incompetent with vaginal exams

[sarcopenia]

Greetings,

I have perused these forums for quite awhile, but have never posted, partly out of fear of redundancy.

I have tried searching for this information (in my text books, on-line, on this site), but have been unsuccessful.

***

I am a first year family medicine resident in Canada. My program has limited Obs/Gyn experience (1-2 months out of a 24-month residency).

I'm midway through my Obs month, and it is an incredibly disheartening experience.

My knowledge base seems adequate, and I have done about 20 deliveries reasonably well. I've achieved some level of competence at repairing tears / episiotomies, although some of the grade III/IV's still look like "a bloody mess" to me, and I usually still ask the consultant to hang around to guide me through the mucosal suturing ... the whole "find the apex" and identifying the hymenal ring and whatnot is a little challenging for me, especially if the patient is still bleeding a fair bit.

My most glaring inadequacy is vaginal exams / cervical checks. Even in non-pregnant women, I'm barely passable. I'm pretty sure I can evaluate whether there is cervical motion tenderness, or if there is a baseball sized ovarian mass, but that's about it.

I can't even really blame anybody else. Although the first week was a bit rocky, now that the nurses know me, everyone on the L&D unit is very receptive to my involvement (I'm a male, and many of the patients in this region are Muslim, so that is a bit of a barrier).

The problem is, I don't even know where I'm feeling / what I'm feeling. The consultant will ask: position ? (anterior / mid / posterior), dilation in cm?, effacement %, etc...and I'm like, "Uhh, sorry, I'm not sure..."

All I feel when I do the exam is a giant, hard sphere, which I'm assuming is the baby's head inside of the stretched out uterus / cervical segment. I keep poking around for some kind of "slit" to try and stick a finger(s) into and don't find anything. I don't want to subject the patient to any unnecessary discomfort, so I try to make my exam only about 10 - 15 seconds (which is about how long the nurses and consultants seem to take). Occasionally, I'll feel what I assume are bulging membranes, but this makes it even harder to assess, because I can't really feel past / around the bulge.

***

My future scope of practice is likely to be un-obstetrical in nature (thank goodness for those patients), as my interest is more toward emergency medicine and sports medicine / MSk. However, I do feel the need to be at least reasonably skilful in all aspects of family medicine care.

I realize that my lack of ability is embarrassing in its degree, and I won't blame anybody for laughing at me and/or openly ridiculing me...

However, if anybody has any advice for how I can rectify this situation, it would be much appreciated.

When I try asking for specific advice from the Obs/Gyn consultants, etc., they just smile encouragingly (patronizingly?) and say that it'll come with practice. I have tried to look for how-to's / guides / videos on-line, but they all seem oriented toward patients in terms of letting them to know "what to expect." My obstetrics textbook "Current Obstetric & Gynecologic Diagnosis & Treatment 9th Ed" (Lange series) by DeCherney and Nathan is not helpful in this regard.

Thanks in advance for any assistance. I apologize for the length of the message ... I think I just needed to emphasize how much I suck ... and how bad this is as a family doctor in training (i.e. it's not realistic for me to think that I can completely ignore pelvic exams for the rest of my career).

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[deleted87716]

It just takes a lot of practice. Have somebody who knows what they're doing check after you and confirm what you think you're feeling. That'll help.

Effacement (the thickness of the cervix) in particular takes a lot of practice, and is basically an estimate, in percentages. Dilation is simply how may fingers (each finger is roughly 1cm) you can fit into the cervix.

I haven't done OB in years, so I'm not really the best one to answer this.

 

[Leukocyte]

I tell the patient to put her arms behind her butt while lying supine. I then tell her to open her legs wide, placing the sole of her feet together like a butterfly. I then put on VERY THIN gloves, one size smaller than my regular glove size. If I am a 71/2, I use the thinnist 7 or even 61/2 size glove available (I want my fingertips clear of any "extra latex"). I then stand on the patient's left side, putting 2 fingers of my RIGHT hand in the vagina while putting slight downward pressure on the uterine fundus with the LEFT hand. I then go as far as I can posteriorly with my 2 vaginal fingers, and try to "scoop" a cervix. If the cervix is short and effaced, then I TAKE MY TIME to feel for a cervical margin or lip. I then feel along that cervical margin, and estimate the dialation.

It is tricky, and requires LOTS of practice. Do not be afraid to take your time while in the vagina. Yes, I know it is awkward, but you are new at this, and it must be done.

