PROCEDURE
– Switch on the light source and direct this on the vulva.
– Sit on a stool.
– Put gloves on.
– Inspect the vulva and the mons pubis and note:
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- Anatomical development of the vulva.
- Pubic hair pattern.
- Symptoms of inflammation.
- Swellings.
- Skin lesions.
- Colour.
- Discharge.
– Spread out the labia by placing the thumb and index finger or the second and third finger between the labia major and minor, at the height of the vaginal orifice, and move these laterally and ventrally. Look for Chadwick’s sign.
– Inspect the perineum.
– Look for lacerations and the presence of scars from ruptures and episiotomies.
– Inspect the anus.
– Look for haemorrhoids.
For detailed information about abnormalities refer to the The Gynaecological Examination.
The Speculum Examination And The Cervical Smear
After the external examination, the speculum examination with inspection of the internal genitals can take place, together with a Pap smear, if required.
A cervical smear is only indicated if the last one took place more than two years ago, was classified as higher than PAP II, or if the woman belongs to a risk category.
When performing a Pap smear on a pregnant woman, due consideration must be given to oedema of the uterine cervix and a greater vulnerability due to increased vascularisation of the underlying stroma. This hinders the collection of endocervical cells.
Some practitioners believe it is preferable not to take the smear from the endocervical canal, as this disrupts the cervical mucous barrier (danger of infection) and the amniotic membranes could be torn. Therefore, during pregnancy, the Pap smear should be taken from the ectocervix.
Pregnancy and parturition have far-reaching effects on the cervical epithelium and the subepithelial tissue. Due to eversion of the endocervical epithelium and the opening of the external cervical ostium, the epithelium comes into closer contact with the acidity of the vaginal discharge. Metaplastic squamous epithelium subsequently forms in the exposed epithelium. It can be difficult to differentiate between physiological cellular pregnancy changes and pathological cellular changes. Therefore, for the benefit of the pathologist, the existence of a pregnancy should be clearly stated on the request form.
PROCEDURE
– The examiner should perform the speculum examination while sitting.
– Dip the tip of the speculum several centimetres into glycerine or oil and allow the excess fluid to drip off into the kidney bowl. Alternatively, moisten the lowest few centimetres of the speculum blades with Hibitane® or warm water. The use of lubricating agents is not recommended when taking samples of discharge or performing a smear test.
– Spread the labia so that the vaginal orifice is clearly visible and keep these spread until the speculum has been inserted to sufficient depth, in order to prevent pubic hair or parts of the labia minor being pulled inwards [Figure 1].
Figure 1
– Hold the closed speculum ‘loosely’ in the hand and keep the forearm low.
– Insert the closed speculum at an angle of 45° into the vaginal orifice in the direction of the vaginal axis. With this approach, the urethra at the height of the orifice is avoided [Figure 1].
– Allow the speculum to slowly slide into the vagina in the direction of the vaginal axis. Exert pressure on the posterior vaginal wall with the speculum to prevent pressure on the urethra.
– When 1/3 of the closed speculum is inserted in the vagina, it should be rotated by 45° to the horizontal position [Figure 2].
Figure 2
– Allow the speculum to glide further into the vagina until the blades have been completely inserted. The tip of the rear blade of the speculum should be positioned horizontally in the posterior vaginal fornix [Figure 3].
Figure 3
– Retract the speculum by several centimetres and slowly open it with a ‘scooping’ movement until the cervix glides between the blades [Figure 4].
Figure 4
– If the vaginal portion of the cervix does not spontaneously come to lie between the blades, then with gentle movements, carefully change the angle of the speculum relative to the vaginal axis. By doing this, the cervix is scooped up and will end up directly between the blades. If the examiner still experiences difficulties bringing the vaginal portion of the cervix into view, they should ask the woman to relax as much as possible by pressing the lumbar part of the vertebral column against the examination table.
– If necessary, push the open speculum several millimetres further into the fornices and fix it. Never allow the speculum to be freely located in the vagina. If necessary, ask the woman to hold the upper edge of the speculum with one or two fingers [Figure 4].
