Checking patients

SmilingBluEyes · Dec 6, 2004

I found it easier to "practice" on anesthesized women-----it does not bother them for you to reach all around and feel until you get it. In any check, I lay the woman's head of her bed as low as possible, and then have her put her hands under her hips to elevate the pelvis a bit. I ask her to put her feet together and knees apart to open up her pelvis maximally to allow for room to check. These things go a LONG way toward making even a high and posterior cervix more reachable.

When going in, remember to guide your fingers toward the small of the woman's back, feeling along the posterior wall of her lady parts, while ascending to find the cervical os. This really is is the best way to find a posterior cervix. Sometimes, the baby's presening part may be IN FRONT of the cervix, so you may have to go behind this to find the os. I have had babies' heads be zero or plus one station and had to actually go

Once in the most posterior and high point of the woman (her posterior fornix), move forward with your fingers til you locate the os. Once there, feel for a presenting part and also spread your fingers til you feel the entire circumference of her cervical dilatation, rotating your fingers until you have felt all around the entire cervix.

Your preceptor is right, you will "get" it at some point. It just takes lots of practice, patience and persistence. I recommend you check a person and then have your preceptor or another seasoned nurse check behind you to verify what you feel. Again, this is done well on women who have epidural anesthesia in place as it's less distressing for them.

I have to also give you one more caution: Be careful checking women whose membranes are ruptured too often. They are at risk for infection and therefore, SVE's must be limited in order to avoid these infections. Much more preferable to "practice" on women whose membranes are intact.

Good luck, be patient with yourself and have faith. You WILL get it, it just takes time and practice. HUGS!

Dayray, RN · Dec 6, 2004

Hi Melissa, welcome to OB.

Some tips from another short fingered nurse (mine are fat too).

1. Have your patient make fists and put them under their hips, this tips the cervix forward and makes it easier to reach.

2. Make sure they have their knees bent up allot and open as much as possible, every patient is different but you might even try having them put the soles of their feet together with their knees bent.

3. Get them as relaxed as possible, have them breath several deep slow breaths before you check them.

4. You can tell them to open their mouth and relax their jaw muscles, muscles in perineum naturally relax if the mouth muscles relax ( you can try this out your self, you cant tighten your muscles in your perineum if your mouth is relaxed.) The less tightening they do the easier it is to reach the cervix.

5. go under those folds you are feeling, the cervix is under or behind them.

6. If your patient has an epidural take the time to do a long exam and make sure you find the cervix, this takes the pressure off you because it wont hurt them

7. cervical exams hurt and as much as we hate hurting patient, no matter how good you are they are never going to be completely comfortable with them. I compare them to Iv starts (I know thats a bad compression but bear with me). I used to suck at Iv's but I would only try once and then call someone else because I hated hurting people. I got much better when I made myself start poking them twice because There was no way I was going to hurt twice for no reason. Now I get 99.9% of my Iv's in 1 quick stick. To get good at cervical exams you have to accept that they are going to hurt. You can motivate yourself to learn quickly by telling your self that it is much better for you to get it right the first time and not have to have your preceptor check after you.

8 (final one0 Relax) cervical exams can really stress new nurses out but they really aren't as important as we pretend they are. If you call someone 3 and they are really 2 or 4 who cares? now calling someone complete when they aren't could be bad but thats kinda hard to miss. If a patient is in active labor your going to know it by the way they act and their contx so cervical exams are the last in a long line of assessments. You are going to have a few embarrassing situations where you are completely wrong but you aren't going to hurt your patient by being wrong you'll just have to eat some humble pie when you tell them you were wrong but its no big deal we have all done it.

SheaTab · Dec 6, 2004

Oh my, Checking the cervix! I have been working L&D for a year now and am just now starting to feel about 85% confident with my exams. Dilation will probably be the first thing that comes to you.... then station... I'm not even sure if I will ever feel 100% sure about effacement. The fact is, it is just difficult to gauge thinning when you are not sure where the woman started in the first place. I typically ask the patient what she was the last time she was in the office... assumming the MD is better at effacement than me! I saw a nurse put 10% effaced on her exam the other day and I wondered if anyone can really tell 10%! That being said, vag exams are very subjective. Sometimes you will have an MD come behind you and give a totally different exam which is very frustrating. There is one where I work that will always be much smaller and generally is doing it so she can justify a c-section (ftp)! HATE that! Not to mention the fact that it can really make you feel like a completely incompetent nurse in front of your patients. You will get better and better at it as you do more exams. After you are done examining a patient, show your preceptor what you got with your fingers, tell her what you think it is... and then ask her to do the same. You can also measure your fingers with a ruler to get a good idea of what your fingers are. Like for example: My two fingers together are 3.5 cms. If I can get them in then that is my exam. If my fingers overlap a bit, they are three. If I can get one finger in, then one. If I can get two fingers in and move around a bit, then four. If I can spread my fingers all the way open, then seven. After that, I start measuring the amount of cervix left... Like.. move your fingers to the lady partsl wall, then approximate over to the rim of the cervix until you reach the baby's head. 1-2 cms, 8 or 9. If I have a very slight rim/ or a lip, then 9.5. Everybody really has their own way of doing it so I assume there is not an exact science. But, your exams should be very close to everyone elses because two cms really is 2 cms!

As far as finding the cervix??? I have short fingers too and this can be a challenge with OB. But, I will tell you something. When I first started, I met a couple of cervixes (Cervi?? :roll ) that I couldn't find... Now I will find it... high or low! The most difficult cervix to find for me is one that is very posterior. Like one I had last night... baby was at 0 station and cervix was hiding way behind head at 3.5 cm (at like -4 station! :lol2: ). I always apologize to the patient when I know I will have to reach a bit. Make sure the head of the bed is all the way down because it will help you reach better. Then, when you are in the lady parts, find what you know. Feel for landmarks. If you can feel the baby's head but no cervix, slide your fingers posteriorly until you feel it. It's there, somewhere! If a patient is 100% effaced it cam sometimes be difficult to feel where the cervix starts. I generally go to the baby's head and then gently slide my fingers back and forth until I feel a slight ridge. Or you can move to the posterior fornix and then come forward until you reach the end of the cervix and feel baby's head. Let us know how things go for you. You are going to love OB nursing. There is such a tremendous opportunity to touch so many lives. I am totally blessed each and every time I share the birth of a baby with a family.