Vaginal examination — What it is and what to expect
Vaginal examination requires sensitivity
Parting her legs to have a vaginal examination is one of the most challenging moments for a woman, especially if it is happening to her for the first time. Considering that it requires you to put aside your privacy for a while and to allow somebody else to ‘intrude,’ a vaginal exam must be carried out with utmost gentleness. Most of all, the doctor needs to inform you beforehand why it is being done, to what extent, and what to expect.
A woman does not have to be pregnant to undergo a vaginal examination. It is one of the procedures that may be required during any of her regular visits to the hospital. This examination is however not routine but is undertaken only when necessary.
Why have a vaginal examination?
For non-pregnant women, your doctor will perform this procedure to assess or diagnose certain gynaecological conditions. This involves a complete physical examination of a woman’s external genital area and inside of the vagina and the pelvic organs. During pregnancy, it will be to assess certain factors in pregnancy, during labour and after delivery.
What does a vaginal examination entail?
A full pelvic examination has four successive phases: an external exam, internal exam, bimanual exam and a rectovaginal exam.
External exam:
This is the examination of the genital area around the external genitals (vulva). An external exam is mainly an inspection of the external structures and palpation where necessary. The health professional conducting the exam observes the site for discharge, its smell and amount, any lesions and ulcers, genital warts, redness, irritation, cysts, etc.
Internal exam:
An internal exam requires the use of a speculum — an instrument used to spread apart the vaginal walls to enable the doctor to visualize the inside of the vagina. This examination is also called a speculum exam. It is usually conducted, for example, during a pap test or when inserting an intra-uterine contraceptive device. During a pap test, a small brush or wooden spatula is used. It brushes against the walls of the cervix and collect cells. The cells are taken to the laboratory and observed under a microscope. This helps to determine the presence of any cancerous cells in the cervix.
The cervix is a ring of muscles, about 2.5 cm long, which opens into the vagina. It holds the baby in the uterus. The cervix is sometimes also referred to as the ‘neck of the uterus.’ The speculum exam enables the doctor to check the vaginal walls and the cervix for damage, growth, unusual discharge or discoloration. It can also be used when a woman has an incompetent cervix, that is, when the cervix in unable to hold a pregnancy in the uterus, causing habitual abortions after the 12th week of pregnancy.
A speculum will be used to insert a ‘McDonald stitch’ that is used to keep the cervix closed until the pregnancy is full term. In cases where a woman has discharge a high vaginal swab using a ball of cotton will be taken to be tested and cultured to determine if and which sexually transmitted infection she could be having. The type and size of the speculum used will always depend on whether the woman is a virgin, has given birth before or is post-menopausal.
Bimanual exam
During a bimanual exam, the health professional inserts one or two lubricated, gloved fingers into the vagina while the other hand presses on the abdomen. The fingers in the vagina are moved around to feel the internal pelvic organs, the uterus, the ovaries, the fallopian tubes and the cervix for their size, shape and consistency. Any abnormality such as unusual growths and pain is then noted.
Rectovaginal exam
As the name suggests, this procedure examines both the rectum and vagina. It entails inserting a lubricated gloved first finger of one hand into the vagina and inserting a second lubricated and gloved finger of the same hand into the rectum as the other hand presses on the abdomen. This exam should be done last. It is not mandatory unless the doctor determines that it is necessary. This exam enables the doctor to feel the internal pelvic organs. And detect the abnormal parts of the uterus, the ovaries, or the colon (lower part of the intestine).
What is the use of a vaginal examination?
A vaginal exam is used to detect vaginal infections, sexually transmitted infections, causes of abnormal bleeding, pelvic organ abnormalities, and abdominal or pelvic pain. It is also helpful before prescribing certain methods of contraception such as intrauterine contraceptive devices or diaphragm. Vaginal examinations are also critical when collecting evidence in cases of suspected sexual assault.
