{"id":1692,"date":"2010-12-13T08:17:05","date_gmt":"2010-12-13T08:17:05","guid":{"rendered":"https:\/\/cloverock.info\/mockosce23\/new\/inspection-of-the-external-genitals\/"},"modified":"2023-09-08T17:34:01","modified_gmt":"2023-09-08T16:34:01","slug":"inspection-of-the-external-genitals","status":"publish","type":"post","link":"https:\/\/www.qpercom.com\/sim\/index.php\/obstetrics\/first-check-up\/inspection-of-the-external-genitals\/","title":{"rendered":"Inspection Of The External Genitals"},"content":{"rendered":"<h3><span style=\"text-decoration: underline; color: #003366;\">PROCEDURE<\/span><\/h3>\n<p><span style=\"color: #003366;\">&#8211; Switch on the light source and direct this on the vulva.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Sit on a stool.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Put gloves on.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Inspect the <span style=\"color: #33cccc;\"><strong>vulva<\/strong><\/span> and the <span style=\"color: #33cccc;\"><strong>mons pubis<\/strong><\/span> and note:<\/span><\/p>\n<ul>\n<li style=\"list-style-type: none;\">\n<ul>\n<li><em><span style=\"color: #003366;\">Anatomical development of the vulva.<\/span><\/em><\/li>\n<li><em><span style=\"color: #003366;\">Pubic hair pattern.<\/span><\/em><\/li>\n<li><em><span style=\"color: #003366;\">Symptoms of inflammation.<\/span><\/em><\/li>\n<li><em><span style=\"color: #003366;\">Swellings.<\/span><\/em><\/li>\n<li><em><span style=\"color: #003366;\">Skin lesions.<\/span><\/em><\/li>\n<li><em><span style=\"color: #003366;\">Colour.<\/span><\/em><\/li>\n<li><em><span style=\"color: #003366;\">Discharge.<\/span><\/em><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><span style=\"color: #003366;\">&#8211; 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 <span style=\"color: #33cccc;\"><strong>Chadwick\u2019s sign<\/strong><\/span>.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Inspect the <span style=\"color: #33cccc;\"><strong>perineum<\/strong><\/span>.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Look for <span style=\"text-decoration: underline;\">lacerations<\/span> and the presence of <span style=\"text-decoration: underline;\">scars<\/span> from ruptures and episiotomies.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Inspect the <span style=\"color: #33cccc;\"><strong>anus<\/strong><\/span>.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Look for <span style=\"text-decoration: underline;\">haemorrhoids<\/span>.<\/span><\/p>\n<hr \/>\n<p><span style=\"color: #003366;\">For detailed information about abnormalities refer to the <em><a style=\"color: #003366;\" href=\"index.php\/the-gynaecological-examination\" rel=\"alternate\">The Gynaecological Examination<\/a><\/em>.<\/span><\/p>\n<hr \/>\n<h2><span style=\"text-decoration: underline; color: #003366;\"><strong>The Speculum Examination And The Cervical Smear<\/strong><\/span><\/h2>\n<p><span style=\"color: #003366;\">After the external examination, the <span style=\"color: #33cccc;\"><strong>speculum examination<\/strong><\/span> with inspection of the <span style=\"color: #33cccc;\"><strong>internal genitals<\/strong><\/span> can take place, together with a <span style=\"color: #33cccc;\"><strong>Pap smear<\/strong><\/span>, if required.<\/span><\/p>\n<p><span style=\"color: #003366;\">A <span style=\"color: #33cccc;\"><strong>cervical smear<\/strong><\/span> is only indicated if the last one took place <span style=\"text-decoration: underline;\">more than two years ago<\/span>, was classified as <span style=\"text-decoration: underline;\">higher than PAP II<\/span>, or if the woman belongs to a <span style=\"text-decoration: underline;\">risk category<\/span>. <\/span><\/p>\n<p><span style=\"color: #003366;\">When performing a Pap smear on a <span style=\"color: #33cccc;\"><strong>pregnant woman<\/strong><\/span>, 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 <span style=\"text-decoration: underline;\">endocervical cells<\/span>.<\/span><\/p>\n<p><span style=\"color: #003366;\">Some practitioners believe it is preferable <span style=\"text-decoration: underline;\">not<\/span> to take the smear from the <span style=\"color: #33cccc;\"><strong>endocervical canal<\/strong><\/span>, as this disrupts the <span style=\"color: #33cccc;\"><strong>cervical mucous barrier<\/strong><\/span> (<em>danger of infection<\/em>) and the amniotic membranes could be torn. Therefore, during pregnancy, the Pap smear should be taken from the <span style=\"color: #33cccc;\"><strong>ectocervix<\/strong><\/span>.