Assisted Birth Practitioner (ABP) Midwife - Speculum Examination and Vaginal Assessment between 34 and 36+6 weeks’ gestation

Introduction

Speculum examination of women at <37 weeks’ gestation may be indicated if women present with vaginal bleeding (spotting), abdominal pain, spontaneous rupture of membranes or threatened pre-term labour.

Inform the on-call Registrar of the admission and discuss the proposed management plan including whether it is appropriate for a midwife to perform the speculum.

If agreed a speculum is required and for this patient a midwife can perform this, then midwives who have received appropriate training may carry out this procedure.

Purpose

Speculum examination allows for the inspection of the following: -

• Cervical changes when vaginal examination is otherwise contraindicated
• Assessment of membrane status – confirm rupture of membranes
• Collection of laboratory specimens, high vaginal swab, performing AmniSure or Actim Partus test.

Training

The midwife will be supervised undertaking 2 speculum examinations by the Registrar or Consultant and will complete a Direct Observation of Procedural skill form which should be retained in the midwife’s personal log.

Contraindications to speculum examination

Placenta Praevia - speculum examination should not be carried out where placenta praevia is suspected. Check USS report and note position of placenta prior to carrying out procedure.

Procedure

• Explain the procedure and assure patient privacy.
• Ensure Chaperone present.

 Verbal consent should be sought from the woman and documented in the notes.

• Ask the woman to empty her bladder.
• Position the light source so that the perineum is well lit.
• Ask woman to lie on the bed, place feet apart, draw knees up and allow knees to abduct moderately.
• Wear sterile gloves, use of sterile procedure is important if suspected rupture of membranes.
• Hold speculum with dominant hand, separate the labia and expose the introitus with non-dominant hand.
• Inform patient that you are about to introduce the speculum. If the woman becomes upset or tense during the examination stop the procedure and attempt again when relaxed.
• Slide closed blades obliquely over the fingers into the introitus, introduce instrument into the vagina. Lubricant gel should be used except when fetal fibronectin (fFN) testing will be undertaken. Water based lubricant can be used with Amnisure.
• While inserting the instrument rotate into a clockwise direction until the anterior and posterior blades run along the anterior and posterior vaginal walls with the handles pointing towards the anus or clitoris.
• Maintain a downward pressure on the speculum and press on the thumb piece to hinge the blades open to expose the vaginal vault and cervix.
• If necessary, ask assistant to adjust the light source to illuminate the vagina.
• Inspect the vagina and cervix.
• Note discharge – normal vaginal discharge is clear/milky and this can be increased during pregnancy.
• Curd like white thick discharge may indicate candida and is associated with pain, itching and swelling.
• Observe for signs of abnormalities such as polyps, ulceration, and ectropion.
• If suspected pre-term labour and, if criteria are reached, carry out Actim Partus test.
• If suspected rupture of membranes, ask the woman to cough and look for evidence of liquor trickling through cervix. If membranes have ruptured fluid will be seen coming through the cervical opening, note the colour of liquor. If unsure of rupture of membranes perform an AmniSure test.
• Obtain high vaginal swab if indicated.
• Remove speculum gently allowing blades to close near the introitus, taking care not to pinch the vaginal walls or labia while withdrawing the speculum.
• If no evidence of rupture of membranes, a vaginal examination may be indicated.

Caution

If at any time during the speculum examination the membranes are visualized hour glassing into the vagina or the vaginal vault fills up with blood immediately discontinue the speculum examination.  This will prevent inadvertent rupture of the membranes; refer immediately to the registrar/consultant.

Post Procedure

Document findings, detail action plan in notes and discuss with Registrar.