Good Luck.

 

[Leukocyte]

One more thing. The vagina is a scary empty space. But it is an enclosed scary empty space. You can easily get lost in there, if you do not have a reference point. So, do not just shove 2 fingers in there blindly...you will get lost in there. If you do that, everything will feel like "minced meat" to you.

This is what I do. When I put my 2 fingers in, I make sure I always have a reference point. Mine is the posterior vaginal wall. When I enter, I keep my 2 fingers pressed against the posterior vaginal wall ALL THE TIME until I find the cervix, which I MUST reach eventially if I keep draging my 2 fingers along the posterior vaginal wall AS FAR POTERIORLY AS POSSIBLE.

 

[UCFMOP]

*snicker snicker*...Vagina...

 

[sarcopenia]

...for the tips.

I will definitely try that "posterior landmark" approach. I almost wish I could pay somebody to let me practice on them in a low stress environment ... but given the nature of the exam, it borders on prostitution, so I'll have to pass on that idea.



Although, strangely enough, at some medical schools (mine included as of a few years ago), they actually DO pay women from the community to be standardized patients for breast and pelvic exams. People thought it was "perfectly normal" but I always thought it kind of strange. (Like would you want your Mom ... or Aunt ... or other relative ... to do that as some kind of part-time job?!)

***

Thanks again.

 

[iatrosB]

(i.e. it's not realistic for me to think that I can completely ignore pelvic exams for the rest of my career).

Why not, I plan too.

 

[ici_cute]

This is what I do. When I put my 2 fingers in, I make sure I always have a reference point. Mine is the posterior vaginal wall.

Yup, I remember doing that when I was a houseman. I was stationed for 2 months in labour ward. It seemed that I was 'picked' to be a senior in the labour ward, thus the long stay, therefore the responsibilities of teaching the new HO who just joined. I also taught a couple of my FP resident who was doing Obs rotation.

When I started out, I made sure I did the abdominal and VE first, then my resident will do and confirm it. I even had a great time 'guessing' estimated birth weight via physical examination, and confirmed it when my resident does a bedside pelvic ultrasound.

Oh how I missed delivering babies!

 

[Farmer Jane]

Also, make sure you keep your two fingers together until you're positive you have found the cervical opening. Especially when the cervix is effaced but not very dilated, it is very easy to slide right over the cervical opening if you let your fingers spread apart. Follow the posterior wall, locate the cervical opening, and THEN determine dilation.

 

[periopdoc]

A couple of tips that I hope will help. This is an inherently uncomfortable exam for both participants and there is nothing you can do to eliminate the sexual nature of the interaction except to keep a professional attitude. Do everything you can to minimize the discomfort for both of you.

1 - an experienced examiner will take 10-15 seconds to do an adequate exam on a textbook cervix. Tougher cervixes will take longer. As a beginner even a perfect cervix will take some time. Please do not try to rush and do it in the same time as your seniors it will only be more uncomfortable for the woman and therefore more difficult for you. Take your time, take a minute or more to really get the lay of the land even if it makes you feel uncomfortable to be lingering.

2 - before you start, measure your fingers. My index and middle fingers have a span of 3.5 cm exactly when opposed. With my eyes closed, I can tell exactly how far apart my fingers are out to 10 cm. This is just proprioceptive training and you can only get this by doing exam after exam after exam with an expert repeating and critiquing your findings. You can get a head start by doing repeated blind measurements with a ruler. Close eyes, tell yourself to put your fingers 7 cm apart, then open your eyes and measure. Know the distance from your fingertip to your first and second knuckle. Cervical length (effacement) is loosely based on a 4 cm long ideal cervix and so if you know that the cervix is 2 cm long, you can report 50% effaced etc.

3 - Watch her face while you are doing the exam. You will get a tremendous amount of feedback by watching her expression. If she is placid, you could be more aggressive if needed. If she is wincing, you should slow down and be more gentle.

