1176 Edington: Examination

of

Birth Canal

Canad. Med. Ass. J. June 22 and 29, 1968, vol. 98

Routine Examination of the Birth Canal

R. F. EDINGTON,
not
a

Following Delivery
ab
are on

M.D., F.R.C.S.[C], Sudbury, Ont. jaws, twisted gently and removed. Any normality of the uterine cavity is noted, as
uterine or adnexal tumours. An assistant presses down the posterior vaginal wall is

routine manual exploration of the reproTHE ductive tract following delivery is pro cedure that is

generally taught or practised.1, 2 The fear of thereby introducing infection and causing an increase in maternal morbidity is well ingrained, and the benefits which result from such an examination of the uterine cavity and vagina are not generally realized. Hemorrhage still ranks in the forefront as a cause of maternal deaths. It is responsible for 29.8% of these tragedies in the United States.3
In Ontario, between 1958 and 1961, 33% of all direct obstetrical deaths were due to hemor rhage; if deaths from rupture of the uterus were included, over half (52%) occurred in the post

partum period.4

undertakes to show that there is no increase in morbidity attributable to the procedure, which reduces to a minimum both early and delayed postpartum hemorrhage. In addition, the ex amination may reveal hitherto unsuspected pelvic conditions. The 1050 patients reported are those personally delivered by the author between 1959 and 1966. The technique is simple, requires no special instruments and needs no scrubbed assistant. Anesthesia is not a pre-

walls, can prevent a considerable number of postpartum hemorrhages. This paper describes the technique used for this examination, and

Routine manual exploration of the uterine in the immediate postpartum period, followed by visual and manual examination of the cervix, the fornices and the lateral vaginal

cavity

the fundus, and depressed with the examiner's left hand, while the cervix is grasped with the sponge forceps. The whole circumfer ence of the cervix is systematically examined, and any lacerations are then repaired. The assistant then dips the fingers down be hind the patient's symphysis pubis and elevates the uterine body cephalad, thus opening up and tenting the vaginal fornices. The light is adjusted and any blood in the vagina is re moved with swabs. The lateral and posterior fornices are examined, as well as the areas over the bladder and over the ischial spines. The apex of the episiotomy is located and a suture suitably placed to begin the episiorrhaphy.

patients is reported, 68% of whom were delivered under conduction or in halation anesthesia. Twenty-nine per cent of the patients were delivered using a combination of pudendal block or local inflltration of the perineum with anesthetic solution and trichlorethylene (Trilene) by Duke inhaler. Three per cent of the patients had no anesthesia for

Results A total of 1050

delivery.

requisite.
Technique

Immediately after delivery of the placenta and before repair of the episiotomy, the hands are rinsed in sterile solution in the splash basin, and the vulva, perineal and perirectal areas are swabbed with wet sponges. The drapes are not into the changed. The cupped hand is inserted other cervix. The the and hand, through vagina on the patient's abdomen, steadies the uterus and pushes it gently down towards the examin ing hand. The uterine cavity is systematically examined and the placental site identified. Any retained placental fragments are removed manually and any membranes are grasped with a straight sponge-holding forceps with serrated
to: Dr. R. F. Edington, 60 Drinkwater Reprint requests Ontario. Street, Sudbury,

of membrane. During the course of study number of other conditions were detected by this examination (Table I). The occurrence of miscellaneous conditions that were discovered by this method at the time of delivery was quite surprising, and as the physician becomes more skilled in the technique of intrauterine examination, fibroids and uterine anomalies previously unsuspected may also be detected. In the two cases of fibroids, the tumours were present in the posterior uterine wall and could not have been palpated by routine abdominal examination. In both cases the fibroids became very much smaller and after six weeks were hardly palpable. Two ovarian cysts were found, one of which disappeared by
nants
a

Abnormalities Detected by Manual Exploration At first the main reason for the routine exploration of the uterine cavity was to confirm that the uterus was empty of placenta or rem-

Canad. Med. Ass. J. June 22 and 29, 1968, vol. 98

Edington: Examination
by

of

Birth Canal 1177

TABLE I..Abnormalities Detected Manual Exploration 1. Unsuspected cervical laceration over 2.5
cm.

