1. Taking a Cervical Sample
Cervical Screening QARC Training School
October 2012

2. Cervical Cancer Risk Factors
Never had a cervical screen
Infection particularly HPV
Smoking
Contraception
Pregnancy
Sexual behaviour
Immunosuppression

3. Taking a Cervical Sample
A Screening test should be taken in such a way as to provide an adequate sample for assessment with the minimum of distress or discomfort.
Cervical Screening RCN Guidance for Good Practice.
December 2006

4. The environment Privacy Warmth Lighting Relaxed atmosphere Comfort
Modesty blanket

5. The equipment Specula (Disposable) Waste disposal
Sampler (check condition of brush)
Pot with Fixative solution (check the expiry date)
Lubricant
Ball point pen
Forms (Open Exeter)
Gloves (including latex free)
Leaflets including ‘The Facts’
Good light source

6. The woman
Welcome
Check identity – do not complete form before woman is present
Explanation
Information
Answer questions
Obtain informed consent

7. Consent Consent must be obtained by the nurse taking the sample
Consent should be informed or it is not valid
Women should be made aware of the risks and benefits of screening
Consent can be withdrawn at any time during the procedure
Self referral shows implied consent - a written consent is not needed

8. Taking a history Obtain and record relevant details
Any abnormal bleeding i.e. heavy periods, post coital, intermenstrual or post menopausal bleeding and/or unusual vaginal discharge
Consider if a cytology sample is still appropriate – or should direct referral to COLPOSCOPY be considered?

9. Taking a history cont …
Check on contraception - is she taking COC, POP, Depo Provera, IUCD, Mirena, implant?
Is she on HRT/Tamoxifen?
If not using pre-populated form i.e Open Exeter or Ice, details of past screening hx/treatment/follow-up should be recorded

10. Preparation of the form
Woman’s current full name, previous name, address with postcode, date of birth
NHS number
Name & address of GP and GP code
Personal sample taker code
Clinic number, if appropriate
Date of last sample
Past history of abnormal sample, and details
First day of last period
Abnormal bleeding
Use of hormones, IUCD etc
Clinical details, e.g post-natal status if less than 3/12

11. Labelling the sample
Pre-printed labels maybe used (but details must be clarified with patient and initialled)
Write clearly in ball point pen
Surname & Forenames
Date of birth
NHS Number

12. To Print HMR from Open Exeter and view screening history
Guidance for Practice Staff
Adobe Reader has to be installed on your PC. You can download this for free by going to and following the instructions on screen
Quick tip – do remember to enable pop up boxes otherwise you will not be able to print the form
Go to:-
Same password and log-in for Open Exeter
In Application drop down box choose Patient Details
Press CONTINUE box
Select Patient by inputting her NHS Number if available. Otherwise input her surname, forename and date of birth
Press SEARCH
From the choice displayed in box situated top left hand corner of screen choose either HMR101 form – editable or HMR101 form – A5PDF (2009)
If you have chosen HMR101 form A5PDF(2009), the form you wish to print will be displayed on screen. You cannot make any amendments on screen to this form
Press the printer icon at the top of the page
You need to print the form at the top of a piece of A4 – remember to have the paper in portrait, not landscape
Go to properties, Paper/Quality = A5, Effects = Print Doc on A5, Finishing = Portrait. This last instruction applies to the printer used at the screening department – depending on which printer you use, this could vary.

13. It is essential to complete the following fields on the form when you have taken the sample: Source of sample Sample Taker Sample Taker code Implement used Specimen type Condition Clinical Data – 360 sweep, Cervix visualised and Date of this Test

14. Choosing the speculum Points to consider : Age of women Build of women
Parity
A range of sizes should be available from virgin to Winterton

15. Visualising and assessing the cervix
4/20/2017
Positioning the woman
Inspecting the vulva
Locating the cervix by speculum or digital examination
What to do if you can’t find the cervix
Visualising the cervix
Assessing the cervix
Interpreting what is seen

16. Choosing the sampler A Cervex brush must be used
Consider using an Endocervical Brush IN ADDITION TO A CERVEX BRUSH if there is stenosis of the os, or to pick up glandular cells when following up a previous glandular abnormality
An endocervical brush should never be used on its own
Consider the state of the os
Look at the shape and contours of the os
The transformation zone
Any unusual features

17. Sampling the cervix Technique
Lubricants – use sparingly, if at all – water soluble single use sachet
360 degree sample x 5 with cervex brush/cervex broom
90 degree turn with endocervical brush if used
Adequate pressure (pencil like)
Transformation zone

18. Practical tips for difficult samples
Ask woman to cough
Clenched fists or pillow under buttocks
Winterton speculum
Condom or glove
Digital examination
Seek help – it’s ok to ask!
Refer to Colposcopy

19. Bi-manual examination
Bi-manual examination is NOT necessary when undertaking cervical screening and is not a pre-requisite for the sample taker. Digital examination may only be necessary to assist in the location of the cervix, and not as a means of physical assessment that will aid diagnosis.
Cervical Screening RCN Guidance for Good Practice, December 2006
Further training must be undertaken prior to performing Bi-manual examination.