4- Start with two fingers well lubed. If she appears uncomfortable with that you can stretch with a single finger, then insert two. For most patients, pressure exerted posteriorly is the least uncomfortable with lateral being next least uncomfortable. Never exert anterior pressure as this area is very sensitive. For some patients, especially those with dyspareunia, lateral pressure tends to be least uncomfortable

5 - Now the tricky part which I suspect is giving you the most problem... Finding and feeling the cervix. The problem is that every cervix is going to feel different and will be in a different position. This is where practice is the only thing that will help. The easiest cervixes tend to be early in the dilation/ effacement process. Feel for the firm tissue, run one to two fingers behind the cervix, and pull it inferior/ anteriorly into exam position. If the fetal head is well applied and the cervix is further along in the process, try to find an edge anteriorly. Once an edge is identified, place both fingers along the edge and trace it around to the maximal point of dilatation. Do not stretch the cervix, just feel how stretched out it is by itself.

The hardest exam is the cervix which is dilated and/ or effaced without a well applied head or with the head proceeding ahead of the cervical opening (you have to get around the head to get to the cervix) Each one of these exams is so different that you really need an expert to teach you by doing the exam with you.

My recommendation is to find a senior ob resident who you can trust and let them know about the problems you are having. Ask them to follow all your exams to ensure you are getting the right results. You will never learn this very difficult exam on an internet forum or by watching videos as it is all done by feel. I used to crack up at the nurses who insisted on turning on the light for me when I was doing an exam. No matter how hard I tried, I could not convince them that the light made no difference to an exam that was done totally by feel.

pod

 

[elizabeth5863]

I agree with the excellent post by periop doc.

The other thing I would add is that, after about 5-6 cm dilation, it becomes more difficult to assess cervical dilation by determining how far your two fingers spread. After 5-6 cm dilation, I usually feel for the rim of cervix that is remaining on the sides and anteriorly and posteriorly. For example, if there is 2 cm cervix remaining on the right and left sides (and anteriorly and posteriorly), you would know that 10 cm - 4 cm = 6 cm dilation. Similarly, if there is 2 cm cervix remaining on the right side and 1 cm cervix remaining on the left side, you would know that 10 cm - 3 cm = 7 cm dilation.

Hope that isn't more confusing. When I was first learning, I asked all the OB nurses to check after me. Good luck!

 

[MeowMix]

I also thought the periop post above was really great; I think I have been making the mistake of putting my fingers in too anterior, which is causing pain, rather than making sure I am posterior, as I would with a speculum.

I come home every night of my OB rotation as an intern and read my midwifery textbook (I like Anne Frye's book). The midwifery and nursing books are much more elementary in their explanations of how to do things like cervical exams, which the ob books don't even discuss. They also give lots of basic and useful information for working with women in labour.

good luck!

 

[Dr McSteamy]

i'm only a med student.

but i share the same problem. i can do paps fine. i can feel around the vagina easily for lack of lumps and stuff.

but i can't palpate ovaries. when i reach for those, i don't feel anything different.

i also have a tough time feeling the size of the uterus.

 

[sophiejane]

but i can't palpate ovaries. when i reach for those, i don't feel anything different.

i also have a tough time feeling the size of the uterus.

You shouldn't be able to palpate ovaries unless there is a mass on them, so that's a good thing.

It is extremely difficult to appreciate the size of the uterus on anyone except thin or pregnant (>20 weeks) patients, so don't worry about it. Again, if there is a huge mass or a baby, you should be able to feel it unless they are obese.

Cervical exams get easier with time, really they do. Take your time. Be gentle but thorough. Ask pt to sit on her hands, or sit on one hand, depending on where the cervix is. Make sure you have her in full "butterfly" or "frog leg" position. Tell her to take a deep breath and as she does, relax her pelvic muscles. You'd be amazed at how this helps immediately to find what you are looking for.

If you have small hands or short fingers, you may have to be a little more aggressive. Use your 3rd and 4th fingers since they are longer.

When you are first learning, ALWAYS have someone experienced check behind you. I don't care if it makes you look dumb. DO IT. It's the only way to learn if you are getting it right. Nurses are great to ask to do this. If they give you attitude, ignore the attitude and ask again nicely until they do it.

 

[sophiejane]

The other thing I would add is that, after about 5-6 cm dilation, it becomes more difficult to assess cervical dilation by determining how far your two fingers spread. After 5-6 cm dilation, I usually feel for the rim of cervix that is remaining on the sides and anteriorly and posteriorly. For example, if there is 2 cm cervix remaining on the right and left sides (and anteriorly and posteriorly), you would know that 10 cm - 4 cm = 6 cm dilation. Similarly, if there is 2 cm cervix remaining on the right side and 1 cm cervix remaining on the left side, you would know that 10 cm - 3 cm = 7 cm dilation.

