How a Pelvic Exam is Performed
The client should not douche before the examination. On the examination table the client should be lying in the lithotomy position (lying flat on back), her thighs flexed and abducted (knees up), her feet resting in stirrups for support, and her buttocks extending slightly beyond the edge of the examining table. A pillow should support her head.
Relaxation is essential for an adequate examination. To achieve it:
1. The client should be given an opportunity to empty her bladder. An ideal solution would be to obtain the client's urine test before beginning the exam. This way her bladder has been emptied and you have her urine sample for testing.
2. Drape her appropriately with a clean sheet or paper drape. Some clients are more comfortable when a drape is extended well over the thighs and knees. Others prefer to watch both the practitioner and the examination itself and object to drapes that obscure their view. Ask the client which method she prefers.
3. The client's arms should be at her sides or folded across her chest.
4. Explain in advance each step in the examination, avoiding any sudden or unexpected movements.
5. Have warm hands and a warm speculum.
6. Monitor your examination when possible by watching your client's face.
SET UP ALL SUPPLIES NEEDED.
Equipment should be within reach and should include a good light source, a vaginal speculum of appropriate size, and materials for bacteriologic cultures and Papanicolaou smears (Pap smears), if these are to be done. Wear gloves. Male examiners should be attended by female assistants. Female examiners may or may not prefer to work alone but should be similarly attended if the client is emotionally disturbed or upset.
The examiner should be sitting comfortably between the clients legs, low enough to obtain a good visiual of the genitalia, but high enough to maintain visual eye contact with the client's face for communication.
INSPECTING THE CLIENT'S EXTERNAL GENITALIA
The examiner should sit comfortably and inspect the mons pubis, the labia and perineum. With a gloved hand, separate the labia and inspect:
1. The labia minora.
2. The clitorus.
3. The urethral orifice.
4. The vaginal opening or introitus.
Itchy, small, red maculopapules suggest pediculosis pubis (pubic lice). Look for nits and lice at the bases of the pubic hair.
Enlarged clitoris in masculinizing conditions.
Lesions of the vulva.
Note any inflammation, ulceration of Skene's glands (e.g., from gonorrhea) is suspected, insert your index finger into the vagina and milk the urethra gently from the inside outward. Note any discharge from or about the urethral orifice. If present, a culture should be taken.
If there is a history or appearance of labial swelling, check Bartholin's glands. Insert your index finger into the vagina near the posterior end of the introitus. Place your thumb outside the posterior part of the labia majora. On each side in turn palpate between your finger and thumb for swelling or tenderness. Note any discharge exuding from the duct opening of the gland. If present, culture it. Note any surgical scars (episiotomy or other scars) and other abnormalities.
Assess the support of the vaginal outlet. With the labia separated by your middle and index finger; ask the client to strain down. Note any bulging of the vaginal walls.
INTERNAL EXAM INSTRUCTIONS
Inspect the vagina and cervix next using a speculum. A speculum is placed inside the vagina and opened. The speculum is an instrument that holds the vaginal walls apart and allows the examiner to see the cervix and vagina and check for inflammation, infection, scars or growths. There may be some feeling of pressure on the bladder or rectum with the speculum in place. Select a speculum of appropriate size, lubicate it and warm it with warm water. (Other lubricants, such as K-Y Jelly, may interfere with cytological or other studies but they may be used if no such tests are planned.) By having your speculum ready during assessment of the vaginal outlet, you can ease speculum insertion and increase your efficiency by proceeding to the next maneuver while the client is still straining down.
Place two fingers just inside or at the introitus and gently press down on the perineal body. With your other hand introduce the closed speculum past your fingers at a 45-degree angle downward. The blades should be held obliquely and the pressure exerted toward the posterior vaginal wall in order to avoid the more sensitive anterior wall and urethra. Be careful not to pull on the pubic hair or to pinch the labia with the speculum.
After the speculum has entered the vagina, remove your fingers from the introitus. Rotate the blades of the speculum into a horizontal position maintaining the pressure posteriorly.
Open the blades after full insertion and maneuver the speculum so that the cervix comes into full view.
When the introitus is retroverted, the cervix points more anteriorly than diagrammed. Position the speculum more anteriorly, i.e., more horizontally, in order to bring the cervix into view.