<\/span><\/p>\n<p><span style=\"color: #003366;\"><span style=\"color: #33cccc;\"><strong>Pregnancy<\/strong><\/span> and <span style=\"color: #33cccc;\"><strong>parturition<\/strong><\/span> have far-reaching effects on the <span style=\"color: #33cccc;\"><strong>cervical epithelium<\/strong><\/span> and the <span style=\"color: #33cccc;\"><strong>subepithelial tissue<\/strong><\/span>. Due to <span style=\"text-decoration: underline;\">eversion<\/span> of the endocervical epithelium and the <span style=\"text-decoration: underline;\">opening<\/span> of the external cervical ostium, the epithelium comes into closer contact with the <span style=\"text-decoration: underline;\">acidity<\/span> of the <span style=\"text-decoration: underline;\">vaginal discharge<\/span>. Metaplastic squamous epithelium subsequently forms in the exposed epithelium. It can be difficult to differentiate between <span style=\"color: #33cccc;\"><strong>physiological cellular pregnancy<\/strong><\/span> changes and <span style=\"color: #33cccc;\"><strong>pathological cellular<\/strong><\/span> changes. Therefore, for the benefit of the pathologist, the existence of a pregnancy should be clearly stated on the request form.<\/span><\/p>\n<hr \/>\n<h3><span style=\"text-decoration: underline; color: #003366;\">PROCEDURE<\/span><\/h3>\n<p><span style=\"color: #003366;\">&#8211; The examiner should perform the speculum examination while <span style=\"color: #33cccc;\"><strong>sitting<\/strong><\/span>.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Dip the <span style=\"color: #33cccc;\"><strong>tip of the speculum<\/strong><\/span> several centimetres into <span style=\"color: #33cccc;\"><strong>glycerine<\/strong><\/span> or <span style=\"color: #33cccc;\"><strong>oil<\/strong><\/span> and allow the excess fluid to drip off into the kidney bowl. Alternatively, moisten the lowest few centimetres of the speculum blades with <span style=\"color: #33cccc;\"><strong>Hibitane\u00ae<\/strong><\/span> or <span style=\"color: #33cccc;\"><strong>warm water<\/strong><\/span>. The use of <span style=\"color: #33cccc;\"><strong>lubricating agents<\/strong><\/span>\u00a0is not recommended when taking <span style=\"text-decoration: underline;\">samples of discharge<\/span> or <span style=\"text-decoration: underline;\">performing a smear test<\/span>.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; 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 <em><strong>[Figure 1]<\/strong><\/em>.<\/span><\/p>\n<p><span class=\"jce_caption\" style=\"display: inline-block; color: #003366;\"><img loading=\"lazy\" decoding=\"async\" class=\" size-full wp-image-1688\" style=\"margin: auto;\" src=\"https:\/\/cloverock.info\/mockosce23\/new\/wp-content\/uploads\/2010\/12\/Obstetrics_ob-fig-1.jpg\" alt=\"\" width=\"400\" height=\"294\" srcset=\"https:\/\/www.qpercom.com\/sim\/wp-content\/uploads\/2010\/12\/Obstetrics_ob-fig-1.jpg 400w, https:\/\/www.qpercom.com\/sim\/wp-content\/uploads\/2010\/12\/Obstetrics_ob-fig-1-300x221.jpg 300w\" sizes=\"auto, (max-width: 400px) 100vw, 400px\" \/><strong><span style=\"width: 400px; display: block;\">Figure 1<\/span><\/strong><\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Hold the closed speculum \u2018<em>loosely<\/em>\u2019 in the hand and keep the forearm low.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Insert the closed speculum at an angle of <span style=\"color: #33cccc;\"><strong>45\u00b0<\/strong><\/span> into the vaginal orifice in the direction of the vaginal axis. With this approach, the urethra at the height of the orifice is avoided <em><strong>[Figure 1]<\/strong><\/em>.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; 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.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; When <span style=\"color: #33cccc;\"><strong>1\/3 of the closed speculum<\/strong><\/span> is inserted in the vagina, it should be <span style=\"color: #33cccc;\"><strong>rotated by 45\u00b0<\/strong><\/span> to the horizontal position <em><strong>[Figure 2]<\/strong><\/em>.<\/span><\/p>\n<p><span class=\"jce_caption\" style=\"display: inline-block; color: #003366;\"><img loading=\"lazy\" decoding=\"async\" class=\" size-full wp-image-1689\" style=\"margin: auto;\" src=\"https:\/\/cloverock.info\/mockosce23\/new\/wp-content\/uploads\/2010\/12\/Obstetrics_ob-fig-2.jpg\" alt=\"\" width=\"400\" height=\"294\" srcset=\"https:\/\/www.qpercom.com\/sim\/wp-content\/uploads\/2010\/12\/Obstetrics_ob-fig-2.jpg 400w, https:\/\/www.qpercom.com\/sim\/wp-content\/uploads\/2010\/12\/Obstetrics_ob-fig-2-300x221.jpg 300w\" sizes=\"auto, (max-width: 400px) 100vw, 400px\" \/><strong><span style=\"width: 400px; display: block;\">Figure 2<\/span><\/strong><\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; 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 <em><strong>[Figure 3]<\/strong><\/em>.