Getting ready for a vaginal exam
• Do not use vaginal creams, pessaries or douches on the day that you’ll have the exam. Keep off sex for at least 24 hours before the exam. This is to ensure that the specimen that will be collected is not mixed up with anything that will alter the results.
• Empty your bladder before the exam, for your comfort.
• Schedule the exam when you are not on your periods.
• The doctor may ask you the first day of your last menstrual period, so be informed.
• Let the doctor know of any unusual symptoms such as unusual odour, itching, redness, sores, etc.
What is expected of you during the exam?
• Roll up your clothes up to the waist, then lie on a couch that you will be shown by the doctor or nurse.
• In many cases it is enough to just fold your legs with your feet on the couch and separate them as instructed. This position is called the lithotomic position. In some cases, your feet may be raised and supported by stirrups (hoops of leather or metal that help to put your legs in position).
• Privacy will be observed. If the couch is in an open place, it will be screened all round. You may ask for a second health professional, preferably female, to be present during the exam if the examiner is male.
Vaginal examinations in pregnancy
During pregnancy, you are likely to have a vaginal examination. However, this examination is not routine and will only be carried out when there is a need for it. Your obstetrician may perform a vaginal examination during the first weeks of pregnancy to determine the size of the pelvic outlet (birth canal). There are average dimensions of both the pelvic outlet and the fetal skull. The doctor compares the two dimensions to determine how adequate the pelvis is to allow the child to pass through. But because not all women are the same size, the doctor may find dimensions that indicate that the outlet is small yet the woman will still be able to deliver. A woman with a small pelvis will usually be given special treatment during labour.
It helps to monitor the progress of labour
A vaginal examination during labour helps to monitor the progress of labour. The obstetrician or midwife inserts a lubricated finger into the vagina to find out how much the cervix has opened. The cervix opens up to 10 cm wide to allow the baby to pass through. A woman in labour dilates (opens up) 1 cm per hour after a 4-cm dilatation as soon as labour commences. These are average figures and because all women are not the same, one should not be unduly worried if she does not fall within this range. The dimensions are marked by inserting the fingers and finding out how many fingers the cervix can allow through. One finger passing through means that the cervix has dilated 2 cm, 2 fingers means 4 cm and so on.
These findings are recorded on a partogram and studied. The study gives a picture of whether the labour is progressing well or there is an obstruction. A partogram is a graphical record on which the dilatation of the cervix is plotted.
The baby’s position in the birth canal can also be determined
The ripeness or consistency of the cervix is also checked. The cervix ripens more as labour progresses. This helps the doctor to determine how the labour is progressing by feeling the cervix.
Doing a vaginal exam helps the doctor to detect how thin the cervix is. As labour progresses, the cervix softens and opens up and the length decreases. The baby’s position in the birth canal can also be determined. A vaginal examination will tell how far the baby has descended into the birth canal.
The direction that the baby is facing will also be determined by feeling the suture lines on the skull. The anterior (front) and posterior (back) fontanels are shaped differently. A fontanel is the membranous space at the front and back of the baby’s head. On average, most babies are born facing down, so the posterior fontanel can be felt on examination.
A vaginal examination will be done to check the umbilical cord as the baby descends further into the birth canal. If this cord is over the baby’s head the woman is not allowed to push as the cord may just snap. A displaced cord signals an emergency situation.
Your health care provider will, based on all this information, interpret and consequently monitor more effectively the progress of your labour . This will enable the right interventions as the need arises.
What a vaginal exam will not do
• Tell when the baby is coming. The findings can only estimate this timing based on the fact that the cervix of a woman in labour dilates 1 cm per hour after a 4-cm dilatation.
• Tell whether the baby will fit in the canal. The examination can only tell the size of the pelvis and never the size of the baby.
The midwife, doctor or both of them working together will undertake your vaginal examination, depending on the policy of the institution. Your cooperation is essential.
END: PG 1/35-37