Checking dilation and effacement

It was on the job training, with my preceptor checking and me following behind. As I got better at it, it was pretty much just me checking unless I felt something strange, or didn't feel comfortable with my check. Even the expereienced nurses will have a double check if they don't feel comfortable with what they're feeling. We have models also, but it does NOT feel the same as a squishy soft person

checking dilation, effacement, and station is something that is learned strictly with practice. You will have a preceptor to check with you for some time until you are getting most of your exams right. Even then, you will have times when you'll need someone to check behind you because you are not sure. Some exams are more difficult than others. It is also a very subjective thing. One examiner will call it 2 cm/50%, someone else will call it 3 and 70% or whatever. For me, anything thicker than 50%, I just chart as "thick" which I think most of us do, although once in a while you'll run across some "super expert fingered" doctor who will document 20% effaced!! The nurses always crack up at that! Anyway - time and experience will get most nurses pretty accurate with dilation and effacement. What I think most nurses have more difficulty with is station and presentation. For instance you can have a patient with a closed, very posterior cervix but the head be at a zero station. Just because the cervix is difficult to reach does not mean the head is high. As for presentation - even after all my years, it is still tough for me to tell if a baby is LOA, ROA, transverse or OP. I can actually tell better if baby's OP just based on how it's coming down in the pelvis than by truly feeling the landmark sutures, etc. I know most nurses I have worked with say the same thing. So no Jen, not a stupid question! The only "stupid question" is the one that is never asked!!

JentheRN - sorry - didn't proofread that response very well. re: my last comments - I should have said "position" not "presentation". Presention refers to vertex/breech/etc. Not terribly difficult to learn. Some l and d nurses are authorized to do a brief U/S to confirm presentation.

Thank you for your responses. I am a little nervous about learning this skill.. I delivered my son in May and the nurse taking over for my primary one (lunch break) said I was 10cm and told me to push....I did three pushes and my OB comes in and says STOP she is only 7cm...Then after a long long painful day (epidural lost its effect twice) I ended up having a c section...my son looked like he had three heads when he came out from all my pushing...After I went through all this pushing my baby was 'sunny side up' which they knew the whole time and asked me if I wanted a c section or to have the OB "try to turn him". Of course at that point, I was like 'take him'. I was in so much pain for quite awhile and even though I wanted to be a trooper couldn't. I am not judging....but am confused how they didn't know that there was NO way he would have ever fit lady partslly. If I hadn't said I couldn't push anymore they would have let me continue for at least another hour or two they said....awwwww my poor baby's head!! So that day made me realize that OB is really subjective...and I just want to do the very best I can....(not to say they didn't try)

Thank you for your responses. I am a little nervous about learning this skill.. I delivered my son in May and the nurse taking over for my primary one (lunch break) said I was 10cm and told me to push....I did three pushes and my OB comes in and says STOP she is only 7cm...Then after a long long painful day (epidural lost its effect twice) I ended up having a c section...my son looked like he had three heads when he came out from all my pushing...After I went through all this pushing my baby was 'sunny side up' which they knew the whole time and asked me if I wanted a c section or to have the OB "try to turn him". Of course at that point, I was like 'take him'. I was in so much pain for quite awhile and even though I wanted to be a trooper couldn't. I am not judging....but am confused how they didn't know that there was NO way he would have ever fit lady partslly. If I hadn't said I couldn't push anymore they would have let me continue for at least another hour or two they said....awwwww my poor baby's head!! So that day made me realize that OB is really subjective...and I just want to do the very best I can....(not to say they didn't try)

I guess the subjective part is the assessment of the D and E, but as far as delivering an OP baby, I thought it's possible to do it lady partslly. It a'int easy but it's possible.

Just curious. Was anyone providing counterpressure to your back?

Just curious. Was anyone providing counterpressure to your back?

No....all they did was hold up my legs and tell me to push..I pushed for 1 1/2 hours (doesn't sound long but my epidural had stopped working before the beginning of the pushing)....was exhausted and said I couldn't do it anymore. I wasn't getting any 'break' with the pain...then the OB came in and said 'want me to try to move the baby or do you want a c section'. I opted for c section which ended up being right choice because like I said my little guy had HUGE oddly shaped head (would post pic here I knew how..)

I've seen a few babies with heads so large you have to wonder how they even fit in there in the first place! Congrats on your little (big) one.

It is possible to deliver an OP baby lady partslly, but more likely without an epidural. Epidurals contribute to malposition and reduce mom's ability to push and limit the positions she can give birth in so given those to factors in combination with lithotomy pushing you can see why it is often difficult. Both of my babies have been OP and I have been fortunate that they came out without an issue.

I am still learning the art of exams myself. I just check and my preceptor checks. Often I will get something 1 cm off of what she had and I consider that correct even though she doesn't (I just don't think 1 cm is a big deal when two different people are measuring a cervix). Station is my current challenge and what I need to work on.

Strictly on the job practice, with a preceptor checking behind. I mean, there is a board, with the circles for you to feel, but wooden board with a 3cm circular hole is not hte same. It took a while before I felt comfortable with it, probably near a year. One day, i put my hand in and bam, there was the ever mystifying cervix.

10cm was always easier. b/c if you feel baby head and nothing else, its good. My problem previously was not telling how dilated it was, but finding it in the first place! My best tip for finding it is knowing that it is in there, and not giving up until you find it. unless, of course, the pt isn't tolerating it. I used think that if i didnt put my fingers in and find it right away, then i couldn't. I learned they aren't always directly right there. sometimes you have to reach to the side, or the back.

Funny thing is I'm on my break now at 5am and I just now was talking about "station" with one of the new OB residents. I said I was doing ok with cervix's but really wanted to know how to find the point of station. I think it just comes with lots of vag exams. I am about a month off orientation here and feeling just a tad bit stronger each shift I work. I think it will all just come along slowly with time. Keep up the good work!

Wow, I just can't imagine putting my hand up there and knowing what I am feeling :) but I know it is an acquired skill like any other...Thanks for your help!!

Hi, Experience is the best teacher. The more exams you will become proficient That is how we all learned and we continue to learn.

Sure, babies deliver OP - but it is certainly not the optimal position, requiring a larger diameter of the head to pass through the pelvis than if baby is OA. I agree with one of the other replies - sometimes if the Mom does not have an epidural, you can do more with maternal positioning to assist baby to rotate and come down in a better position. I've also had several deliver OP with epidurals with easy descent and very little pushing. So much has do with the size of Mom's pelvis and no amount of pushing, positioning etc is going to get that baby out lady partslly. An hour and a half of pushing, in my opinion, is a pretty long push. Usually, if I've pushed with a patient for more than 30 minutes or so and we're not moving much - if Mom is comfortable and baby looks good, we talk about "laboring down" and letting the contractions do the work for an hour or even sometimes more. I love it! Babies often will come right down, avoiding hours of pushing for Mom resulting in exhaustion and a bottom that is much more swollen and sore after delivery. What about you guys - do you labor patients down often where you work?