<\/span><\/p>\n<p><span class=\"jce_caption\" style=\"display: inline-block; color: #003366;\"><img loading=\"lazy\" decoding=\"async\" class=\" size-full wp-image-1690\" style=\"margin: auto;\" src=\"https:\/\/cloverock.info\/mockosce23\/new\/wp-content\/uploads\/2010\/12\/Obstetrics_ob-fig-3.jpg\" alt=\"\" width=\"400\" height=\"294\" srcset=\"https:\/\/www.qpercom.com\/sim\/wp-content\/uploads\/2010\/12\/Obstetrics_ob-fig-3.jpg 400w, https:\/\/www.qpercom.com\/sim\/wp-content\/uploads\/2010\/12\/Obstetrics_ob-fig-3-300x221.jpg 300w\" sizes=\"auto, (max-width: 400px) 100vw, 400px\" \/><strong><span style=\"width: 400px; display: block;\">Figure 3<\/span><\/strong><\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Retract the speculum by several centimetres and slowly open it with a \u2018<em>scooping<\/em>\u2019 movement until the cervix glides between the blades<em><strong> [Figure 4]<\/strong><\/em>.<\/span><\/p>\n<p><span class=\"jce_caption\" style=\"display: inline-block; color: #003366;\"><img loading=\"lazy\" decoding=\"async\" class=\" size-full wp-image-1691\" style=\"margin: auto;\" src=\"https:\/\/cloverock.info\/mockosce23\/new\/wp-content\/uploads\/2010\/12\/Obstetrics_ob-fig-4.jpg\" alt=\"\" width=\"400\" height=\"294\" srcset=\"https:\/\/www.qpercom.com\/sim\/wp-content\/uploads\/2010\/12\/Obstetrics_ob-fig-4.jpg 400w, https:\/\/www.qpercom.com\/sim\/wp-content\/uploads\/2010\/12\/Obstetrics_ob-fig-4-300x221.jpg 300w\" sizes=\"auto, (max-width: 400px) 100vw, 400px\" \/><strong><span style=\"width: 400px; display: block;\">Figure 4<\/span><\/strong><\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; If the <span style=\"color: #33cccc;\"><strong>vaginal portion of the cervix<\/strong><\/span> <span style=\"text-decoration: underline;\">does not<\/span> spontaneously come to <span style=\"text-decoration: underline;\">lie between the blades<\/span>, then with gentle movements, carefully <span style=\"text-decoration: underline;\">change the angle<\/span> of the speculum relative to the vaginal axis. By doing this, the cervix is <em>scooped up<\/em> 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 <span style=\"text-decoration: underline;\">relax<\/span> as much as possible by <span style=\"text-decoration: underline;\">pressing the lumbar part<\/span> of the <span style=\"text-decoration: underline;\">vertebral column<\/span> against the examination table.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; If necessary, push the open speculum several millimetres further into the fornices and fix it. <span style=\"text-decoration: underline; color: #33cccc;\"><strong>Never<\/strong><\/span> 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 <em><strong>[Figure 4]<\/strong><\/em>.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; When inspecting the cervix note:<\/span><\/p>\n<ul>\n<li style=\"list-style-type: none;\">\n<ul>\n<li><span style=\"color: #003366;\">Cervical length (<em>long\/effaced<\/em>).<\/span><\/li>\n<li><span style=\"color: #003366;\">Cervical orifice (<em>open\/closed<\/em>).<\/span><\/li>\n<li><span style=\"color: #003366;\">Chadwick\u2019s sign (<em>livid discolouration of vaginal portion of the cervix<\/em>).<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><span style=\"color: #003366;\">&#8211; Carefully remove any <span style=\"text-decoration: underline;\">excess cervical mucus<\/span> using a cotton bud or a syringe.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Position the rounded\/blunt end of the Ayre spatula in the external orifice. Make <span style=\"color: #33cccc;\"><strong>two 360\u00b0 rotations<\/strong><\/span> in the same direction.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Pick up the slide.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Place the spatula flat on the slide, push firmly and wipe off the spatula with a single smear.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Fixate as quickly as possible, preferably <span style=\"color: #33cccc;\"><strong>within 10 seconds<\/strong><\/span> of taking the preparation, by spraying the slide at a <span style=\"color: #33cccc;\"><strong>distance of about 20 cm with a fixating spray<\/strong><\/span>. Hold the slide perpendicular to the direction sprayed in. When <span style=\"text-decoration: underline;\">too much<\/span> fixating spray is used, or if the slide is sprayed at <span style=\"text-decoration: underline;\">too close a distance<\/span>, drops may form on the slide and cause the <span style=\"color: #33cccc;\"><strong>smeared cells to<\/strong> <strong>accumulate on the edge<\/strong> <strong>of the slide<\/strong><\/span>. When the slide is sprayed from <span style=\"text-decoration: underline;\">too far away<\/span>, the fixating spray will not sufficiently cover the preparation as a result of which the <span style=\"color: #33cccc;\"><strong>cells can dry out<\/strong><\/span> and can no longer be assessed.