Modified by: Dr/Amaal Rayan Pelvic examination Modified by: Dr/Amaal Rayan

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 (sexual transmitted diseases) Determine pregnancy or miscarriage Screen for cervical cancer, which can be treated and cured if found early

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 you to miss school or work Any signs of pregnancy Side-effects of birth control

1-PV

Procedure before examination. 􀂃 Obtain her verbal consent 􀂃 Explain that you are about to perform an internal examination of the vagina and the uterus using fingers. 􀂃 Explain to her that it shouldn't be painful and ask her to let you know if there's any pain

Procedures before examination 􀂃 Ask her to empty bladder . 􀂃 Assure privacy and ask for a chaperone . 􀂃 Ask to lie on the couch and undress, waist down 􀂃 Sheet for dignity 􀂃 Position her on back, hips and knees flexed and thighs abducted. 􀂃 Examine abdomen for any mass and be sure bladder is empty.

Examination 1- Inspect external genitalia 􀂃 Hair distribution 􀂃 warts 􀂃 rashes 􀂃 ulcers 􀂃lumps 􀂃 vesicles 􀂃 excoriation

2- Examination (urinary incontinence) 􀂃 Ask the patient to bear down . 􀂃 Ask the patient to cough (urinary incontinence) 􀂃 Ask the patient to bear down (uterine prolapse). .

3-Gloves then palpate: Urethral meatus, Labia, Bartholin’s glands and Perineum 4- Lubricate the right index and middle fingers. 􀂃 5- Expose introitus by separating labia with thumb and forefinger of gloved left hand . 􀂃6- Gently introduce gloved lubricated right index and middle fingers into vagina. 􀂃 7-Thumb abducted to allow maximum use of length of the index & middle fingers; ring & little fingers flexed into palm.

8- Palpation: Palpate anterior ,posterior and lateral walls of vagina ? obliterated or bulging due to a pelvic swelling mass, cyst or foreign bodies.

9-Examination of the cervix Normally points downwards and slightly backwards.􀂃 Cervix should feel firm, rounded and smooth. Assess mobility move cervix gently Palpate the fornices. This procedure is painless Tenderness is called “cervical excitation.”

2-Speculum exam

Preparation Explain details of the procedure and gain verbal consent Ask the patient to empty her bladder 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

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, hospital 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

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

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