I’m starting to get more comfortable at clinical. I’ve found all my cervices with a speculum for the last three clinical days in a row (I guess there was one time where I found it on a 6wk postpartum woman and didn’t think I had found it because it was still pretty soft and kind of blended in with the vaginal wall. But still, technically, I found it). Bimanuals are still tricky – in the beginning I really struggled to get my hand far enough in to feel cervix. Now I can usually reach the cervix, but I don’t trust what I’m feeling just yet (probably because I’m still wrong a lot of the time). On the prenatal end of things, I’m getting a lot better at finding clear fetal heart tones – in the beginning I was getting a lot of the whooshing sound of the placenta and not a lot of the galloping sound of the baby. It’s still hard for me to get a good tone on women earlier in their pregnancies; the tone is more subtle in the first half of pregnancy and my ears aren’t quite attuned to all the different sounds yet.
My preceptor usually double checks me and I always like watching her work. She often closes her eyes when she does her exams and when she does, she always seems like she’s smiling to herself about something. I like to think it’s because, after all this time, she still really likes what she does. There’s an effortlessness and a peace in her demeanor, like she’s reconnecting with some old, intrinsic part of herself. This may sound strange, but it’s kind of sweet to watch her have that moment. She never uses a tape measure to get a fundal height and never looks at the doppler to figure out the fetal heart rate. She uses her hands and her ears and she’s always right on the money. Obviously, she’s been doing this a long time, but I always want to blurt out, “How are you doing that?!” I know I just need to listen to a million more babies before I start to get the heart tones, but I figured I could start improving my palpation skills by measuring my hands, something we were told every good midwife should do:
These measurements are useful for measuring fundal height. If we go with the general idea that when the fundus is at the umbilicus, the uterus measures 20cm, I can then use my fingers or hand to calculate the fundal height as the uterus grows beyond the navel.
This measurement is good for assessing vaginal depth and also probably for pelvimetry.
This measurement is good for assessing cervical dilation and also for pelvimetry. Now I know that if I can’t reach the edges of a cervix, a woman is probably fully dilated. I haven’t done any pelvimetry, yet, but I imagine that this measurement and the one above will come in handy (no pun intended) for figuring out how far apart different pelvic bones are.
Highlights from this week include finally remembering that I need to order a mammogram for women over 40 (look, it’s the little things), eliciting a positive “chandelier sign” (i.e. +cervical motion tenderness. If you wiggle the cervix of a woman with pelvic inflammatory disease – an infection of the uterus, fallopian tubes or other reproductive organs – she will report a sharp pain, or look like she’s about to “hit the chandelier (ceiling).” It wasn’t cool for my patient that she had this, but it was an interesting case for me), and seeing my first repeat prenatal patient (it’s always fun to see them grow and change).