– When inspecting the cervix note:
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- Cervical length (long/effaced).
- Cervical orifice (open/closed).
- Chadwick’s sign (livid discolouration of vaginal portion of the cervix).
– Carefully remove any excess cervical mucus using a cotton bud or a syringe.
– Position the rounded/blunt end of the Ayre spatula in the external orifice. Make two 360° rotations in the same direction.
– Pick up the slide.
– Place the spatula flat on the slide, push firmly and wipe off the spatula with a single smear.
– Fixate as quickly as possible, preferably within 10 seconds of taking the preparation, by spraying the slide at a distance of about 20 cm with a fixating spray. Hold the slide perpendicular to the direction sprayed in. When too much fixating spray is used, or if the slide is sprayed at too close a distance, drops may form on the slide and cause the smeared cells to accumulate on the edge of the slide. When the slide is sprayed from too far away, the fixating spray will not sufficiently cover the preparation as a result of which the cells can dry out and can no longer be assessed.
– If a cervical brush is used, then only one slide is needed. In this case, a container with ether alcohol is used for fixation and transport. The cells are obtained by placing the tip of the cervical brush in the orifice and rotating the cervical brush three to five times around its axis in a clockwise direction.
– The direction of rotation is important due to the shape of the hairs.
– Laboratories are increasingly opting for “liquid-based” thin layer cytology after cyto-centrifugation of the cells from the fixation and transport medium. The cervical brush is then no longer smeared on a slide but is instead sent in the transport medium to the cytology laboratory. The sensitivity and specificity of the procedure can be significantly increased as a result of this.
– Retract the speculum by several millimetres so that the cervix is exposed.
– Reduce the pressure on the handle so that the speculum half closes.
– Exert some pressure on the posterior wall of the vagina so that the anterior, posterior and lateral walls of the vagina become visible. Make sure that the anterior wall of the vagina (urethra) is not touched by the side of the speculum.
– Inspect the vagina wall and note:
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- Surface.
- Colour.
– Reduce the pressure on the handle such that the speculum, under the pressure of the vagina walls, almost completely closes. The speculum should stay slightly open so that no pubic hair or mucous membranes are caught in between.
– Remove the speculum once it has been brought back into the 45° position, in the direction of the vaginal axis.
– Place the speculum in a kidney bowl.
– Place the slide in the preparation holder for delivery to the cytopathology laboratory.
– State on the request form that the woman is pregnant.
Bimanual Examination Of The Genitals
The aim of this examination is to assess the position, size, consistency, surface, mobility and sensitivity of the internal genitals. The patency of the bony pelvis is determined by means of an internal pelvic examination.
PROCEDURE
– Moisten the other glove with lubricant or water.
– The examiner should perform the bimanual examination while standing.
– Use the non-examining hand to spread the external labia at the height of the vaginal orifice by placing the thumb and index finger between the labia major and minor and subsequently moving these laterally and ventrally. Keep the labia spread until the examining fingers have been inserted to sufficient depth.
– Examine with a relaxed wrist, with the forearm roughly horizontal.
– First insert about 1/3 of the middle finger past the posterior commissure, along the posterior vaginal wall. Make space for the index finger by exerting perineal pressure. Then, push the index finger past the middle finger. Avoid pressure on the urethra.
– Keep the wrist low, the thumb away from the clitoris and upper legs, the little finger and ring finger bent.
– Insert the relaxed fingers as deeply as possible into the vagina.
– Place the palm of the external hand (with the fingers held together), transversely across the abdomen above the symphysis, to fix the uterus by exerting pressure on the abdominal contents.
– Palpate first with just the fingers inside the vagina.
– Try to locate the position of the cervix by making a circle around the cervix with the middle finger.
– Determine the position of the cervix with respect to the vaginal axis.
– Feel for:
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- Surface Irregularities: Nabothian cyst, polyp, carcinoma, laceration.
- Consistency: Very firm, firm-elastic, soft (the tissue becomes tender and engorged with blood vessels at an early stage in the pregnancy).
