objectives • To know the indication for pelvic examination • To know the technique and value of speculum examination. • To know the technique and value of bimanual examination. • To know how to do a pap smear and what is its value. • To know how to examine the vagina during labor.
Indications of pelvic exam • Check the health of the reproductive organs and to diagnose any problem. • Prescribe and/or fit birth control devices • Check for vaginal infections or STDs • Determine pregnancy or miscarriage • Screen for cervical cancer, which can be treated and cured if found early
Before the exam(What patient should do?) • Tell your health care provider the reason for your visit • You will be asked about your period • You will be asked about your medical history • You will get ready for the exam, undress and put on a gown
The Actual Exam(What patient should do?) • The pelvic exam is simple. There are 3 or 4 steps. You will lie down on a table. The table has stirrups for your feet. You will spread your knees and legs open so your genital area is easier to see. • Try to relax. The more relaxed you are, the more comfortable the exam will be.
1-External Exam(What patient should do?) • First, your vulva or outside sex organs are checked for any growths or rashes. Be sure to say if you’ve noticed anything unusual.
Preparation • Explain details of the procedure and gain verbal consent • Ask the patient to empty her bladder & remove any sanitary protection. • Allocate a separate private area for the patient to undress. • Chaperone should always be present.
Equipment • Gloves • Speculum • Lubricating jelly • Examination couch and a ‘modesty sheet’ • Adequate lighting • Ensure speculum is warmed and all equipment is in working order
Inspection • Hair distribution • Vulval skin • Look at the perineum for scars/tears • Gently part labia – inspect urethra • Look for discharge, prolapse, ulcers, warts
Visualisation of Cervix • Inspect for: • Discharge • Warts • Tumours • Size of cervical os • Bleeding
Univalve Speculum Positioning • Position patient in the left lateral position • Knees drawn up to chest • Hold back anterior vaginal wall with lubricated speculum
Findings • Ask the patient to cough: • Rectocele • Cystocele • Liquor
Indications of cervical smear • Women are invited to have routine smears performed every 1-3 years • Needs to be done in the mid-late follicular phase and NOT during menstruation • Worldwide- cancer cervix second most common malignancy
Taking a cervical smear( technique) • Following insertion of bivalve speculum • Equipment: • Aylesbury spatula • Confirm name, DOB, hosp number etc • Label frosted end of slide • Explain that the procedure may be uncomfortable
Taking a Cervical smear( technique) • Rest point of spatula within the os and rotate clockwise 360° then rotate 360° anti-clockwise. • Exert light pressure (pencil). • Ensure contact with cervix throughout.
Concluding Cervical Smear • Spread both sides of the spatula onto the slide. • Place immediately into the fixative for between 10 – 90 mins. • High-risk specimens should be left in for a minimum of 1 hour. • Inform the patient how long the results will take and how they will be delivered.
Bimanual Examination • Separate labia with gloved left hand • Inserted index finger into vagina then slowly insert middle finger to palpate cervix • Left hand then palpates uterus abdominally
Tips of the vaginal fingers placed into each lateral fornix and the adnexae are examined on each side • The uterosacral ligaments can be felt in posterior fornix
When to have a pelvic exam: • Routine checkup every year • Heavy vaginal discharge that itches, burns or smells • Heavy vaginal bleeding or bleeding between periods • Painful intercourse • Menstrual cramps that cause to miss school or work • Any signs of pregnancy • Side-effects of birth control • No periods by age 16
Examination during labor • Palpate uterine contractions • Assessment of the cervix dilatation • 1 finger 1-2 cm dilated • 2 fingers 3-4 cms dilated • 3 fingers 5-6 cms dilated • 4 fingers 7-10 cms dilates
3. Effacement of the cervix: thinning of the cervix (%) or length (cm). The cervix is normally 3-5 cms. If cervix is about 2 cm from external to internal os 50% effaced 50% effaced 100% effaced
4. Consistency of the cervix: soft vs. hard. During labor the cervix becomes soft. 5. Position of the cervix: posterior vs. anterior. During labor the cervix changes from posterior to anterior. 6. Membrane is intact or ruptured: assessed by fluid collection in the vagina