46 2. Retained membrane. (4.4%) 3. Vaginal lacerations (including episiotomy 42 (4.0%) extension). 4. Retained placental tissue. 16 (1.5%) 5. Bicornuate uterus. 5 (0.5%) 2 6. Fibroids. (0.2%) 2 7. Ovarian cyst. (0.2%) 8. Vaginal cyst. 1 (0.1%)

69(6.6%)

lead to increased postpartum morbidity, and this conclusion is also evident in other series of cases.1618
Discussion The routine exploration of the uterus is not taught in many medical schools or residency training programs. The main objection to this

the second month post partum; the other per sisted and at operation proved to be a 5-cm.
serous

cystadenoma. Repair of all cervical lacerations, including those not bleeding actively, leads to healthier cervices and to fewer delayed cervical complica tions of delivery. Of the cervical lacerations de tected in the series, 64% were associated with spontaneous or outlet forceps delivery. Therefore it is not necessarily the difficult deliveries that are associated with cervical trauma. In a series of cases quoted by Danforth,15 large tears occurred in non-traumatic deliveries and the incidence of lacerations over 3 cm. in length was 11.2% in primiparas and 4.1% in multiparas. Bleeding does not always occur from cervical lacerations, and some surprisingly deep tears, measuring up to 4 cm. in extent, may be present without due blood loss, especially when located posteriorly.

These asymptomatic cervical lacerations are overlooked unless routine examination of the cervix is practised. The whole of the cervix should be examined, bringing it into view by traction with sponge forceps. Only by doing this will these asymptomatic cervical lacerations be seen. Vaginal lacerations including episiotomy extensions were found in 42 patients and were these lacerations were not repaired. Some of and if the vagina had not bleeding actively, been examined they would have been missed.
Morbidity

procedure has been the high morbidity rate quoted in cases of manual removal of the placenta.57 In these reports, maternal mortality rates of 2.7% and maternal morbidity rates of 43.1% were not uncommon. However, the cases quoted are those in which manual removal of the placenta and invasion of the uterus was per formed after considerable blood loss and procrastination. Thus, the intrauterine manipulation was a last resort in an already traumatized patient. The distinction between manual re moval of the placenta, performed of necessity for postpartum hemorrhage, and the routine postpartum exploration of the uterine cavity in a stabilized patient who is not bleeding is certainly an important one, and mortality and morbidity rates cannot be compared. Recent series of cases of manual removal of the placenta reported by Hoffman,8 Thomas9 and Sauer10 show no maternal mortality and a morbidity rate equal to that of the respective service as a whole. At the beginning of the study considerable difficulty was encountered in differentiating the normal from the abnormal. The collapsed post partum uterine cavity is longitudinally rugose with a rough placental area that may lead the
unwary to think that there are retained secundines. The lower uterine segment is

Morbidity was defined as a temperature eleva F., occurring on any two of the first 10 days post partum exclusive of the first 24 hours. By this definition, 24 patients were
tion of 100.4

2.3%. Of these 24 patients, there

uncorrected incidence of were 14 with for the causes morbidity, 6 due to genital and 8 due to endometritis. infection episiotomy There were extragenital causes in 10 patients: 3 had upper respiratory infection, 5 had genitourinary infection and 2 developed thrombophlebitis. Thus, genital causes for the morbidity occurred in only 1.4% of all the pa tients examined. This low figure would seem to demonstrate that manual exploration did not

considered morbid,

an

flaccid and easily traumatized, and the junction of this with the upper segment is quite abrupt, leading the examiner to believe that there is a definite contraction ring. Intrauterine blood clots give the sensation of placental cotyledons until they are removed and examined. It is con sidered, therefore, that planned exploration of the birth canal done electively and in the nonemergent cases gives the examiner confidence in the detection of those abnormalities that are potentially dangerous in the emergency case. In the series of cases here reported 24 pa tients were morbid, a gross rate of 2.3%. How ever, some of these patients had extragenital causes for their morbidity, such as upper respira tory or genitourinary infection. Comparison of this series with those of other authors (Table II) shows that in non-traumatized stabilized pa tients the morbidity rate is certainly not high, and if the corrected figure is taken, the genital

1178 EDINGTON: EXAMINATION

OF

BmRTH CANAL

Med. Ass. J. Canad. June 22 and 29. 1968, vol. 98

TABLE II.-COMPARISON OF MORBIDITY

Author

Year 1966 1965

Number of patients 1050 1000 921 3022

Gross
2.5
-

Corrected
1.5 1.6 1.2 0.26

Jones et al. 17 ............... Thomasg ..................

Edington......

Mozley'2

1960
1957

2.4
-

..................

membranes were removed successfully without recourse to inhalation anesthesia. That this procedure is possible with minimal analgesia is also borne out by Doolittle's report16 of 1000 cases delivered using pudendal block
anesthesia, supplemented with predelivery meperidine and scopolamine. In some of these cases even manual removal of the placenta was accomplished without added anesthesia.
A personal series is presented of 1050 Summary patients who had routine intrauterine

metritis
1955 Hawkins" ................. DuCkman and Dennen'9..... 1955 Hoffman8 .................. 1954 1954 Briscoe18 .................. 1269 83 977 500 2.5 2.7 2.25
1.9
-

