Part 2

1. Part 2 Routine Gynecologic Health Care

2. Module 1 Facilitating a GYN Examination

3. ObjectivesFacilitating a GYN Examination At the completion of this module the participant will be able to: • Identify the areas that may require special attention when taking a reproductive health history in WWD. • Discuss the preparation and components required in safely transferring WWD to the examination table. • Describe strategies to minimize spastic activity during pelvic examinations. • Describe 5 alternative positions for accomplishing a pelvic examination.

4. Preparation for the Appointment • Schedule a longer appointment • Select the most accessible exam room and have necessary equipment available • Practice with staff • Ask for patient’s preferences • Providing assistance • Safe transfer techniques • Flag the chart to indicate patient requires accommodation

5. History: what to include • Reason for the visit • Menstrual history: • Menstrual calendars can be very helpful • Ask about specific symptoms associated with the periods, e.g. increased seizure activity, mood changes • Sexual history: • Women with disabilities are often seen as asexual. Ask specifically about sexual activity, past and present, abuse history and need for birth control. • Gynecological history • Reproductive history and reproductive plans/desires • Discuss past pelvic exam history and experience

6. Preparing for the Pelvic Exam

7. ADA Requirements for Office Adaptation If a physician's office does not provide an examination table that can be accessed, the office must provide assistance to help patients onto the high tables, including lifting them if necessary. Such measures must be undertaken in a safe manner to avoid injury to the patient and to preserve the dignity of the patient as much as possible. Source: ADA 1990 1

8. Transferring to the Examination Table

9. Adjustable Examination Table Lowers to 17-20 in. Side rails and leg rests

10. Transfer Assistance

11. Accomplishing Safe Transfers

12. Transfer to a High-Low Table Source: Simpson KM. Table Manners and Beyond.20012

13. Assisted Transfers with a board • A transfer board can provide support and increase safety • Requires exam table to be close and at the same height as the wheelchair seat height Source: Sure Safety Transfer Board 3

14. Easy Pivot Lift • Safe and effective transfers • Useful for skin inspection and undressing as well as transfers • Operated by single assistant • Requires no effort from user Source: Easy Pivot Lift 4

15. Sling (Hoyer-type) Lift • Manual or battery powered • May be portable or permanently installed • User is suspended in sling during transfer Source: Ultralift 1000 5

16. Two-Person Transfer One assistant stands behind the patient and lifts under the arms A second assistant stands in front of the patient and lifts under the knees Patient seated in wheelchair crosses her arms Source: National Institute of Dental and Craniofacial Research, NIH 6

17. Positioning on the exam table Be aware of:

18. Pelvic Exam – Managing Spasticity • Slow, gentle positioning can minimize spastic activity • Use of diazepam or Baclofen should be done with great care 7, 8(see text) • A local anesthetic gel may be helpful in minimizing discomfort and unintended stimulation

19. Pelvic Exam – Important tips

20. Pelvic Exam – Choice of Speculum • Try a small narrow Pedersen for women with narrow introitus • Some WWD will have pelvic laxity and a larger Graves speculum is helpful Pederson Speculum Graves Speculum

21. Pelvic Exam – Other Considerations

22. Side-Lying Knee Chest Position • When side-lying position needed • Lower leg may be straightened • Assistant supports legs, turning • Insert speculum with blades pointing to back Source: Simpson, Table Manners and Beyond, 20012

23. Diamond Position • Offers more support • Assistant(s) may support knees and feet • Insert speculum handle up • Perform bimanual from side of table Source: Simpson, Table Manners and Beyond, 20012

24. OB Stirrup Position • Assist in leg placement • Use padding and straps if necessary • Insert speculum handle down • Perform bimanual from foot of table Source: Simpson, Table Manners and Beyond, 20012

25. V Position • Assistant(s) support one or both legs at the knee and ankle • Insert speculum handle up • Perform bimanual from side of table Source: Simpson, Table Manners and Beyond, 20012

26. M Position • Offers support • Useful for amputees • Insert speculum handle up • Perform bimanual from side of table Source: Simpson, Table Manners and Beyond, 20012

27. Coding Suggestions • Understanding and using E/M service codes is essential for appropriate billing. • See ACOG Quick Reference on CPT Coding for Women with Disabilities (12)

28. Summary – The GYN Examination Preparation and communication are key • Prepare patient, space, staff, equipment • Communicate with patient, staff • Review and refine

29. Facilitating the GYN ExaminationModule Quiz True/False • When taking a patient history, discuss previous experience with a pelvic exam. • Ask the patient about her transfer needs and techniques that work for her. • A technique to manage spastic activity during the examination include using a slow and gentle approach. • Use a pediatric speculum for who have a narrow introitus or limited hip mobility. • Positioning for a pelvic examination requires that the patient be on her back

30. References – Part 2 Module 1

31. References – Part 2 Module 1

32. Module 2 GYN Health Care

33. ObjectivesGYN Health Care At the completion of this module, the participant will be able to: • Identify the barriers to and special considerations needed for breast and cervical cancer screening for women with disabilities. • Discuss barriers to identification and treatment for sexually transmitted infections in WWD. • Understand the requirement for the examination of the skin and identification of potential skin breakdown.

34. GYN Cancer Screening

35. GYN Cancer Screening

36. Cervical Cancer Screening

37. Cervical Cancer ScreeningOccurrence Source: Chan 1999 (1) and Diab 2004 (2)

38. Attitudinal BarriersCervical Cancer Screening

39. Environmental BarriersCervical Cancer Screening Source: Nosek & Howland 19974

40. Autonomic Dysreflexia (ADR)

41. Overcoming Attitudinal BarriersCervical Cancer Screening • Ask all patients about sexual activity and other risk factors for HPV • Involve the patient in her care and ask how the exam can be made easiest for her • Take time with the patient or reschedule for the exam at a better time

42. Overcoming Practice Barriers Cervical Cancer Screening

43. Cervical Cancer Screening Frequency Considerations • Criteria for screening start and intervals are the same as in the general population • If too uncomfortable to do exam, assess risk of HPV infection • Sexual activity • Number of partners • Smoking • History of previous HPV • Discuss with patient a reasonableapproach

44. Using Anesthesia for Pelvic Exam

45. Breast Cancer Screening

46. Mammography Scenario

47. Breast Cancer Screening • Women over age 65 with 3 or more functional limitations (FLs) were less likely (28.3%) to receive a mammogram in the last year than women with no FLs (37.9%). Chevarley, 200612 • Women over age 50 with self-reported cognitive limitation were 30% less likely than women without cognitive limitation to utilize mammography. Legg, 200413

48. Breast Cancer Screening Women’s Identified Barriers Source: Nosek & Howland 19974

49. Attitudinal BarriersBreast Cancer Screening

50. Environmental BarriersBreast Cancer Screening • Physical • Access to mammography sites and machines • Social • Adequate help not available