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! Inspection Palpation Percussion Auscultation (if appropriate) Inspection – look at contour, any obvious mass or distension Presence of surgical scars, dilated veins or stretch marks Raise her head and cough-checking for hernias Palpation-pain ask for site of pain (leave until last) palpate in 4 quadrants Examination for masses and organomegaly Characteristic of pelvic mass is that you cant palpate below it Look for signs of peritonism (guarding and rebound tenderness) Inguinal herniae and lymph nodes Percussion- useful if free fluid suspected (?asities) Shifting dullness/fluid thrill Enlarged bladder will be stony dull to percuss Auscultation-not specifically useful in gynae but a pt will sometimes present with an acute ado ?bowel obstruction/ post op with ileus so you could listen for bowel sounds

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

Speculum Examination & Smear testing

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

So why do we do it??

Speculum Examination Indications Routine screening Prolapse Postcoital bleeding, intermittent menstrual bleeding Painful intercourse Presence 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 Gloves Speculum Lubricating jelly Examination couch and a ‘modesty sheet’ Adequate lighting Ensure 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 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.

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 Cystocele Liquor

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 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 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