Great suggestion!!

 

[sarcopenia]

I just wanted to thank everybody for all the valuable advice.

I've tried 2 cervical checks since my last post.

The first, I actually "felt the slit / os" and estimated 6 cm (the nurse told me it was 8 cm, but I didn't feel too bad since it was the first time I ever felt ANYTHING). The nurse did look at my a little funny (and pulled me aside to comment a few minutes later), because my wrist was pronated for the exam (I did this b/c of the suggestion above to use the posterior wall as the reference point).

For the next exam, I tried "the proper way" with my wrist supinated, and once again, failed to feel anything.

The bad thing is that I'm not that closely supervised during this rotation (consultants continuously changing). The "main" consultant evaluating me occasionally asks me "how things are going" and I try to be as honest and forthright as possible. She raised her eyebrows a bit when I mentioned "my vag exams need a lot of improving." I felt like I had to be slightly cagey in my explanation of this (without actually lying), because I was afraid I might fail my rotation if she knew how much I suck...

Canadian FM residency is only 24 months. I only have 1 month of Ob/Gyn, and at this rate ... yikes.

Hopefully, the learning curve will not be a bit less steep from now on? (I could not find an emoticon of crossing fingers, just imagine one).

 

[McDoctor]

i'm only a med student.

but i share the same problem. i can do paps fine. i can feel around the vagina easily for lack of lumps and stuff.

but i can't palpate ovaries. when i reach for those, i don't feel anything different.

i also have a tough time feeling the size of the uterus.

Don't sweat it. Bimanual exams are useless in asymptomatic patients. There is no good reason to do one with routine PAP's in most cases, other than for the fact that every other doctor does them. The inter-examiner reliability is very poor and the bimanual exam has no proven health benefit as a routine screening test.

 

[deleted87716]

Don't sweat it. Bimanual exams are useless in asymptomatic patients. There is no good reason to do one with routine PAP's in most cases, other than for the fact that every other doctor does them. The inter-examiner reliability is very poor and the bimanual exam has no proven health benefit as a routine screening test.

Perhaps not, but this one falls into the category of "better safe than sorry," both for you and for the patient. If you don't perform and document bimanual exams and one of your patients someday turns up with something (e.g., an ovarian CA) that theoretically might have been detected had you done so, you'll be screwed.

I'm a supporter of evidence-based medicine in theory, but you mustn't forget that you're still in the real world.

 

[smq123]

The first, I actually "felt the slit / os" and estimated 6 cm (the nurse told me it was 8 cm, but I didn't feel too bad since it was the first time I ever felt ANYTHING). The nurse did look at my a little funny (and pulled me aside to comment a few minutes later), because my wrist was pronated for the exam (I did this b/c of the suggestion above to use the posterior wall as the reference point).

For the next exam, I tried "the proper way" with my wrist supinated, and once again, failed to feel anything.

Don't let the nurse's reaction bother you. It might be untraditional to have your wrist pronated, but who cares? If you can feel the cervix better in that position, and can't in any other position, then do whatever works.

 

[McDoctor]

Perhaps not, but this one falls into the category of "better safe than sorry," both for you and for the patient. If you don't perform and document bimanual exams and one of your patients someday turns up with something (e.g., an ovarian CA) that theoretically might have been detected had you done so, you'll be screwed.

I'm a supporter of evidence-based medicine in theory, but you mustn't forget that you're still in the real world.

That's why I said there is no good reason to do them other than for the fact that every other doctor does them. I didn't suggest not doing one, I just suggested to the above student should not to be overly concerned with it. It is done almost entirely for medico-legal reasons, as you stated.

This study examined doing transvaginal ultrasounds, similar but even better than a bimanual exam, as a screening test.

http://www.cancer.gov/newscenter/pressreleases/PLCOOvarian2005Release

Out of 28,816 women screened, 29 had cancer, only 9 of which were not already invasive. 541 had an unnecessary laparoscopy. Women were almost 20 times more likely to have an unnecessary surgery than have ovarian cancer detected. These 29 women may or may not have lived any longer because of it...we'll have to wait and see.

So my advice to the student is to do the bimanual exams so that you don't miss anything obvious and for medico-legal purposes, but don't be concerned about palpating every little abnormality. As this study showed, the more you try to detect every subtle finding, you increase your patient's likelihood of having unnecessary testing and procedures far beyond the likelihood of detecting an ovarian cancer.