[shortstuff31117]

I'm new to L&D and have actually been having really good luck with finding the cervix of my patients. Yesterday I had a pt, first baby, head was way low, 0 station, but her cervix was way up behind the head. My preceptor had me check her but I could not find the cervix, even with the pt. sitting on her fists. Anyone have any other tricks for finding a posterior cervix?
Also...my preceptor encouraged the pt. to get her epidural so she would relax and the cervix would move, or at least my preceptor could pull it forward..Is pulling on a cervix a good idea??

Thanks!

[JaneyW]

Sometimes I would use an upside down bedpan instead of fists.

[nizhoni]

It is remarkable how far back a cervix can be, especially in a first-time mom with a well-engaged fetal head. As a new examiner you might even be fooled into thinking that the patient is complete, except for the fact that nothing else (pt's behavior, strength/frequency of contractions, etc.) supports that.

If you need to check, sometimes you can "walk" the cervix forward if you can reach an edge of it. You do this by finding the edge of cervix, placing one or two fingers just inside, and then gently encouraging it forward (usually a little at a time--hence the term "walking the cervix") till you can actually assess the dilation and effacement. However, if you know that this is a first time mom and she's clearly not in heavy labor (i.e, close to complete), the reasons for checking are pretty negligible. Especially with the head so far down into the pelvis, you can probably make a very accurate estimation of cervical status without ever introducing your fingers into the introitus.

Marla

[tntrn]

On a primip, if the cervix is that far posterior, I figure it's also closed or pretty much closed. At the very least, it's not an active labor situation. I've reported that to the attendings in just that way and never gotten an argument. If the cervix is that far posterior, is it really worth all the discomfort to the patient, especially when the resulting report is going to be that it's closed.

[SmilingBluEyes]

I have the patients laying w/their heads as low as possible. I also have them put their hands under their buttocks to elevate the pelvis more and make the elusive cervix easier to reach. Also, when checking the patient, make sure you run your (hopefully warm) gloved hand along her posterior vaginal wall and once you reach the fornix, or baby's presenting part, gently "scoop" the hand forward, from posterior to anterior until you find the cervix. Indeed, posterior cervices, particular in patients whose babies are at 0 station or below are tough to reach. But if you can get patient to elevate her pelvis, either with her hands or an upside-down bedpan (as suggested above), your chances of reaching even a very high, posterior cervix improve greatly.

With time, you will get the hang of it. Never be afraid to ask your experienced colleagues for help if you have trouble finding or telling how dilated a cervix is. After 10 years, I have learned every lady's anatomy is very different, and I am not afraid to have my coworkers "back me up" for weird, unusual checks. WAIT til you get a patient who is bicornate, and has TWO cervices----THAT is a very interesting check indeed! I had one lady who had two cervices, both of which dilated to 4 or 5 until one of them dilated more---and that was where the baby came out. It was really something else!

I don't like to pull cervices any way, if I can help it. WHY? CAUSE IT HURTS!!!! Also, no need to risk minor tearing/laceration. Now, if you are reaching a posterior cervix, you can gently feel the borders, but I do not recommend pulling on it in the process.

Time and practice will certainly help!. Good luck.

[mitchsmom]

I don't usually "hook" a cervix, either. This is why - if I can reach enough to be able to hook it, I can generally feel enough to estimate dilation based on the amount of curve that I can feel, even if I can't feel all the way around the circle. (Make sense? I.E. if you feel half or a third of a regular soup can rim vs. a rim of a little bottle of vanilla you are going to know the difference). I have done it, but I just personally don't usually find it necessary.

Also, I find that sometimes just asking pts to lie on their hand/fists isn't enough for them to understand what I'm getting at/why.. I make sure to tell them that by doing that it gets their bottom up higher and it usually makes the exam easier (everyone is usually on board with that plan, right?!!) - then they tend to gladly get that bottom way up in the air, and get a better pelvic tilt going (get that lower back in a "c" shape with pelvis tilted upward) than simply sitting on their hands and not making much positional change.

I also usually do like SBE said, run my finger all the way up the posterior wall, then up and anterior until I find it.
When you have a low baby head there like you described, sometimes you can do the opposite and run up around that head as a guide until your finger steps down on the lip of the cervix since it's got to be there continuous with the baby head somewhere!

I'm still fairly new but I've come a long way with those exams That said, I still get people to check behind me any time I'm not sure - I'm not comfortable guestimating; even though some things are generally going to be the case (the primip high and posterior or whatever) - as sure as I'd do it, it would be the one person that didn't fit the bill & would go have a baby on the side of the road somewhere! LOL

[mommy2boysaz]

I agree with some of the others, that if a cervix is that far posterior, I probably don't need to know the exact dilation. It won't be very much! I prefer not to put the mother through agony. Whenever I tell a doc that his patient remains very posterior and difficult to reach, they know what that means and don't ever ask for any "more specific" details. Once enough progress is made, it won't be hard to reach anymore!

[tntblonde]

I agree with all, first off lay patient flat as possible and ask her to lift her hips up, like a pelvic thrust exercise... but basically if the cervix is that posterior the dilation makes little difference, that baby isnt going to fall out! and why put the patient through unnecessary discomfort!