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

Technique

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.

2-Speculum Exam

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 Hair extending towards umbilicus and onto inner thigh can be associated with disorders of androgen excess and clitoromegaly. Vulva can be a site of chronic skin conditions such as eczema, psoriasis, Lichen sclerosis and warts, cysts of the Bartholin’s gland and cancers. Ulceration may imply herpes, syphilis, trauma or malignancy. Perineal scars maybe secondary to childbirth.

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

Taking a Cervical Smear

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.

3-Bimanual examination

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

4-Examination during labor

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) 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 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

Thank you