Vaginal Exams (How Often?)

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As a new practicing nurse I am trying to put learning into practice. Everything that I have read tells me that numerous lady partsl exams are not neccessary and can indeed be dangerous....especially to a pt who is ruptured. I would like to be able to pay attention to a woman's body and outward signs that she is prgressing and keep lady partsl exams to minimum.

Most of our docs like their patients checked q2 hrs. I am somewhat OK with this but will usually stretch this to 2.5-3 hrs for the ruptured pt. However, the chief of OB at our hospital is an ex military doc who insists that all of his pts. be checked every hour ruptured or not. He is VERY quick to cut for failure to progress and very pt UNFRIENDLY.

OK fine..... put here is my problem..... the other night my charge nurse was telling me of this doctors preference. I told her that I didn't agree with it and that it was not in the orders. She said "well it's gonna be you who's gonna get chewed out" I said Yeah and it's also me whose name is signing that chart that I checked this patient every hour for no reason and without an order."

She said, "well nothing like that would ever go to court". I said, "If this lady gets an infection and something happens to her or her baby it could very well go to court. I will be happy to check her every hour if there is an order but otherwise I don't feel comfortable doing that"..... Luckily this lady progressed quickly and it wasn't an issue..... but what do you guys do? Is there a policy in place where you guys are?

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We don't have a policy per se on SVEs, but at our hospital the residents do them. Q1 hour seems excessive to me, especially for primips who are ruptured because the risk of infection increases witheach exam. How discouraging for patients who hear a few hours in a row, "You're still 3-4". Just my opinion. It's not like someone is going to get to complete and you're going to miss it, ya know. They're going to let you when they've got rectal pressure!! I can see more frequent exams if it's been hours and you're thinking of starting pit/pt wants an epi or special circumstances where you need to know she's making good progress. If that doc wants you to check her cervix every hour, then ask him to write it or tell him you'd be happy to take it as a verbal order! Sounds like maybe he ought to retire!

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

LESS IS BETTER, especially after membranes are ruptured.

I only check if maternal and/or fetal changes in condition indicate it.

Got to keep infection rates down. Not to mention, cervical checks can be so UNCOMFORTABLE for the MOMS; they are NOT science projects , yanno.:)

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I had my last child in the "big city" because I was too shy to have him where I work. ;) Anyway, the nurses didn't check me at all, not even for a first nursing assessment. I had been leaking green amniotic fluid, so I sorta understood BUT I wanted to know where I was. The docs were against checking patients very often.

I finally talked the nurse into checking me and I promised not to tell the doc. I was 2 cm. Boo hoo.

We don't have a real policy for how often to check either. Obviously the less the better and we just watch for signs. But sometimes I've been surprised and that is a little scary.

Is there really an increased risk of infection from vag checks? Is there research or is this just a "gut feeling"? It is afterall her own germs.

Q1H seems pretty excessive even to me.

steph

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There is research to support limited vag exams. You are basically pushing up any normal lady partsl flora each time you do it, and they are uncomfortable generally. Q2 seems excessive to me, and Q1 seems sick. If there are no changes in mom or babe, why do I need to keep sticking my hand up her lady parts?

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
Originally posted by fergus51

There is research to support limited vag exams. You are basically pushing up any normal lady partsl flora each time you do it, and they are uncomfortable generally. Q2 seems excessive to me, and Q1 seems sick. If there are no changes in mom or babe, why do I need to keep sticking my hand up her lady parts?

exactly. I read a study (wish I could remember which) that gave a round number of "SIX" lady partsl checks, average, before infection chances increase.

think about it, her flora or not, you are pushing these things up where they may NOT be fetus-friendly, where they will multiply.......not to mention nosociomial germs that MAY be around, despite sterile gloves.

it makes sense to SERIOUSLY limit vag checks to what is vital.

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However, the chief of OB at our hospital is an ex military doc who insists that all of his pts. be checked every hour ruptured or not. He is VERY quick to cut for failure to progress and very pt UNFRIENDLY.

