Vaginal examination during labor

Reviewed: February 15, 2019

Introduction

During first-stage labor, a practitioner or a nurse with special skills performs a vaginal examination to assess
cervical dilation, effacement, membrane status, and fetal presentation, position, engagement, and station.
Important considerations during the examination include respecting the patient's privacy, providing simple
explanations to the patient and her support person, and using sterile technique. With experience, the typical
examiner develops a well-honed routine for collecting necessary information. This enables the examination to
proceed precisely and efficiently.

Contraindications to a vaginal examination include excessive vaginal bleeding, which may signal placenta
previa.1

Equipment

Sterile gloves
Sterile water-soluble lubricant or sterile water
Fluid-impermeable pads
Sterile gauze
Optional: gown, mask with face shield or mask and goggles, mild soap and water

Implementation

Gather the necessary equipment.

Perform hand hygiene to reduce the transmission of microorganisms.2 3 4 5 6 7
Confirm the patient's identity using at least two patient identifiers.8
Provide privacy.9 10 11 12
Explain the procedure to the patient and support person (if appropriate) according to their individual
communication and learning needs to increase their understanding, allay their fears, and enhance
cooperation.13
Give the patient an opportunity to empty her bladder. A distended bladder can interfere with accurate
examination findings.
Position the patient supine with her head slightly elevated, and expose her abdomen.14
Help the patient into the lithotomy position for the vaginal examination.
Place a fluid-impermeable pad under the patient's buttocks.
Perform hand hygiene.2 3 4 5 6 7
Put on sterile gloves.15 16 Put on additional personal protective equipment as needed to comply with
standard precautions.
Inform the patient when you are about to touch her to avoid startling her.
If necessary, clean the perineum with mild soap and water.
Lubricate the index and middle fingers of your examining hand with sterile water or sterile water-soluble
lubricant to facilitate insertion.
Ask the patient to relax by taking several deep breaths, releasing the air slowly, and relaxing her perineum.
Separate the labia with your nondominant hand and insert your lubricated fingers (palmar surface down)
into the vagina. Keep your uninserted fingers flexed to avoid the rectum. (See Step-by-step vaginal
examination.)

STEP-BY-STEP VAGINAL EXAMINATION

Begin the vaginal examination by inserting your gloved index and middle fingers palm side down into the
vagina. Use your nondominant hand to gently but firmly press on the uterus to steady the fetal presenting
part against the cervix for examination.

Confirm the presenting part and position. Rotate your fingers to palpate and confirm the fetal presenting
part (a fetal head feels firm, the buttocks soft) and position (left, right, anterior, posterior, or transverse)
identified by locating the sagittal suture and the anterior and posterior fontanels in relation to the
maternal symphysis or sacrum.

Assess cervical effacement and dilation. Estimate cervical dilation by palpating the internal os. Each
fingerbreadth of dilation averages 1.5 to 2 cm, depending on the width of the examiner's finger.

Next, determine the percentage of effacement by palpating the ridge of tissue around the cervix. Assign
a low percentage of effacement to defined and thick cervical tissue. Indistinct, wafer-thin cervical tissue
scores 100%.

Assess fetal engagement and station. Estimate the extent of fetal engagement (descent of the fetal
presenting part into the pelvis).
Palpate the presenting part and grade the fetal station (where the presenting part lies in relation to the
ischial spine of the maternal pelvis). Station grades range from –3 (3 cm above the maternal ischial
spine) to +4 (4 cm below the maternal ischial spine, causing the perineum to bulge). A 0 grade indicates
that the presenting part lies level with the ischial spine.

Evaluate membrane status. If appropriate, also check amniotic membrane status. If you feel a bulging,
slick surface over the presenting fetal part, then the membranes are intact.

Rotate the fingers to palmar surface up and palpate the cervix, noting its position in relation to the
presenting part and the vagina (anterior, midposition, or posterior). A posterior cervix may be difficult to
locate and is associated with early or preterm labor. Assisting the patient in performing a pelvic tilt or
applying mild fundal pressure during the examination will facilitate locating the posterior cervix. When you
find the cervix, note its consistency. The cervix gradually softens throughout pregnancy. (See Cervical
effacement and dilation.)

CERVICAL EFFACEMENT AND DILATION

As labor advances, so do cervical effacement and dilation, thereby facilitating birth. During effacement,
the cervix shortens and its walls become thin, progressing from 0% effacement (palpable and thick) to
100% effacement (fully indistinct—or effaced—and paper thin). Full effacement obliterates the
constrictive uterine neck to create a smooth, unobstructed passage for the fetus.

At the same time, dilation occurs. This progressive widening of the cervical canal—from the upper
internal cervical os to the lower external cervical os—advances from 0 to 10 cm. As the cervical canal
opens, resistance decreases, further easing fetal descent.

No effacement or dilation
Early effacement and dilation

Full effacement and dilation

  

After identifying the presenting fetal part and position, evaluating dilation and effacement, assessing fetal
engagement and station, and verifying membrane status, gently withdraw your fingers.
Let the patient clean her perineum herself with sterile gauze if she can walk to the bathroom. If she's
confined to bed, clean her perineum and change the fluid-impermeable pad.
To encourage the patient and help reduce her anxiety, explain how her labor is progressing and define the
stage and phase if appropriate.
Discard used supplies in appropriate receptacles.15 16
Remove and discard your gloves and other personal protective equipment if worn.15 16
Perform hand hygiene.2 3 4 5 6 7
Document the procedure.17 18 19 20

Special Considerations

In early labor, perform the vaginal examination between contractions, focusing primarily on the extent of
cervical dilation and effacement. At the end of first-stage labor, perform the examination during a
contraction, when the uterine muscle pushes the fetus downward. Focus this examination on assessing
fetal descent.
If the amniotic membranes rupture during the examination, record the fetal heart rate (FHR). Then note the
time and describe the color, odor, and approximate amount of fluid. If the FHR becomes unstable,
determine fetal station, check for umbilical cord prolapse, and notify the practitioner. After the membranes
rupture, perform the vaginal examination only when labor changes significantly to minimize the risk of
introducing intrauterine infection.