Inspect the cervix and its os. Note the color of the cervix, its position, any ulcerations, nodules, masses, bleeding or discharge. A normal cervix will appear pinkish in color. The cervix will appear as purplish in color if a woman is pregnant. Secure the speculum with the blades open by tightening the thumb screw.
OBTAINING SPECIMEN SAMPLES
If you are going to obtain specimens for cervical cytology (Papanicolaou smears, also known as a pap smear). Take these steps in order:
1. The Endocervical Swab: Moisten the end of a cotton applicator stick with saline and insert it into the os of the cervix. Roll it between your thumb and index finger, clockwise and counter clockwise. Remove it.
Smear a glass slide with the cotton swab, gently in a painting motion. (Rubbing hard on the slide will destroy the cells.) Place the slide into the ether-alcohol fixative at once.
2. Cervical Scrape: Place the longer end of the scraper on the os of the cervix. Press, turn and scrape. Smear on a second slide as before.
3. Vaginal Pool: Roll a cotton applicator stick on the floor of the vagina below the cervix. Prepare a third slide as before. If the client has an infection or a discharge from the cervix or the vagina, this would be a good time to take a sample with a cotton swab for analysis.
If the cervix has been removed, do a vaginal pool and scrape from the cuff of the vagina.
VAGINAL INSPECTION
Do a vaginal examination. Withdraw the speculum slowly while observing the vagina. As the speculum clears the cervix, release the thumb screw and maintain the speculum in its open position with your thumb. Close the blades as the speculum emerges from the introitus, avoiding both excessive stretching and pinching of the mucosa. During the withdrawal, inspect the vaginal mucosa, noting its color, inflammation, discharge, ulcers or masses.
BIMANUAL INSPECTION
Perform a bimanual examination. From a standing position, introduce the index and middle finger of your gloved and lubricated hand into the vagina, again exerting pressure primarily posteriorly. Your thumb should be abducted, your ring and little fingers flexed into your palm. Note any nodularity or tenderness in the vaginal wall, including the region of the urethra and bladder anteriorly.
Identify the cervix, noting its position, shape, size, consistency, regularity, mobility and tenderness. Palpate the fornix around the cervix. Note that during pregnancy, the cervix will be softer in consistency (like palpating your lips) as compared to nonpregnancy (like the end of your nose).
Place your abdominal hand about midway between the umbilicus and symphysis pubis and press downward toward the pelvic hand. Your pelvic hand should be kept in a straight line with your forarm, and inward pressure exerted on the perineum by your flexed fingers. Support and stabilize your arm by resting your elbow either on your hip or on your knee which is elevated by placing your foot on a stool. Identify the uterus between your hands and not its size, shape, consistency, mobility, tenderness and masses. This procedure may cause some discomfort for the client. Uterine enlargement suggests pregnancy, benign or malignant tumors.
Place your abdominal hand on the right lower quadrant, your pelvic hand in the right lateral fornix. Maneuver your abdominal hand downward, and using your pelvic hand for palpation, identify the right ovary and nay masses in the adnexa. Three to five years after menopause, the ovaries have usually atrophied and are no longer palpable. If you can feel an ovary in a post-menopausal woman, suspect an ovarian tumor. Note the size, shape, consistency, mobility and tenderness of any palpable organs or masses. The normal ovary is somewhat tender. Repeat the procedure on the left side.
Vaginal-Rectal Exam: Withdraw your fingers, removing your gloves and throwing them away. Reglove using fresh, clean gloves. Place lubricant (K-Y Jelly) on internal exam glove. Then slowly reintroduce your index finger into the vagina, your middle finger into the rectum. Ask the client to strain down as you do this so that her anal sphincter will relax. Tell her that this examination may make her feel as if she has to move her bowels - but, she won't. Repeat the maneuvers of the bimanual examination, giving special attention to the region behind the cervix which may be accessible only to the rectal finger. In addition, try to push the uterus backward with your abdominal hand so that your rectal finger can explore as much of the posterior uterine surface as possible. Check the rectum itself and other nearby structures for any abnormalities.
AFTER EXAMINATION
After the examination, wipe off the external genitalia and anus or offer the client some tissue with which to do it herself.