:rolleyes:

Gave birth to my children in a military hospital. Yeah, sounds like a typically regimental military OB. What a cold and very impersonal experience. I don't even know the name of the doctor who delivered my first child. Don't think I ever saw his face except in the delivery room.

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We don't have a policy but we try to watch mom and baby for signs that progress is being made. We do have a few doctors that will call every few hours to find out their progress and will have expected us to have checked them. We avoid checking on ruptured patients.

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I only check on initial assessment (if she came in for labor, not for inductions ect.) then again in 1-2 hours to make sure she is in labor. then I only check if the pt asks for pain meds. has an urge to push or if there are changes in the FHR. For an insuction pt I dont do an initial check at all.

The OP stated that she would check Q1H if MD ordered, but as a nurse you have the responsibility to determine if the MDs orders are appropriate right? I am thinking that if you go ahead and check her Q1H and the pt gets an infection its not gonna stand up in court that you were following doctors orders. What does everyone else think?

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It depends on the situation,

As I said in another post, many of our patients are induced. If its prostin/cytotec induction then we are kind of stuck checking them every 3 hours. If its someone who is on pit q 3- 4. Natural patients really only need to be checked when they have the urge (unless there is some reason to suspect stalled labor or other problems)

All that being said I usually end up checking more often at the request of the doc (not q 1 hr I would refuse to do that).

I did allot of thinking about this issue when I first started working L&D. Vag exams do nothing for the patient and in a natural delivery wouldn't be needed at all. However, hospital deliveries are not natural. For patients who are induced/augmented aggressively and have an epidural it's a little harder to manage that induction/augmentation because the patient cant tell you what they are feeling and the normal cues aren't there to predict dilation/position without an exam. For patients getting IV meds I always check to make sure I'm not giving pain meds to a baby thats going to be born soon.

So my advise is before you do an exam, ask yourself if the exam will have any bearing on your care, will it cause you to increase or not increase pitocin? will it effect how you position the patient? do you think they are complete? has this patient not changed in 3 hours? Are you about to give pain meds that will cause problems if the baby is born in an hour? If it won't change how you are caring for the patient don't do it, if it will change it then information is probably worth the small but very real risk of infection.

Now as for this q 1 hr nonsense, Id tell him to come do it himself and ask him how it benefits the patient to have vag checks q 1 hr. I could imagine situations where q 1 hr vag checks might be necessary but certainly not with every patient. Your not wrong for questioning this policy of his and you are within your scope as the patient advocate to ask him to explain. He wont like it but you don't work for him. I can understand when a doctor calls in and asks what a patients cervix is so they can make sure they arrange there schedule to be there on time but q 1hr is absurd. I doubt he would cut a patient for falling off the curve for only 1 hour and if he does then there are deeper problems then this.

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Originally posted by Dayray

I doubt he would cut a patient for falling off the curve for only 1 hour and if he does then there are deeper problems then this.

You are wrong about this...... the other day we had an induction.... started on pit about 0630. At 1500 she had progressed to 8 and 1600 she was still an 8 so she was cut 1630. Baby was 9lbs + so it was hypothesized by the nurses that it was probably ok because she wouldn't have delivered anyway.

I think it was because it was his night on call and he wanted to go home......:rolleyes:

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Originally posted by fourbirds4me

You are wrong about this...... the other day we had an induction.... started on pit about 0630. At 1500 she had progressed to 8 and 1600 she was still an 8 so she was cut 1630. Baby was 9lbs + so it was hypothesized by the nurses that it was probably ok because she wouldn't have delivered anyway.

I think it was because it was his night on call and he wanted to go home......:rolleyes:

That is horrid. We have had pts sit at 8 or 9 cms for HOURS. And like 10 lb babies aren't delivered lady partslly?

I think your theory is right. I would hate to have to work with that doc.

As far as VE's, we do very little. There's definitely not a timetable. If meds or an epidural are asked for, if Mom is c/o feeling pushy or lots of pressure, or if varaibles are noted on EFM. Otherwise, I prefer not to do them.

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