Uncomfortable feeling during dilitation check?

[EMJrn]

I am a new grad in ob... If a woman does not have an epidural I feel incredibley uncomfortable doing dilitation checks. The pt usually squirms with discomfort, and it makes me feel bad! Of course I try to be as gentle as one can possibley be, but when they are at a -3/-2 station I have to reach far. Does this feeling go away with time, or how do you cope with it? Am I just being overly sensitive?

[Queen2u]

Hey EMJrn, I worked in Postpartum for 1 year as a new grad and started orientation in L&D officially in about May of this year. I hope I can ease your anxiety by telling you that it will get easier over time! When I first started, I ALWAYS had another more experienced nurse in the room with me to check my checks (ha ha ha) to make sure I was properly assessing my patient's progress. Of corse I would explain things to the patient and introduce the other nurse and all. Now I feel like I am doing well. Yes, every now and then I may have checks where I am not 100% sure what I am feeling, but this may be once every 3-4 weeks, and I would get a more experienced nurse to check behind me. It comes with practice. Hang in there; the anxiety will go away!!!!!

[HazeKomp, BSN, RN]

Early labor/Cervidil placement lady partsl exams are uncomfortable.

The cervix is typically very posterior, up high, and difficult to reach for even nurses with LONG fingers.

There are, however, several things you can do to make it less traumatic for the patient and for you.

First is patient education. Explain why you are doing the exam, that it will be very uncomfortable but you will do your best to do it quickly and as gently as possible. Explain that sometimes medical/nursing procedures require you to be "a good nurse not a nice nurse" and do things that hurt. (another OB example of "good nurse vs nice nurse" is fundal massage after delivery. It hurts but if NOT done, patient may have retained clots and unnecessary heavy blood loss)

Another is developing a rapport with your patient. Do not walk in, announce to your patient your name and that you are going to do a VE that "is gonna hurt" and dive into her lady parts from the door!!! (we have all seen doctors and nurses who use THAT technique!) Help her to relax a bit and get comfortable with your caregiving skills and her environment.

Protect her modesty, minimize her exposure. Many very painful exams are on primigravidas who still are modest. Be sure unnecessary family/visitors/staff exit the room. Be sure the door to the room is closed. Keep her covered as much as possible.

Position her optimally for the exam. I know nurses who have their patients make fists of their hands and have the patient put their fists behind the sacrum to make the exam easier-- I don't like this one personally. On VE where I anticipate the cervix being very posterior and high, like for Cervidil placement or the first VE prior to induction, I prefer a different position. I have them lying flat with the HOB down, pillow under their head is OK but not under their back. I have them bring their knees up, grab their knees and pull their knees back towards their armpits in a curled up position. This tilts their pelvis and makes it easier to reach the cervix. You could almost compare the position to a "McRobert's Maneuver" position. I'm right-handed, so I often push gently on their right foot and have a coach helping them hold their left leg. (By touching their foot, I can feel them starting to move before they kick me, so I have time to get out of the way! hehehe)

Use a lot of lubricant. (lady partss are best visited when moist)

Go in very slowly. First touch the perineum and wait a second to let them adapt to the initial touch. Then slowly enter the introitus and stop again to allow time for them to adapt and cope. Then do what you have to do, reach the cervix, and get the heck outta there!

Have a washcloth ready to wipe her perineum afterwards. No one likes that post-GYN-visit K-Y jelly slime left on them! Cover her up. Apologize if it was traumatic/uncomfortable. Tell her she did a good job getting through the difficult exam. and position her for comfort afterwards.

I hope this will help you.

Again, many times in L&D, and in nursing in general, one must choose to be a GOOD nurse not a NICE, gentle, "oh, poor baby" wimpy nurse!

L&D nurse of many, many years who still loves her job and her patients,

Haze

[HazeKomp, BSN, RN]

And kudos to the patient-advocate nurses

who refuse to check patients

just because the clock says it has been two hours!!

If they are early in an induction and not contracting well, why check them?

If they have prolonged ruptured membranes, minimize lady partsl exams!

If the doctor insists on an unnecessary exam, I chart it as an order on his/her order sheet, chart it in the record as a VE ordered by the MD, and tell the patient the VE is one ordered by the MD! (I know, sorta ****** of me I suppose)

I started in L&D with a group of midwives and OBs who were trained where they were only allowed FIVE lady partsl exams of a patient in the entire labor! Those folks were very, very conservative about doing exams, saving them for time when the info is more important.

With induction patients, when I am left on my own to decide, typically I do a VE on arrival, prior to IV pain meds, after epidural placement, and every 2-3 hours in active labor, and as needed during transition. In the early stages of an induction I will go hours & hours without doing a VE, if the contractions are mild or irregular or the patient is only cramping.

Patients sometimes ask "Aren't you gonna check me soon?" I tell them I do VE upon MD order, upon medically indications like before pain meds or with decelerations, or as appropriate for their stage of labor.

(IF I have a good rapport with them, and they are already used to my somewhat perverted* sense of humor, I'll tell them I won't check them to satisfy THEIR curiosity or their mother's curiosity about their labor progress!)

Haze

*perverted sense of humor: after 30 years in lady partss, I can get a little silly and twisted in my language. Example: trying to get a patient to get their knees apart to let me do a lady partsl exam "Honey, you've gotta get those legs apart like you did when you GOT pregnant!" Perhaps not ideally professional, but sometimes humor works best with some patients!)

[nurselinds86]

I have this same problem and my issue is that I work nights and do alot of cytotec inductions where I MUST reach their cervix to place the cytotec even if it is super posterior and high. I always feel bad and wonder if I am hurting them more than the previous nurse did or something.

[Nurse2b7337]

Shark diver I have had four children and no one ever told me I could refuse a lady partsl check. Wow! I'm not sure I would have agreed to that but it just sounds good. I would have wanted them to check to make sure my baby was doing alright. My goodness is it ever uncomfortable.

[kmarie724]

Regarding cervical checks...I think they are important tools when a woman is induced and/or has an epidural. But for those who are not having either, then they need not be subjected to them and instead their emotional signposts can be used to determine how far along she is progressing in her labor. This is just my own opinion though.

I'm not an OB nurse, but as a patient, I tend to agree. When I had my first baby, cervical checks left me feeling upset and discouraged because I wasn't progressing as quickly as I thought I should be.

With my second baby, my plan was to labor at home as long as possible, have a cervical check when they did my initial assessment and refuse any further until I felt the urge to push or felt I wanted/needed one for some other reason. But I arrived at the hospital complete and ready to push, so there was no need for any further cervical checks after the first one.

[somedayCNM, CNM]

Explain that sometimes medical/nursing procedures require you to be "a good nurse not a nice nurse" and do things that hurt. (another OB example of "good nurse vs nice nurse" is fundal massage after delivery. It hurts but if NOT done, patient may have retained clots and unnecessary heavy blood loss)

THANK YOU! This is a revelation. I'm still orienting in labor and delivery and have been trying to figure out how to explain to my patients that certain procedures are unpleasant, but have to be done. Thanks for the tip!

[NurseNora, BSN, RN]

When doing Pit inductions, I do the initial exam, then pit the patient in a recliner or rocking chair. I give her permission to refuse an ordered exam if she is still talking thru contractions. I explain the labor curve to her before any subsequent exams and emphasize ( before the exam) that a change from 1 to 2 cm is much more significant than it sounds and that effacement is as important as dilation in the earliest phase of labor.My explanation is that the job of the cervix for nine months is to keep the baby in, so it's not just going to pop open because we (rather than her body) decided that the baby should be born today.