The Gynaecological Examination

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The Gynaecological Examination

• Angela Laughton
• Clinical Education Manager/Midwife
• Bradford Teaching Hospitals NHS Trust

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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

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Abdominal examination

• Patient preparation!
• Inspection
• Palpation
• Percussion
• Auscultation (if appropriate)

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Pelvic Examination

• Patient informed consent and chaperone
• Inspection of external genitalia
• Ask patient to strain and/or cough
• Speculum examination
• Bimanual examination

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Speculum Examination Smear testing
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Aims

• To understand
• Indications for speculum examination
• The process of bivalve univalve speculum
  examination
• Common findings
• Indications for cervical smear
• The process of taking a cervical smear

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So why do we do it??
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Speculum Examination Indications

• Routine screening
• Prolapse
• Postcoital bleeding, intermittent menstrual
  bleeding
• Painful intercourse
• Presence of infection / discharge

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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.

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Equipment

• Gloves
• Speculum
• Lubricating jelly
• Examination couch and a modesty sheet
• Adequate lighting
• Ensure speculum is warmed and all equipment is in
  working order

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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.

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Inspection

• Hair distribution
• Vulval skin
• Look at the perineum for scars/tears
• Gently part labia inspect urethra
• Look for discharge, prolapse, ulcers, warts

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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

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Visualisation of Cervix

• Inspect for
• Discharge
• Warts
• Tumours
• Size of cervical os
• Bleeding

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Univalve Speculum Positioning

• Position patient in the left lateral position
• Knees drawn up to chest
• Hold back anterior vaginal wall with lubricated
  speculum

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Findings

• Ask the patient to cough
• Rectocele
• Cystocele
• Liquor

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Taking a Cervical Smear
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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

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Taking a cervical smear

• 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

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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.

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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.

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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

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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

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• 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