(Endoonly)
0.4
1.12

1.0

infection rate is low. The lack of morbidity in both this small series of patients and in larger series't' 12 would seem to overrule the main objection to incorporating this technique in the method of delivery. Examination of the uterine cavity with removal of retained placental remnants and membranes which otherwise would have been left behind reduces postpartum hemorrhage and postpartum morbidity with fever, uterine tenderness and foul lochia. The secondary anemia and dangers of multiple blood transfusions that can be a consequence of postpartum hemorrhage are thus avoided. In Ontario in 1963, 20 out of 39 direct obstetrical deaths were due to hemorrhage. Included in these 20 maternal mortality reports were five cases due to uterine rupture, and not one of these cases was recognized even though the patient was bleeding briskly. A study of maternal mortality reports'3' 14 in The Canadian Medical Association Journal brings to notice a disquieting number of cases due to postpartum hemorrhage. These include cases of undiagnosed vaginal lacerations, rupture of the uterus and extensive cervical tears. The majority of these cases either were not examined adequately or were examined after serious blood loss had rendered the patient a poor risk for any type of surgical intervention. Whether this failure to carry out a proper examination of the whole birth canal was due to ignorance of the procedure or to fear of producing infection it is impossible to say. However, if the reluctance to perform this type of examination can be dispelled, perhaps maternal deaths due to undiagnosed uterine rupture and vaginal lacerations will gradually cease. The fact that general or regional anesthesia is not necessary for this procedure is borne out by the fact that 32% of the patients received either trichloroethylene inhalation analgesia by Duke inhaler or no analgesia at all. In this group, routine manual exploration of the genital tract was carried out without incident, and on several occasions small placental remnants and

and vaginal canal examination performed immediately post partum. Adoption of this technique as a part of delivery room procedure is suggested. From this series of cases it would appear that when performed carefully this examination carries no undue danger to the patient. The general morbidity rate is not increased, and valuable information about the patient's uterus, cervix and vagina can be gained. Causes of postpartum hemorrhage can be diagnosed rapidly and simply, so that prompt treatment can be lifesaving, while future gynecological complications may be prevented.

L'auteur passe en revue 1050 accouchements qu'il a pratiques lui-meme. Chacune des parturientes a ete soumise a un examen approfondi de la filiere pelvienne immediatement apres la delivrance. Cet examen n'a entraine aucune augmentation de la morbidite au cours du postpartum mais a eu l'avantage de pouvoir deceler des lacerations cervicales et vaginales chez plus de 10% des femmes. La retention de debris placentaires a ete egalement notee chez 9.9% des accouchees. D'autres anomalies ont ete egalement constatees. L'auteur est grand partisan d'un examen approfondi de la filiere pelvienne apres l'accouchement et considere qu'il doit etre partie integrante de tout accouchement.

Re'sume

R m

1955. 12. MOZLEY, P. D.: Ibid., 75: 1126, 1958. 13. Canadian Medical Association, Committee on Maternal Welfare: Canad. Med. Ass. J., 94: 1314, 1966. 14. Idem: Ibid., 95: 219, 1966. 15. DANFORTH, W. C.: Amer. J. Obstet. Gynec., 32: 710, 1936. 16. DOOLITTLE, H. H.: Obstet. Gynec., 9: 422, 1957. 17. JONES, R. F.. WARREN, B. L., JR. AND THORNTON, W. N., JR.: Ibid., 27: 699, 1966. 18. BRISCOE, C. C.: Ibid., 4: 375, 1954. 19. DUCKMAN, S. AND DENNEN, P.: Ibid., 5: 628, 1955.

REFERENCES 1. LULL, C. B. AND KIMBROUGH, R. A., editors: Clinical obstetrics, J. B. Lippincott Co., Philadelphia, 1953, p. 472. 2. DELEE, J. B. AND GREENHILL, J. P.: Principles and practice of obstetrics. 9th ed., W. B. Saunders Company, Philadelphia, 1947, p. 278. 3. EASTMAN, N. J. AND HELLMAN, L. M.: Williams obstetrics, 12th ed., Appleton-Century-Crofts Inc., New York, 1961. 4. ALLEMANG, W. H.: Clin. Obstet. Gynec., 6: 825, 1963. 5. SCHWARTZ, H. A. AND RIcHARDS, W. R.: Amer. J. Obstet. Gynec., 45: 235, 1943. 6. PECKHAM, C. H.: Bull. Hopkins Hosp., 56: 224, 1935. 7. ODEL, L. D. AND HoVIs, W. F.: Surg. Gynec. Obstet., 77: 553, 1943. 8. HOFFMAN, R. L.: Amer. J. Obstet. Gynec., 68: 645, 1954. 9. THOMAS, W. O., JR.: Ibid., 86: 600, 1963. 10. SAUER, H. H. A.: Obstet. Gynec., 12: 221, 1958. 11. HAWKINS, R. J.: Amer. J. Obstet. Gynec., 69: 1094,