1. 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.

2. 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

3. Technique

4. 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

5. 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.

6. 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.

7. 2-Speculum Exam

8. 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.

9. Equipment Gloves Speculum Lubricating jelly
Examination couch and a ‘modesty sheet’
Adequate lighting
Ensure speculum is warmed and all equipment is in working order

10. 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.

11. Visualisation of Cervix
Inspect for:
Discharge
Warts
Tumours
Size of cervical os
Bleeding

12. Univalve Speculum Positioning
Position patient in the left lateral position
Knees drawn up to chest
Hold back anterior vaginal wall with lubricated speculum

13. Findings
Ask the patient to cough:
Rectocele
Cystocele
Liquor

14. Taking a Cervical Smear

15. 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

16. 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

17. 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.

19. 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.

20. 3-Bimanual examination

21. 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

22. 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

23. 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

24. 4-Examination during labor

25. 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

26. 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

27. 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

28. Thank you