Postpartum pelvic Examination

Patient Profile: A $28$ -year-old female attending a regular $6$ -week postpartum check-up.
Delivery Details:
- Normal vaginal delivery (NVD) resulting in a $2.8\,kg$ infant.
- Surgical Intervention: An episiotomy was performed during delivery which extended to the perineum. This deep cut was surgically repaired immediately following delivery.
Current Symptoms and Concerns:
- The baby is feeding well.
- The patient has resumed sexual activity but reports experiencing superficial pain during intercourse.
- The patient is complaining of urine leakage (incontinence) and the sensation of a "lump down below" specifically triggered by coughing or sneezing.

Introduction and Objectives: Introduce yourself as Amir and explain the nature of the examination, which focuses on the private parts to check for urine leakage and the presence of any lumps.
Procedure Components: Explain that the examination involves a visual inspection, the insertion of a speculum, and a bimanual examination (fingers inserted internally while the other hand feels the stomach).
Exposure and Environment: Request full exposure of the private parts. Provide the patient with privacy, time to undress, and a sheet for coverage.
Patient Positioning: The patient should lie down with knees bent and legs moved away from each other.
Safety Protocol: Advise the patient that they can request to stop the procedure at any point. Confirm the patient is happy to proceed.
Hygiene and Chaperone: Sanitize hands, apply gloves, and offer the presence of a chaperone as a matter of good clinical practice.

General Appearance: Observe the patient for wellness; specifically check for pallor, which may indicate significant blood loss during delivery.
Peripheral Examination: Inspect the hands and palms for pallor.
Vitals Check: Hold the pulse for approximately $5$ seconds to screen for tachycardia. While a standard count might take $15$ seconds, a brief check is sufficient to detect an elevated heart rate.
Ocular Inspection: Check the eyes for pale conjunctiva.

Inspection: Briefly look for abdominal distension, visible masses, or any remaining linea nigra from the pregnancy.
Palpation: Perform one deep palpation on the lower part of the abdomen.
Uterine Assessment: At $6$ weeks postpartum, the uterus is typically no longer palpable. The examiner should check for any unexpected masses.

Episiotomy Site: Explicitly state to the examiner that you are checking if the episiotomy wound has healed well. Note if the wound is intact or if any issues are present on the manikin.
Prolapse Inspection: Look for any visible tissue protrusion (Grade $4$ prolapse).
Valsalva Maneuver: Ask the patient (Julia) to strain or "push down" as if having a bowel movement. Alternatively, describe a maneuver where the patient pinches their nose and blows with their mouth closed to increase intra-abdominal pressure. Observe for any protruding lumps.
Pad Test (Cough Test): Pick up a pad or piece of gauze from the desk, place it against the genitalia, and ask the patient to cough. Observe if the pad becomes wet, which indicates stress incontinence.
Routine Observations: Check for bleeding, discharge, redness, rashes, swelling, or masses.

Insertion: Apply one drop of lubricant to the speculum. Advise the patient to take a deep breath as the instrument is inserted; inform her that it may be uncomfortable but should not be painful.
Vaginal Wall Assessment: Observe the condition of the vaginal walls. In postpartum breastfeeding women, walls may appear pale, thin, and dry, a condition referred to as lactational atrophic vaginitis (or colloquially as lactational atrial fibrillationitis).
Cervical Inspection: Look for bleeding, discharge, redness, or abnormal masses on the cervix. Check for the presence of a cervical ectropion.
Secondary Prolapse Assessment: While the speculum is inserted, ask the patient to strain again to check for prolapse, specifically looking for signs of a cystocele or rectocele.

Internal Palpation: Insert two lubricated fingers into the vagina.
Cervical Motion Tenderness: Periodically move the cervix to check for pain or tenderness.
Uterine Evaluation: Rotate the forearm and use the external hand to feel the lower abdomen. Assess the size, borders, and tenderness of the uterus. A normal uterus at this stage will likely not be palpable, and no tenderness should be present.
Adnexal Evaluation: Spread the internal fingers to the sides to check the adnexa for masses or tenderness.

Rationale: This is a valuable step to assess potential damage to the anal sphincter caused by the episiotomy or delivery.
Procedure: Inform the examiner of the intent to perform a rectal exam to check anal tone. Ask the patient to squeeze their muscles around the finger to ensure the back passage was not damaged during the surgical cut.

Muscle Weakness and Incontinence: Explain that vaginal delivery can damage the muscles in the lower abdomen and pelvic floor. This damage often results in stress incontinence, where urine leaks during activities that increase stomach pressure, such as coughing or sneezing.
Prolapse Sensation: Describe the "lump" as a uterine prolapse, which occurs when the pelvic floor muscles are too weak to hold the organs in their proper place.
Hormonal Changes and Dyspareunia: Explain that breastfeeding causes hormonal changes that lead to a dry and thin vaginal wall. This condition is the most likely cause of the pain experienced during intercourse.
Wound Recovery: Confirm that the episiotomy, the cut made during delivery, appears to have healed well.

Case Specificity: A standard pelvic exam is insufficient for this case. Specific additions—checking the episiotomy wound, performing the cough test with a pad, and checking for prolapse twice—are mandatory for a passing grade.
Sims Position and Speculum: While the Sims position and Sims speculum are technically superior for assessing prolapse, they are considered "extra cherry on the cake" and are not required to pass if the manikin is in a standard position.
Sajid's Experience: During a clinical exam involving cervical screening, Sajid encountered a broken speculum. The examiner allowed the candidate to proceed as best as possible despite the equipment failure.
Time Management: Candidates should avoid performing extraneous systemic exams (like respiratory or bowel exams) if they are not relevant to the specific clinical stem, as this risks running out of time for the essential pelvic components.