As clinicians, it is necessary to adapt our skills to deliver new techniques and enable advances in practice. Clinicians should be reassured this ability has already been mastered during pre-registration training and throughout their career, and although it can be daunting initially, with some practice, this new skill will become common practice. We need to ensure we teach these new skills in a way that will build upon their existing skills, enabling clinicians to feel confident and competent.
As the number of Dilapan-S® users grows, the insertion technique has begun to evolve, which led us to create this guide to be applicable to clinicians with different skillsets and what they find most suitable.
Dilapan-S® can be inserted via speculum or digital examination, with both methods achieving desired outcomes. The most important point is to use the technique you are most confident in and that the technique is also adaptable to suit variations in anatomy. For example, it might be easier to undertake a digital insertion for a multip, since there is an increased laxity in the vaginal wall. Whereas for a primip it may be more suitable to perform a speculum examination.
Other factors may include cervical position, station of fetal head and maternal preference.
To determine the best position of the speculum, a vaginal examination can be useful to locate the cervix prior to insertion. The cervix may be ‘walked forward’ during this process as well.
The most important point is to use the technique you are most confident in and that the technique is also adaptable to suit variations in anatomy.
If performing a speculum insertion:
An important factor whilst performing a speculum examination is to always ensure good lighting is available.
To assist with bringing the cervix forwards as much as possible, use an ultrasound wedge or pillow, ask the woman to sit on her hands or use of lithotomy stirrups if available.
Avoid touching the clitoris or pinching labial skin.
Insert the closed speculum at the anatomic angle of the vagina (45° angle downwards, towards the small of the woman’s back) whilst maintaining downward pressure until resistance is met, and then pull back slightly.
When you feel some resistance, pull back slightly and open the speculum only so much to allow visualisation of the cervix.
If the cervix is not visible, close the speculum blades, withdraw slightly and repeat the process.
If the cervix is posterior, slightly compress the perineum with the lower blade. This will allow the blade tips to slip under the cervix in the posterior fornix and aid visualisation.
If the cervix is anterior because of an introverted uterus, the speculum should be more forward and itself inverted.
Once the cervix is located, use sponge forceps(which have grooves to secure the grooved Dilapan-S® dilator handle), insert the first dilator as per training and continue until 4-5 dilators are in situ.
Once the desired dilators are in place, check that all you can visualise is the plastic handles outside the cervix, and the whole length of the brown dilator is within the cervical canal. You may have to adjust the dilators to ensure this.
Remove the speculum carefully to avoid dislodging the dilator handles. Be careful not to pinch the skin when closing the speculum or pulling the strings which could dislodge the dilators.
If performing digital insertion:
As with speculum insertion, ask the woman to position herself in way to tilt her pelvis.
Use the sponge forceps to hold the Dilapan-S® securely as per training. The forceps will provide additional length to access the cervix.
Proceed as you would when performing an ARM: as if the sponge forceps and dilator are like an amnihook.
Locate the cervix and run the Dilapan-S® along your finger until you are through both the external and internal os. You may feel a ‘pop’ sensation as you do this.
Continue the same process until the desired number of dilators (4 – 5) are inserted.
Keep hold of the cervix with your finger throughout the procedure for maternal comfort. It may be helpful to ask a colleague to place the additional dilators in the sponge forceps until you are comfortable doing this yourself.
One of the most important points to remember for both digital and speculum insertions:
Ensure that the dilators are inserted through both the internal and external os, otherwise, there will be funnelling of the cervix where the internal os remains closed (only the external os was dilated).
To ensure that the dilators are inserted correctly, regardless of whether the cervix is shorter than the length of the dilator or if the fetal head is low, is to check that all dilators are fully inserted and their plastic handles are in line. This is important for both digital and speculum insertions. This can be done visually or by feel, using the end of the sponge forceps.
Make a note of the number of rods inserted and remind the patient what she can and cannot do while the rods are in situ.
Refer to your Dilapan-S® training, read your IOL guideline and use the patient information resources available.
Email midwives@aghealth.co.uk to arrange training in your hospital.
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