Patients without vaginal bleeding should be examined both bimanually and with a sterile speculum. Patients presenting with vaginal bleeding should initially be evaluated with ultrasound prior to any speculum or bimanual examination to rule out placenta previa (see below). 1 If ultrasound is not available for an actively bleeding patient in labor, careful examination with sterile speculum may be performed to estimate the degree of cervical dilatation. However, no digital exam should be performed, and emergent obstetric consultation should be obtained. If spontaneous rupture of membranes (SROM) is suspected, examination with a sterile speculum should be performed and digital exam avoided, as studies have shown an increased risk of infection after a single digital examination. 2 It is particularly important to avoid digital examinations in the preterm patient where prolongation of gestation is desired. Sterile speculum examination allows confirmation of SROM, visualization of the cervix as well as estimation of dilatation and collection of cervical cultures, particularly group B streptococcus, Neisseria gonorrhoeae and Chlamydia. For pelvic examination, the lithotomy position is typically used. Stirrups are not necessary, although they are helpful. Alternatively, a bedpan may be employed to elevate the patients buttocks enough to allow speculum examination. Lubricant should be avoided unless rupture of membranes has been confirmed, as lubricant may produce a false-positive nitrazine test.
The abdomen should be inspected and palpated to determine fundal height. The cervix is then examined to determine effacement, dilatation, and station. Effacement of the cervix is the process of thinning that occurs during labor. Effacement has conventionally been described in terms of a percentage of normal cervical length. This method is confusing and has poor interrater reliability. More recently, the preferred method is to describe the degree of effacement in terms of actual length of remaining cervix in centimeters. Cervical dilatation describes the diameter of the cervical os and is an indicator of the progression of labor. The index and middle finger of the examining hand are used to determine the diameter, expressed in centimeters (fingertip to 10 cm); 10 cm indicates full dilatation. The station indicates the level that the fetus occupies in the pelvis, with the reference point being the maternal ischial spines, palpable on either side of the vaginal canal at about 4 and 8 o'clock. If the fetus remains above the ischial spines, the station is described as negative. Once the fetal head has reached the level of the ischial spines, the station is zero, with further descent into the pelvis described as +1 or +2. A +3 station corresponds to visible scalp at the introitus, indicating a fetal position consistent with impending delivery.
Both digital exam and Leopold maneuvers provide information about the presentation of the child and can indicate a potential breech presentation or cord prolapse. Leopold maneuvers involve the palpation of the fetus through the maternal abdomen to determine fetal position and presentation. Such maneuvers are relatively unreliable in inexperienced hands. A pregnant woman should not be kept flat on her back for a prolonged period of time, since compression of venous return by the gravid uterus can lead to maternal hypotension and fetal hypoperfusion. After examination, the patient should be placed in the left lateral position.
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