CHECKLIST FOR INTERNAL EXAMINATION

Task/Procedure CASES
1 2 3 4 5 6 7 8 9 10
1. Prepares articles completely.
2. Explains the procedure to the patient.
3. Put the patient in a dorsal lithotomy position.
4. Wash or flush the perineum.
5. Wash hands, dry.
6. Put on sterile gloves.
7. Lubricate two fingers of the right hand with antiseptic or lubricating jelly.
8. Separate the labia with the thumb and little finger of the left hand.
9. Insert the 2nd and 3rd fingers sidewise deep into the vagina in downward
direction.
10. Palms facing upward, sway the fingers on the wall of the vagina till they come
in contact with cervix.
11. Assess the following:
a. Vagina/perineum : firm/distensible
b. Condition of the cervix: firm, soft, close, open, effacement, dilation
c. Memebranes : intact/ruptured ( character of amniotic fluid )
d. Presentation of fetus : cephalic, breech, shoulder, others
e. Station of the presenting part.
f. Pelvic architecture
1) Ischial spines
Prominent
Not prominent
2) Diagonal Conjugate
11.5 cm (less than)
11.5 cm (greater than)
12. Check findings accurately with facilitator or clinical instructor
13. Record findings.
Supervisor’s Initial

Instruction: Accomplish this form by using the legend according to the observed task/activity. Name of Scholar : ___________________________
Legend: ( ) done correctly ( X ) not done correctly ( * ) not done Name of Supervisors: ___________________________
___________________________
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Date of Accomplished: _____________________________