Complications

Vaginal examination during labor may cause chorioamnionitis and puerperal infections.
 Documentation

After each examination, record the percentage of effacement, dilation, station of the presenting fetal part, fetal
position, amniotic membrane status, and the patient's tolerance of the procedure. Document any patient
teaching, the patient's understanding of the teaching provided, and any need for follow-up teaching.

References

1. Silbert-Flagg, J., & Pillitteri, A. (2017). Maternal & child health nursing: Care of the childbearing & childrearing
family (8th ed.). Philadelphia, PA: Wolters Kluwer.
2. The Joint Commission. (2019). Standard NPSG.07.01.01. Comprehensive accreditation manual for
hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
3. Centers for Disease Control and Prevention. (2002). Guideline for hand hygiene in health-care settings:
Recommendations of the Healthcare Infection Control Practices Advisory Committee and the
HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR Recommendations and Reports, 51(RR-16),
1–45. Accessed January 2019 via the Web at https://www.cdc.gov/mmwr/pdf/rr/rr5116.pdf (Level II)
4. World Health Organization. (2009). "WHO guidelines on hand hygiene in health care: First global patient
safety challenge, clean care is safer care" [Online]. Accessed January 2019 via the Web at
http://apps.who.int/iris/bitstream/10665/44102/1/9789241597906_eng.pdf (Level IV)
5. Accreditation Association for Hospitals and Health Systems. (2018). Standard 07.01.21. Healthcare
Facilities Accreditation Program: Accreditation requirements for acute care hospitals. Chicago, IL:
Accreditation Association for Hospitals and Health Systems. (Level VII)
6. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2018).
Condition of participation: Infection control. 42 C.F.R. § 482.42.
7. DNV GL-Healthcare USA, Inc. (2018). IC.1.SR.1. NIAHO® accreditation requirements, interpretive guidelines
and surveyor guidance – revision 18.1. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
8. The Joint Commission. (2019). Standard NPSG.01.01.01. Comprehensive accreditation manual for
hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
9. Accreditation Association for Hospitals and Health Systems. (2018). Standard 15.01.16. Healthcare
Facilities Accreditation Program: Accreditation requirements for acute care hospitals. Chicago, IL:
Accreditation Association for Hospitals and Health Systems. (Level VII)
10. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2018).
Condition of participation: Patient's rights. 42 C.F.R. § 482.13(c)(1).
11. The Joint Commission. (2019). Standard RI.01.01.01. Comprehensive accreditation manual for hospitals.
Oakbrook Terrace, IL: The Joint Commission. (Level VII)
12. DNV GL-Healthcare USA, Inc. (2016). PR.1.SR.5. NIAHO® accreditation requirements, interpretive guidelines
and surveyor guidance – revision 18.1. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
13. The Joint Commission. (2019). Standard PC.02.01.21. Comprehensive accreditation manual for hospitals.
Oakbrook Terrace, IL: The Joint Commission. (Level VII)
14. Simpson, K. R., & Creehan, P. A. (2014). AWHONN perinatal nursing (4th ed.). Philadelphia, PA: Wolters
Kluwer.
15. Siegel, J. D., et al. (2007, revised 2018). "2007 guideline for isolation precautions: Preventing transmission
of infectious agents in healthcare settings" [Online]. Accessed January 2019 via the Web at
https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf (Level II)
16. Accreditation Association for Hospitals and Health Systems. (2018). Standard 07.01.10. Healthcare
Facilities Accreditation Program: Accreditation requirements for acute care hospitals. Chicago, IL:
Accreditation Association for Hospitals and Health Systems. (Level VII)
17. The Joint Commission. (2019). Standard RC.01.03.01. Comprehensive accreditation manual for hospitals.
Oakbrook Terrace, IL: The Joint Commission. (Level VII)
18. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2018).
Condition of participation: Medical record services. 42 C.F.R. § 482.24(b).
19. Accreditation Association for Hospitals and Health Systems. (2018). Standard 10.00.03. Healthcare
Facilities Accreditation Program: Accreditation requirements for acute care hospitals. Chicago, IL:
Accreditation Association for Hospitals and Health Systems. (Level VII)
20. DNV GL-Healthcare USA, Inc. (2016). MR.2.SR.1. NIAHO® accreditation requirements, interpretive guidelines
and surveyor guidance – revision 18.1. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)

Additional References
Bell, C., et al. (2018). What is the result of vaginal cleansing with chlorhexidine during labour on maternal and neonatal
infections? A systematic review of randomised trials with meta-analysis. BMC Pregnancy and Childbirth, 18, 139. Accessed
January 2019 via the Web at https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-018-1754-9(Level I)
Downe, S., et al. (2013). Routine vaginal examinations for assessing progress of labour to improve outcomes for women and
babies at term. Cochrane Database of Systematic Reviews, 2013(7), CD010088. Accessed January 2019 via the Web at
https://www.researchgate.net/publication/249648515_Routine_Vaginal_Examinations_for_Assessing_Progress_of_Labour_to_I
mprove_Outcomes_for_Women_and_Babies_at_Term(Level V)