Documentation for student midwives: how to write up a vaginal examination

This is the second in a series of blog posts that I am writing about documentation for student midwives - if you read this blog because you are interested in social media, please feel free to skip this post! The first post is looking at how you write up an abdominal palpation in pregnancy - this post is focusing on how to document a vaginal examination when a woman is in labour. Obviously a vaginal examination is part of the big picture, which I'll look at in my next post. For the moment, I want to talk about vaginal examination as one procedure.

Using a framework for carrying out a VE and documenting your findings
Learning the skill of vaginal examination is not easy so I recommend that you develop a framework or plan for carrying them out and document using the same framework. That way you are much less likely to forget things. This is the framework I use. Talk to the midwives you work with and find out their tips for carrying out VE and documentation.

I start with the reason for carrying out the VE and write about any particular information I gave mum and that she gave her consent.

External appearance of vulva and perineum - is there anything of note such as genital warts, viscosities or perineal scaring?
How does the vagina feel? For example, if it feels hot and dry, that may be a sign that the woman is dehydrated.

Cervix - I always remember there are 5 things to comment on

• Position - is it posterior, anterior or midline?
  
• Consistency - is it soft, thick, thinning, stretchy?
  
• Effacement - is it effaced or not?
  
• Application to presenting part - well or poorly applied?
  
• Dilatation - if you think the cervix is fully dilated, make sure you've excluded an anterior lip of cervix.

Presentation - what is presenting...head, vertex, sacrum....?
Don't forget you cannot confirm that the vertex is presenting unless you can feel saggital sutures and fontanelle.
Station - where the presenting part is lying in relation to the ischial spines
Position - you will need to identify landmarks such as fontanelle before you can make this judgment
Attitude - is the presenting part flexed, deflexed or extended?
Moulding and Caput - can you feel any? How much?
Membranes - are the forewaters intact? If not, can you see liquor? How much and what colour?
Cord - can you feel the cord presenting or prolapse?
Pelvis - is there anything about the pelvis you have noticed that may impact on birth eg narrow sub-pubic arch?
Fetal heart rate - document that you have checked the heart rate and what it is.

Finally, I document what information I gave the mother and any action plan that I agreed with her. When I sign off, I put the date, time, my signature, print my name and designation.

An example (As I said, keep in mind there is other things that go along side the VE that I would document at the same time such as an abdominal palpation.)

VE to assess progress in labour with Lisa's consent. Lisa emptied bladder prior to VE.
26/7/2011 10.00 hours
External genitalia looked normal. Old episiotomy scar visible. Vagina warm and moist.
Cervix was slightly posterior, soft, thick, not stretchy, fully effaced, poorly applied to presenting part, 4 cms dilated. Head presents, 1cm above ischial spines, unable to feel identifying features or determine attitude. No moulding or caput felt. Membranes intact. No cord felt. Pelvis appears normal. Fetal heart heard following VE with pinard, 140 beats per minute, no deceleration heard at that time.
Lisa informed of findings and advised that she is in early labour.
Plan: to have a soak in a warm bath.
Name, signature and designation.

What do you think of this example of documentation. Have I forgotten anything? How would you do it - is there anything you would write differently?


Image: 'MidwifeJasper-3'
http://www.flickr.com/photos/69041429@N00/2491593942