Cervical exam help

[SBL]

I'm currently on an OB sub-i, and I've been trying to do as many cervical exams as possible. However, I'm feeling very incompetent! I've only done a few over my total OB/GYN rotation experiences, since often patients were ruptured already and med students were discouraged from doing them. Basically, I'm at a point where I can palpate the baby's head if the patient is dilated enough, but I can't gage dilation, station, or effacement with any confidence yet. Sometimes I just feel like I'm palpating soft tissue and cannot even differentiate the cervix in there. Granted, I've only done 4-5 cervical exams in my life. When the patients are in a lot of discomfort, I also get flustered and do the exam quickly, not really knowing what I'm palpating.

I'm just worried because I'm going to be an OB intern next year (hopefully) and I better know what I'm doing! Is it something I'll just get with practice? For OB residents, how much time did you need before you became confident with them?

Thanks for any advice about this.
-SBL

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[IdiotBoxen]

It takes time to learn the exam. I've got a few suggestions:

-It's OK to say that you don't know. Ask the midwives/OBs to teach you. More often than not, in my experience, they'll be happy to help if you ask nicely and at the right time. If you can't do the exam (for one reason or another), follow the nurses or the doc and watch if you can.

-Don't rush. Please don't. Apologise to the patient, but, this exam is important to do right.

-It is something you will get with practice. Just keep trying to learn and do as many as you can, and it will come with time.

-If you're male, be ready to have to fight to get to do some of the exams as often as you need to. I had to beg and plead...

Also, what gloves are you using? Latex? Poly?

 

[Diane L. Evans]

Look at your hand.
Put you hand palm up

Fold down the 4th 5th and 1st fingers
Point hand at a downward 45 degree angle
If right handed sit on ride side bed next to patient your legs outward toward wall
place left hand onto pts abdomen about navel area this is to feel baby
tell patient about cervical check to check for progress
with right hand palm up 2,3 fingers downward at 45 degree angle inset into canal
then place at 90 degree angle downward when 4 inches in
inch fingers now upward 45 and try and find cervical lip
inch with fingers until find the cervix see chart below for dilitation
when find cervic sweep around by rotating your hand impt for 5cm-10cm
also to check station

sometimes you need to have your hand in up to the wrist.


for dilitation ask a resident/nurse for the dilitation model charts
then practice below
1 cm is fingertip
3 cm is 2nd third finger together
4 cm is2-3 finger .5 cm apart
5 cm is 2-3 finger 1-2 cm apart
etc

 

[Global Disrobal]

A common occurence with our med students arises from a very posterior cervix, early in labor. In this case nicely ask the patient to make 2 fists and to put it under the small of their back. This elevates the cervix and makes the exam easier.

Another good way is to pick an induction patient. This way you can track the same pt and pick up on the changes in dilation and effacement.

But, as I'm sure Diane would attest, it'll come to you with experience. Don't worry to ask for help as an intern. In my first month, I would ask the patient if it was ok for the nurse to check the cervix behind me (on difficult exams). This was good especially since alot of midwives/nurses have the years behind them and m,any PEARLS to go along w/that for everything from cervical checks to the overall management of the pt. Besides, this will give you good rapport w/the L&D nurses which makes life much easier.

Good Luck

 

[neilc]

i have been doing the czech version of a sub-i for a while now...only now is my resident trusting my judgement, and not following up my cervical exams. but, i do still have to ask him for verification fairly often (maybe 1 in ten), usually on a posterior cervix...thanks for the fist in the small of the back pearl, global. i will try it next time.

but, i found some comfort in this thread. i was worried that i was just an idiot. at least it seems like this (like pretty much everything else) is experience dependant ...now, if i could just get consistent with my stupid knot tying!

 

[SBL]

I recently examined a patient and was able to find the cervix and gage the dilation-I was so relieved! I know I still need more practice, but at least finally understand what I'm looking for. This patient already had an epidural in, which really helped because she didn't feel anything and was very patient. I just needed more time. Once I found the cervix, I just focused on that area and then found the baby's head-she was about 4cm dilated. Then, my resident let me rupture her membranes and put in her IUPC.

Thanks for everyone's advice,

-SBL

 

[grounded]

I don't know if you are aware, but there is a new product on the market called the Pocket Dilation Guide (pocketdilationguide.com) that is very useful for learning correct cervical dilation. It is a little plastic tool that you can keep right in your scrubs pocket that will give you accurate cervical dilation measurements on one side and cm effacement measurements on the other.
Feels very similar to a real cervical exam so you can practice with it before you even start doing exams on patients. Very useful little item, cheap to buy and you won't have to run around asking for the dilation charts. Check it out.

 

[ekmo]

I think the most important thing to learn is this: It takes practice, a lot. I myself am very good at pelvic exams and as a intern this year have been asked by 2nd years to check a patient behind them. Do I posses a special gift, sadly, NO? But what I did do was make the most of what experiences I've had.

1st) I actually think as a medical student, if the patient is uncomfortable you should hurry up, because there is no reason for them to be uncomfortable for an exam that will need to be verified by a MD. This isn't to discourage you to do exams, but patient comfort is important.

2nd) The epidural patient is where the money is at. I don't care if it takes 2 minutes, they're comfortable, take your time and find the cervix, find the ischial spines, feel the sutures, and become familar with the position of the cervix (ant, post, mid).

3rd) In all honesty the most important things to learn in dilation is 1-5 and 9-10. What do I mean? The pelvic exam is very subjective, especially from 6-8cm, however it is very important to know 1-5 because you have to rule out labor and if you are calling a 2cm dilation 1cm, then you may think a patient did not dilate who has in her chart 1cm last exam (this can be crutial if preterm). The same goes for 9-10. No one cares if someone is 8 or 9, they are not ready, you will know if they change, the important thing is to not be pushing when a large cervical lip or 9cm dilation is there because you could cause a cerical tear.

4th) Lets be honest, I know attendings who can not agree on exams. I've even had one attending call a pt 4cm until I proved that the pt had a cystocele and was actually only 1cm and hadn't even changed dilation after 8 hours (it was quite funny). The point is, it takes time! Lost of time to be great at, and you only have to be good. So take a deep breath because we all are going into Ob/Gyn because it's not brain surgery! ahh.

EKMO
http://ekmo.blogspot.com