20. The sample
A high cellular yield will be achieved with correct use of the Cervex brush
Rinse the Cervex brush into the Thin Prep vial using a vigorous swirling motion
Agitate the brush forcefully at least 10 times in the preservative liquid
Check the brush to ensure that no material is clinging to the fronds.
Screw the lid on until the black marks meet or just beyond
Ensure fluid level in vial is visible – do not completely obscure with the label
Ensure vial is correctly and clearly labelled

21. Basic Sample Method Insert longer central bristles into cervical os
Turn in clockwise direction pushing onto the cervix X 5 rotations
The lateral bristles will splay over the ectocervix

23. Stenosed Os
MUST be used TOGETHER
1st then 2ND

24. Endocervical Canal Sampling
AFTER Cervex Brush – insert endocervex brush until flange is at entrance to canal Rotate 1x90° in clockwise direction
Samples from BOTH brushes go into the same vial and should be clearly indicated on the form

25. Wide Ectropian Use cervix brush first to sample+
Use cervix brush first to sample
If required a second Cervix Brush can be used to sample the wide transformation zone – this should be collected by sweeping the transformation zone at least twice
Material sampled from both brushes should be put in the same vial and clearly indicated on the form

26. Transformation Zone

32. Post-menopausal Women
Difficult to sample
Thinner squamous epithelium
Atrophic changes
Painful for the Patient
SCJ difficult to visualise

37. Ending the consultation
The woman must understand -
That a sample has been taken
How she will receive her result
A brief outline of the possible results and follow up
That help, support and written information are available
Double check details and completion of form and pot!!!

38. What every woman should know about screening
The purpose of cervical screening
The meaning of a normal result - LOW RISK not NO RISK
The likelihood of a normal result
The current inadequate rate
What happens after an abnormal result
When and how results are given
The importance of reporting symptoms

39. Completion of the sample request form (HMR101)
On the sample form note if the sample is cervical or vault
Tick that you have visualised the cervix and taken a 360 degree sweep x 5
Note the appearance of the cervix
Abnormal bleeding on taking the sample
Abnormal discharge
Use of additional sampler (endocervical brush)
Insert your Sample Taker Number (mandatory)
Sign own name and date form

40. Documentation Record in notes &/or computer
Visualisation of cervix & sampling of TZ
Date sample taken and by whom
Any pertinent comments related to the procedure or what you have seen
Audit

41. Audit Sample takers need to keep a continual record of their samples
Sample takers need to know personal, local and national statistics for inadequate samples
At least 80% of samples taken from women aged years should contain evidence of TZ sampling
It is the responsibility of the sample taker to ensure that the TZ has been fully sampled
If sample takers’ inadequate rate is out of line with national &/or local standard appropriate advice should be sought
Each practice is notified of their inadequate rate quarterly by Screening Department

42. General points for discussion
Cervical mucus and vaginal discharge
High vaginal & chlamydia swabs
Ectropion
Lubrication
Pregnancy
Post menopausal samples
Vault samples
Inadequate samples
Woman with special requirements

43. Communicating abnormal results
Give clear information when sample is taken
Women will receive results in writing from PCSS
Include an information leaflet
Ensure availability of information, advice and support
Give clear explanation of results and follow up
Be able to discuss terminology, investigations and treatments

44. Inadequate samples
Specimens that are technically inadequate at screening:
Heavily blood stained specimen – insufficient cells seen
Insufficient cells present – possibly due to specimen contamination with lubricant
Insufficient cells present
Mostly endocervical cells (EC) present, insufficient squamous cells
Squamous cells only – insufficient EC cells for follow-up
Squamous cells obscured by polymorphs/debris
Specimens that are inadequate due to Paperwork/Technical reasons
Unlabelled vial arrives with form
Vial contains brush head
Specimen leaked insufficient for processing
Sample taken more than 6 weeks prior to receipt in laboratory
No specimen received - Lab will contact sample taker - if sample with clear identifiers found, will screen as usual
Incorrectly labelled vial/partially incorrect identifying information - Lab will give sample taker opportunity to correct identifying information if appropriate
Speciments that are inadequate due to Sample Taker id number issues
Sample takers must be aware of the necessity for training evidenced by valid sample taker id numbers and the sample taker must be identifiable on all samples screened.
Sample Taker id number absent - Sample takers will be asked to provide a valid sample taker number. If they are unable to do this, the matter will be referred to the local PCT.
Sample Taker id number not recognised

45. Clinical Management National & local guidelines for results
Practice protocols
Provision of support
Referral arrangements