– Feel towards the external orifice with a fingertip:
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- Open or closed.
- Shape: cleft-shaped, ‘pinpoint’.
– Hold the cervix between the spread fingers and move it from side to side. While doing this remove the hand from the abdomen.
– Note the following:
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- Mobility
- Tenderness (extra-uterine pregnancy).
– Feel the fornices by moving two fingers next to each other from the lateral left side (high up along the cervix) via the posterior fornix, and then laterally to the right to the anterior fornix.
– Note the following:
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- Shape and depth of the fornices.
- Tenderness (extra-uterine pregnancy).
- Consistency of the tissue.
- Pulsating blood vessels next to the uterus.
– Place the two examining fingers at the transition between the vaginal portion of the cervix/uterus in the posterior fornix and push the uterus upwards. As a result of this, the uterus can be palpated between the two hands and its size, shape and consistency can be determined. If the uterus is palpable between the two examining hands, then it is in the AVF (anteversion/anteflexion) position.
– Press the abdominal wall slowly and gradually inwards such that the fundus can be felt through the abdominal wall.
– Move the fingers in the anterior fornix, or bilaterally in the lateral fornix, towards the external fingers so that pressure can be exerted on the uterus which is located in between (to determine the position and consistency of the uterus).
– Note the following aspects of the uterus:
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- Position.
- Mobility (can move freely or fixed).
- Consistency: Softening lower uterine segment (LUS). Hegar’s sign is positive if the cervix appears to be positioned ‘free’ from the uterus (from 6th-7th week of pregnancy)
- Shape: In the first 12 weeks of pregnancy, the foetus often grows asymmetrically. This can result in a localised outward protrusion of the uterine fundus. This phenomenon is termed Piskacek’s sign.
- Size: This is indicated according to the number of pregnancy weeks or in centimetres. The uterine body of a non-pregnant uterus is about 8 cm in size.
– Try to gain an impression of the adnexa and parametria.
– Move the vaginal fingers high into the right lateral fornix and keep them still.
– Move the palpating fingers of the external hand about 3 cm medially to the level of the right anterior iliac spine, with the wrist level with the symphysis. Ask the woman to breathe slowly in and out, and during the expiration gradually push the fingers deeper, keeping them flat and together. If necessary, repeat this several times.
– Spread the examining fingers slightly and move them in the lateral fornix towards the external fingertips.
– Move the external hand in a sweeping manner towards the symphysis ensuring that the examining fingers follow the external fingers.
– Pay attention to the woman’s face.
– Note the following:
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- Ovary: Position, shape, size, consistency: mobility with respect to the uterus: tenderness.
- Fallopian tubes: Normally not palpable.
- Parametria.
- Consistency (succulent).
- Masses.
- Tenderness.
– Repeat the examination in the left lateral fornix to assess the left adnexa.
– When removing the examining fingers, feel the vagina wall.
– Remove the glove (make a fist, slowly pull the cuff over it).
– Inform the woman that the examination has been completed, and help her off the gynaecological examination table and ask her to get dressed again.
– Offer a sanitary towel if there is discharge or blood loss.
– Once the woman is dressed, tell her about the findings of the examination.
– If the cervix bled when the smear was being taken, tell her that she may lose a small quantity of blood either now or in the very near future. Explain the cause of this and tell her that this loss of blood is, in principle, not harmful. Instruct her to contact you if:
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- This loss of blood is more than the blood loss at the end of one of her normal menstrual periods.
- The blood loss persists more than 48 hours.
- Pain symptoms occur during the blood loss.
– Clean the materials used and place these in the disinfectant.
Significant diagnostic difficulties can be encountered during the interpretation of abnormalities of the uterus, adnexa and parametria in the early stages of pregnancy. An ultrasound scan may then be indicated.
After the first trimester, bimanual examination of the adnexa is less reliable. As the uterus becomes larger, the ovaries are luxated out of the pelvis and this makes palpation more difficult. In advanced pregnancy, palpation of the ovaries is no longer possible.