labour: First Stage: Care of the Woman; Partogram; & Management of Delay
5
12. Document the findings and justification for the VE in the medical notes and
partogram (intrapartum).9

Vaginal Examination: Performing King Edward Memorial Hospital

Clinical Guidelines: Obstetric and Midwifery Perth Western Australia

(B1.6.4) All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 5 of 6
 REFERENCES / STANDARDS
1. Bain C, Burton K, McGavigan C. Gynaecology illustrated. 6th ed. Edinburgh: Churchill Livingstone Elsevier; 2011.
2. Ezebialu IU, Eke AC, Eleje GU, Nwachukwu CE. Methods for assessing pre-induction cervical ripening (Review).
Cochrane Database of Systematic Reviews. 2015 (6).Available from:
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010762.pub2/pdf
3. Alexander S, Boulvain M, Ceysens G, Haelterman E, Zhang W-H. Repeat digital cervical assessment in pregnancy for
identifying women at risk of preterm labour (Review). Cochrane Database of Systematic Reviews. 2010 (6).Available
from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005940.pub2/pdf
4. Downe S, Gyte GM, Dahlen HG, Singata M. Routine vaginal examinations for assessing progress of labour to improve
outcomes for women and babies at term (Review). Cochrane Database of Systematic Reviews. 2013 (7).Available
from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010088.pub2/pdf
5. Jackson K, Marshall J, Brydon S. Physiology and care during the first stage of labour. In: Marshall J, Raynor M, editors.
Myles textbook for midwives. Edinburgh: Churchill Livingstone Elsevier; 2014. p. 327-65.
6. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. C-Gyn 30: Guidelines for
gynaecological examinations and procedures: RANZCOG. 2013. Available from:
https://www.ranzcog.edu.au/doc/guidelines-for-gynaecological-examinations-and-procedures
7. Australian Medical Association. Patient examination guidelines: AMA. 2012. Available from:
https://ama.com.au/sites/default/files/documents/Patient_Examination_Guidelines_2012_0.pdf
8. Thorogood C, Donaldson C. Challenges in pregnancy. In: Pairman S, Pincombe J, Thorogood C, Tracy S, editors.
Midwifery: Preparation for practice. 3rd ed. Sydney: Elsevier Australia; 2015. p. 917-85.
9. Pairman S, Pincombe J, Thorogood C, Tracy S, editors. Midwifery: Preparation for practice. 3rd ed. Sydney: Elsevier
Australia; 2015.
10. Communicable Disease Control Directorate. Guidelines for managing sexually transmitted infections: WA. Shenton
Park: Department of Health Western Australia. 2013. Available from: http://silverbook.health.wa.gov.au
11. Department of Health Western Australia. Consent to treatment policy for the Western Australian Health System 2011:
Government of Western Australia. 2011. Available from:
http://www.health.wa.gov.au/circularsnew/attachments/564.pdf
National Standards – 1- Care Provided by the Clinical Workforce is Guided by Current Best Practice
Legislation -
Related Policies –
 DoH OD: 0324/11 Consent to Treatment Policy for the Western Australian Health System 2011
 WNHS W040 Patient Interview and Examination Policy (2012)
 NMHS Chaperone Policy COC 13 (2014)
Other related documents –
 KEMH Clinical Guidelines, O&G, Vaginal Procedures: Vaginal Examination in Children and Young Women;
Speculum Examination; Pap Smear
 KEMH Clinical Guidelines, O&M, Intrapartum Care: Labour: First Stage: Care of the Woman; Partogram;
Management of Delay
 Department of Health WA: Safety and Quality in Healthcare: Informed Consent
RESPONSIBILITY
Policy Sponsor Nursing & Midwifery Director OGCCU
Initial Endorsement August 1999
Last Reviewed August 2015
Last Amended
Review date August 2018

Do not keep printed versions of guidelines as currency of information cannot be guaranteed.

Access the current version from the WNHS website.

© Department of Health Western Australia 2015

Copyright disclaimer available at: http://www.kemh.health.wa.gov.au/general/disclaimer.html

Vaginal Examination: Performing King Edward Memorial Hospital

Clinical Guidelines: Obstetric and Midwifery Perth Western Australia

(B1.6.4) All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 6 of 6