The Gynaecological Examination

Angela Laughton

Clinical Education Manager/Midwife

Bradford Teaching Hospitals NHS Trust

General Examination

Introduction and smile! General examination of hands and mucous

membranes Supra-clavicular lymph nodes should be felt Thyroid gland should be palpated ‘Chest & Breasts’ Proceed with abdominal and pelvic

examination

Abdominal examination

Patient preparation!InspectionPalpationPercussionAuscultation (if appropriate)

Pelvic Examination

Patient informed consent and chaperoneInspection of external genitaliaAsk patient to strain and/or coughSpeculum examinationBimanual examination

Speculum Examination & Smear testing

Aims

To understand:Indications for speculum examinationThe process of bivalve & univalve

speculum examinationCommon findingsIndications for cervical smearThe process of taking a cervical smear

So why do we do it??

Speculum Examination Indications

Routine screeningProlapsePostcoital bleeding, intermittent

menstrual bleedingPainful intercoursePresence of infection / discharge

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

GlovesSpeculumLubricating jellyExamination couch and a ‘modesty

sheet’Adequate lightingEnsure speculum is warmed and all

equipment is in working order

Positioning

Patient should be supine.Place heels together with knees bent &

allow legs to ‘fall’ apart.The light should be adjusted to allow a

good view of the vulva and perineum.

Inspection

Hair distribution Vulval skin Look at the perineum

for scars/tears Gently part labia –

inspect urethra Look for discharge,

prolapse, ulcers, warts

Insertion

• Hold speculum so blades are orientated in direction of vaginal opening

• Part the labia and slowly insert, rotating the speculum until its blades are horizontal

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 CystoceleLiquor

Taking a Cervical Smear

When and why?

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- Ca Cx second most common malignancy

Taking a cervical smear

Following insertion of bivalve speculumEquipment:Aylesbury spatulaConfirm name, DOB, hosp number etcLabel frosted end of slide

•Explain that the procedure may be uncomfortable

Taking a Cervical smear

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.

What do the results mean?

Normal- means you have very low chance of developing ca of the cx but not 100% guarantee)

Inadequate- no true result can be given as ‘inadequate’ sample. Repeat smear indicated

Abnormal- minor changes are quite common, repeat smear 3-12 months advised

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