In a pregnant anteverted uterus:
• Five weeks LMP feels like a small unripe pear.
• Six weeks LMP feels like a small juice orange. • Eight weeks LMP feels like a large navel orange.
• Twelve weeks LMP feels like a grapefruit.
• After 12 weeks LMP, the top of the uterus begins to be palpable above the pubic bone.
6. With hands in the same position the woman’s assistant sweeps the fingers gently to one side to feel the ovaries, which feel like almonds. Sweep to both sides. The woman will probably feel a twinge when the fingers pass gently over each ovary. The fallopian tubes are not usually felt; but if they are felt, they should be soft and about the thickness of a pencil. If they are hard or enlarged or if she experiences pain, this may indicate an ectopic pregnancy. Although rare, it is possible to rupture an ectopic pregnancy during a bimanual exam. Ectopic pregnancies are characterized by doubled over pain. Immediate medical attention must be sought if an ectopic pregnancy is suspected. A ruptured ectopic pregnancy can cause hemorrhaging.
Troubleshooting Bimanual Exam
Moving the Uterus Hurts the Woman (Get Medical Help)
• may have ectopic pregnancy
• may have an infection
• may have endometriosis
Lumps or Growths Felt on the Womb (Get Medical Help)
• may have fibroids
• may have cancer
Uterus Feels Smaller Than Expected
• pregnancy may not be as advanced as previously thought
• may have a missed abortion, where the fetus ceased to grow during gestation
• may have an ectopic pregnancy (get medical help)
Uterus Feels Larger than Expected
• pregnancy may be more advanced than expected
• may have multiple pregnancy
• may have uterine fibroids
• may have a molar pregnancy
Unable to feel the Womb • strong abdominal muscles
• large amount of belly fat • uterus may be retroverted • try moving hand around lower belly and pressing down in different places
Appendix D: Speculum Insertion
1. Speculum should be cleaned and sterilized. The vagina is not a sterile environment, but sterilization will help prevent infection and disease transfer.
2. With the speculum locked in a closed position, separate the labia with one hand while gently inserting speculum with the other hand. Often it is more comfortable if the speculum is rotated at about 45 degrees (so the blades are oblique-not horizontal). Once past the entrance of the vagina, the speculum can be rotated to its normal horizontal position.
3. Once the speculum is inserted, slowly open the speculum and lock it into an open position.
4. Shining a flashlight into a hand mirror (held with the other hand between the legs, will allow the woman to see if the cervix is visible.
5. Often times the cervix will not present on the first attempt. As the speculum is inserted it may help to point the speculum to the left or right and then bring the point of the speculum to the center. This action will often free a cervix that is resting on the top of the speculum.
Appendix E: Cervical Dilation
The benefits of adequate cervical dilation are reduced time to complete abortion, more effective evacuation of the embryo, and reduced bleeding. Menstrual extraction often requires cervical dilation. For a woman who has never given birth vaginally, careful dilation will usually be required, especially after 9 weeks LMP. For a multiparous woman, often cervical dilation is not needed until 12 weeks LMP, as the cervical os will naturally be more open.
In menstrual extraction, often an entire set of plastic cannulas, ranging in size from 3 mm – 14 mm, are sterilized so they may be used as dilators, if needed. Then, the smallest cannulas are introduced into the os to gradually accustom the cervix to a greater diameter, up to required cannula size based on a woman’s estimated gestational age. (The required size of cannula in millimeters roughly corresponds to the number of weeks LMP.[532])
Menstrual extraction has been shown to be most effective at around seven weeks gestation. At seven weeks LMP, the required cannula diameter is approximately 7 mm. Often the cervical os will accommodate the 7 mm cannula, if the os has been gradually opened with the smaller cannulas before the insertion of the 7 mm.
For menstrual extractions over seven weeks gestation, more gradual dilation with cannulas and pharmaceutical cervical dilation may be necessary. According to the World Health Organization, menstrual extraction can be used up through 12 weeks LMP, and possibly up to 15 weeks LMP, if the necessary sized cannulas can be secured and adequate cervical dilation achieved, and one study indicated that manual vacuum aspiration is as effective as electric vacuum aspiration between 14 to 18 weeks of pregnancy.[533]
Taking care to adequately dilate the cervix prior to any second trimester abortion procedure will help to reduce side effects and increase the effectiveness of the procedure. Natural prostaglandins in the body cause the cervix to dilate; synthetic prostaglandins can also be used to artificially cause the cervix to dilate.
Misoprostol has been found to be effective in dilating the cervix in early second trimester abortion.[534] Misoprostol, a synthetic prostaglandin at a single dose of 600 mcg, taken orally or placed in the back of the vagina for six hours, results in approximately 6 to 8 mm of cervical dilation. Mifepristone 200 mg administered 48 hours before the misoprostol resulted in approximately 12.5 mm dilation in weeks 12 – 20 LMP.[535]
Misoprostol and mifepristone are contraindicated for some women (see Medical Abortion).
Auriculotherapy is an ancient form of acupuncture that focuses treatment on the ears. Auricular acupuncture has been found to be useful for dilating the cervix in preparation for an abortion.[536] The use of ear acupuncture to dilate the cervix has been shown to be upwards of 98% effective in studies on women who were unable to undergo a vacuum aspiration abortion because of the tightness of the cervical os. When the points are correctly located and needled, increased circulation and a feeling of warmth was often felt.[537]
Words to the Wise: The cartilage of the ear is not fed by blood vessels, thus any injury or infection may be difficult to treat and may result in serious consequences. Some auriculotherapy schools use cartilage penetration and some forbid it. When cartilage penetration is used, the treatment time is greatly reduced. To open the cervix, when cartilage penetration is used, the time that the needles are retained is about 5 minutes, whereas when only skin penetration is used, the time that the needles are retained is about thirty minutes to one hour.
1. Woman must be calm with no anxiety. If anxiety exists during the application, the possibility exists that the ear acupuncture point stimulation may cause unconsciousness.[538]
2. Clean the ear well before acupuncturing.
3. Do not allow the needle to touch anything before insertion.
Insert size ½ in. or size 23 - 30 needles which have been properly cleaned and sterilized into acupuncture points.
4. Rotate the needle to and fro to stimulate the point.
5. Needles inserted into the ear cartilage are retained for approximately five minutes. Needles inserted into the skin are retained for approximately thirty minutes to one hour.
532
This measuring system is a very rough guide. A 6mm cannula will usually suffice for 6 – 8 weeks LMP. A 14mm cannula will usually suffice for the first half of the second trimester.
533
C. Todd, “Manual Vacuum Aspiration for Second Trimester Pregnancy Termination,”
534
Catherine S. Todd, “Buccal Misoprostol as Cervical Preparation for Second Trimester Pregnancy Termination,”
535
J . Carbonell, F . Gallego, M . Llorente, S . Bermudez, E . Sala, L . González, and C . Texido, “Vaginal vs. Sublingual Misoprostol With Mifepristone for Cervical Priming in Second-Trimester Abortion by Dilation and Evacuation: A Randomized Clinical Trial,”
536
Yu Lihua Zhang, “Observations on the Effect of Ear-AP for Dilation of Cervical Os on 56 Cases,” Beijing: Second National Symposium on Acupuncture and Moxabustion and Acupuncture Anaesthesia, All China Society of Acupuncture and Moxabustion (1984), 87-8.
537
H.Y. Zhang, L.H. Yu, and Q.Z. Ye, “Dilation of the Cervix Uteri by Ear-AP: Analysis of 120 Cases,”
538
Claus C. Schnorrenberger,