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INDEX
1. Purpose
2. Aims
4. Rationale
6. Use of Chaperones
9. Infection Prevention
13. Communication
14. References
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1.0 Purpose
1.1 The purpose of this document is to provide guidelines for the procedures to be
followed when undertaking a vaginal examination (VE).
2.0 Aims
2.1 To provide guidance on vaginal examinations, ensuring privacy and dignity for all
women
3.1 Mid Essex Hospital Services NHS Trust is committed to the provision of a service that
is fair, accessible and meets the needs of all individuals.
4.0 Rationale
4.1 VE (vaginal examination) is a tool to assess the cervix’s favourability for induction or to
confirm the progress of labour by assessing the cervical effacement and dilatation; it
should only be carried out if it will benefit the woman’s management and care.
• Be sure that the examination is necessary and will add important information to the
decision-making process
• Recognise that a vaginal examination can be distressing for woman, especially if
she is already in pain, highly anxious and in an unfamiliar environment
• Explain the reason for the examination
• Ensure the woman’s informed consent, privacy, dignity and comfort
• Explain sensitively the findings of the examination and any impact on the birth plan
to the woman and her birth companion (s)
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5.0 Obtaining Consent for the Vaginal Examination
(Refer to the policy entitled ‘Consent Policy’; register number 04080)
5.1 Valid informed consent must be obtained from the patient before undertaking a
vaginal examination and a clear rationale for the procedure given.
5.2 Consent may be given in writing, verbally or may be implied by the co-operation of the
patient. The practitioner must ensure the woman is legally competent to consent.
5.3 The person completing the VE must be aware that consent may be withdrawn at any
time during the procedure, and therefore examination must stop immediately.
7.5 The patient should be encouraged to empty their bladder to reduce discomfort.
Catheterisation may be necessary.
7.6 The Midwife should ensure that a supply of entonox is available for the patient’s use
should they require it.
7.7 The woman should adopt a semi recumbent position, with her knees bent, ankles
together and knees parted.
7.8 Gently insert the first two fingers of the examining hand into the vagina, in a downward
and backwards direction along the anterior vaginal wall to locate the cervix.
7.9 During the examination:
• Discussion should be relevant and free of unnecessary comments
• The patient’s privacy and dignity should continue to be respected
• Attention should be paid to verbal and non-verbal indications of distress from the
patient
7.10 A full explanation of the results of the VE shall be provided to the patient in a sensitive
manor and documented within the handheld records using a vaginal examination
sticker (Refer to appendix A)
7.11 It is mandatory to comment on each of the following areas during the examination and
must be commented on as follows:
• External genitalia - any abnormalities such as varicosities, oedema, piercings,
warts or signs of infection should be noted
• Vagina - the vagina should feel warm and moist; a full rectum may be felt during
the examination and should be commented upon
• Cervix- Dilatation should be documented in centimetres (cm) and be
documented as one figure i.e. 5cm
• Effacement - is assessed by the length of the cervix and degree to which it
protrudes into the vagina
• Position - should be described as posterior, central or anterior
• Consistency- firm, medium or soft
• Presentation - the identification of landmarks on the presenting part help to
confirm presentation. A pictorial diagram is recommended to evidence the fetal
position. It should be noted how well the presenting part is applied to the cervix
and if the presence of a cord or membranes are felt.
• Station - this is the distance between the presenting part and the ischial spines
in cm. Above the spines will be (–cm) and below the spines should be referred to
as (+cm)
• Vaginal Loss – Show, blood, liquor including amount and colour using the
following definitions ( Intact , clear, thin meconium stained, thick meconium
stained, offensive, absence of liquor
• Caput - This should be circled: Present or not present
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• Molding -These will be circled upon completion of the vaginal examination and
are referenced as follows:
i. 0 = Separated bones, sutures felt easily
ii. + = Bones just touching each other
iii. ++ = Overlapping bones, reducible
iv. +++ = Severely overlapping bones, non-reducible
7.12 The midwife should auscultate the fetal heart with a pinard or sonic-aid and this should
be performed pre and post VE.
7.13 If the patient is in established labour the findings should be charted on the partogram.
(Refer to the guideline entitled ‘Completion of the partogram in pregnancy’; register
number 09046)
7.14 Vaginal examinations should not be carried out in:
• Patients with ruptured membranes who are not in established labour
• Presence of active herpes in a patient with ruptured membranes unless the
patient is in labour
• Unknown placental localisation
• Placenta praevia
• Preterm under 37/52 and midwives
11.1 Audit of compliance with this guideline will be considered on an annual audit basis in
accordance with the Clinical Audit Strategy and Policy (register number 08076), the
Corporate Clinical Audit and Quality Improvement Project Plan and the Maternity
annual audit work plan; to encompass national and local audit and clinical governance
identifying key harm themes. The Women’s and Children’s Clinical Audit Group will
identify a lead for the audit.
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11.2 The findings of the audit will be reported to and approved by the Multi-disciplinary Risk
Management Group (MRMG) and an action plan with named leads and timescales will
be developed to address any identified deficiencies. Performance against the action
plan will be monitored by this group at subsequent meetings.
11.3 The audit report will be reported to the monthly Directorate Governance
Meeting (DGM) and significant concerns relating to compliance will be entered on the
local Risk Assurance Framework.
11.4 Key findings and learning points from the audit will be submitted to the Clinical
Governance Group within the integrated learning report.
11.5 Key findings and learning points will be disseminated to relevant staff.
12.1 As an integral part of the knowledge, skills framework, staff are appraised annually to
ensure competency in computer skills and the ability to access the current approved
guidelines via the Trust’s intranet site.
12.2 Quarterly memos are sent to line managers to disseminate to their staff the most
currently approved guidelines available via the intranet and clinical guideline folders,
located in each designated clinical area.
12.3 Guideline monitors have been nominated to each clinical area to ensure a system
whereby obsolete guidelines are archived and newly approved guidelines are now
downloaded from the intranet and filed appropriately in the guideline folders. ‘Spot
checks’ are performed on all clinical guidelines quarterly.
12.4 Quarterly Clinical Practices group meetings are held to discuss ‘guidelines’. During this
meeting the practice development midwife can highlight any areas for future training
needs will be met using methods such as ‘workshops’ or to be included in future ‘skills
and drills’ mandatory training sessions.
13.0 Communication
13.1 A quarterly ‘maternity newsletter’ is issued to all staff to highlight key changes in clinical
practice, to include a list of newly approved guidelines for staff to acknowledge and
familiarise themselves with and practice accordingly. Midwives that are on maternity
leave or ‘bank’ staff have letters sent to their home address update them on current
clinical changes.
13.2 Approved guidelines are published monthly in the Trust’s Staff Focus that is sent via
email to all staff.
13.3 Approved guidelines will be disseminated to appropriate staff quarterly via email.
13.4 Regular memos are posted on the guideline and audit notice boards in each clinical
area to notify staff of the latest revised guidelines and how to access guidelines via the
intranet or clinical guideline folders.
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14.0 References
National Institute for Health and Clinical Excellence (2008) Antenatal care.
Routine care for the healthy pregnant woman. NICE: London
The Fraser Guidelines. 1985. Gillick v West Norfolk & Wisbech Area Health
Authority (1985)
Available at : http://www.bailii.org/uk/cases/UKHL/1985/7.html