Assessment of the bearing-down manoeuvre in pregnancy and detection of paradoxical levator ani muscle contraction using 2D transperineal ultrasound and vaginal palpation: a concurrent validity and inter-rater reliability study.

OBJECTIVE: To examine the concurrent validity and inter-rater reliability of vaginal palpation as a measure of the quality of the bearing-down manoeuvre (BDM) and the detection of a paradoxical levator ani muscle contraction (LAM) in pregnant women, compared with 2D transperineal ultrasound (TPUS). DESIGN: Concurrent validity and inter-rater reliability study. SETTING: Physiotherapy clinic. POPULATION: Twenty pregnant women in their third trimester. METHODS: The anterior posterior diameter (APD) was measured during the BDM using TPUS by one experienced physiotherapist. An APD that shortened by >2 mm from rest was described as LAM shortening, an APD that moved by 0-2 mm was described as no change and an APD that lengthened by >2 mm was described as LAM lengthening. Vaginal palpation described the LAM during the BDM as no movement, shortening or lengthening. Participants were allowed two attempts and the best attempt was measured. MAIN OUTCOME MEASURES: APD using TPUS and the assessor's subjective description of LAM during the BDM using vaginal palpation. RESULTS: TPUS detected more paradoxical LAM contractions during the BDM than palpation. Agreement between vaginal palpation and TPUS assessment for BDM was poor. The Fleiss kappa coefficients were 0.457 (90% CI 0.16-0.71) between TPUS and one assessor and 0.326 (90% CI 0.01-0.6) between TPUS and the other assessor. In addition, inter-rater reliability was poor between observers palpating the BDM, with a Fleiss kappa coefficient of 0.375 (90% CI 0.13-0.64). CONCLUSIONS: This study did not find vaginal palpation of the BDM in pregnant women to have concurrent validity or inter-rater reliability. Clinicians should be aware of potential inaccuracies when palpating the BDM, and, where possible, seek an assessment via TPUS.

First-generation student veterans: implications of poverty for psychotherapy.

Student veterans are arriving at university and college campuses and many counselors may not be prepared. Multiple and intersecting identities complicate the student's integration and matriculation into higher education. We review literature on first-generation college students and issues pertinent to student veterans. Using the revised Social Class Worldview Model, this article offers a case example to illustrate how counselors may best work with student veterans.