Vaginal examination: a requirement before calling the anaesthetist?

B. Carvalho1 and J. Coghill2

1 Stanford, CA, USA 2 Plymouth, UK

Editor—Vaginal examination policies to assess and monitor the progress of labour vary between maternity units in England. Thirty per cent of units have no vaginal examination policies, one third have a flexible policy, while 36% of units conduct vaginal examinations to assess cervical dilation at a fixed schedule, usually 4-hourly, but some at 2- or 3-hourly intervals.1

Epidural blocks are often requested and sited without knowing the result of a recent vaginal examination. We reviewed our obstetric anaesthesia database over the 2000/2001 period to determine the time interval between placement of the epidural and delivery.

We found 13.5% of epidurals were placed <=30 min before delivery, and 22.5% of patients delivered within 60 min of the block placement. In addition, we estimate that 2–3% of epidurals were abandoned during placement because the patient wanted to ‘bear down’, and subsequent assessment revealed full cervical dilatation. The mean time interval between epidural placement and delivery was 5 h (SD 265 min); however, there was a large proportion of patients in whom the epidural placement to delivery interval did not allow adequate time to provide effective analgesia (Fig. 1).



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Fig 1 Time interval between placement of the labour epidural and delivery.

 
Many units, including our own, perform vaginal examinations at 4-hourly intervals to assess continued progress in labour or to direct a change of management.1 Earlier assessments can often be misleading and the rapid progress of labour often precipitates the maternal request for epidural analgesia. Knowledge of cervical dilation affects the type of analgesia offered by the anaesthetist (for example, a combined spinal epidural vs an epidural), influencing the dose of local anaesthetic and opioid administered, and the risk–benefit discussion and consent for the procedure. We believe maternal request for epidural analgesia in labour should be an indication for a vaginal examination to assess the progress of labour immediately before placement of the block, except when premature rupture of membranes has occurred or infection may be present, when policy dictates a minimum number of vaginal examinations.

B. Carvalho1

J. Coghill2

1Stanford, CA, USA

2Plymouth, UK

References

1 Chalmers I, Garcia J, Post S. Care during labour: hospital policies for labour and delivery. In: Chalmers I, Enkin M, Keirse M, eds. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989; 817–19





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