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; If a <span style=\"color: #33cccc;\"><strong>cervical brush<\/strong><\/span> is used, then only <span style=\"color: #33cccc;\"><strong>one slide<\/strong><\/span> is needed. In this case, a container with <span style=\"text-decoration: underline;\">ether alcohol<\/span> 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 <span style=\"text-decoration: underline;\">three to five times<\/span> around its axis in a <span style=\"color: #33cccc;\"><strong>clockwise direction<\/strong><\/span>.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; The direction of rotation is important due to the <span style=\"text-decoration: underline;\">shape of the hairs<\/span>.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Laboratories are increasingly opting for \u201c<em>liquid-based<\/em>\u201d 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 <span style=\"color: #33cccc;\"><strong>sensitivity<\/strong><\/span> and <span style=\"color: #33cccc;\"><strong>specificity<\/strong><\/span> of the procedure can be <em>significantly increased<\/em> as a result of this.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; <span style=\"text-decoration: underline;\">Retract<\/span> the speculum by several millimetres so that the cervix is exposed.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; <span style=\"text-decoration: underline;\">Reduce<\/span> the pressure on the handle so that the speculum half closes.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Exert some pressure on the posterior wall of the vagina so that the <em>anterior<\/em>, <em>posterior<\/em> and <em>lateral<\/em> walls of the vagina become visible. Make sure that the anterior wall of the vagina (<em>urethra<\/em>) is not touched by the side of the speculum.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Inspect the vagina wall and note:<\/span><\/p>\n<ul>\n<li style=\"list-style-type: none;\">\n<ul>\n<li><strong><span style=\"color: #003366;\"><span style=\"color: #33cccc;\">Surface<\/span><\/span><\/strong><span style=\"color: #003366;\">.<\/span><\/li>\n<li><strong><span style=\"color: #003366;\"><span style=\"color: #33cccc;\">Colour<\/span><\/span><\/strong><span style=\"color: #003366;\">.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><span style=\"color: #003366;\">&#8211; <span style=\"text-decoration: underline;\">Reduce<\/span> the pressure on the handle such that the speculum, under the pressure of the vagina walls, almost completely closes. The speculum should stay <span style=\"color: #33cccc;\"><strong>slightly open<\/strong><\/span> so that no pubic hair or mucous membranes are caught in between.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; <span style=\"text-decoration: underline;\">Remove<\/span> the speculum once it has been brought back into the <span style=\"color: #33cccc;\"><strong>45\u00b0 position<\/strong><\/span>, in the direction of the vaginal axis.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Place the speculum in a <span style=\"color: #33cccc;\"><strong>kidney bowl<\/strong><\/span>.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Place the slide in the preparation holder for delivery to the <span style=\"color: #33cccc;\"><strong>cytopathology laboratory<\/strong><\/span>.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; State on the request form that the woman is <span style=\"color: #33cccc;\"><strong>pregnant<\/strong><\/span>.<\/span><\/p>\n<hr \/>\n<h2><span style=\"text-decoration: underline; color: #003366;\"><strong>Bimanual Examination Of The Genitals <\/strong><\/span><\/h2>\n<p><span style=\"color: #003366;\">The aim of this examination is to assess the <span style=\"color: #33cccc;\"><strong>position<\/strong><\/span>, <span style=\"color: #33cccc;\"><strong>size<\/strong><\/span>, <span style=\"color: #33cccc;\"><strong>consistency<\/strong><\/span>, <span style=\"color: #33cccc;\"><strong>surface<\/strong><\/span>, <span style=\"color: #33cccc;\"><strong>mobility<\/strong><\/span> and <span style=\"color: #33cccc;\"><strong>sensitivity<\/strong><\/span> of the <span style=\"color: #33cccc;\"><strong>internal genitals<\/strong><\/span>. The patency of the bony pelvis is determined by means of an internal pelvic examination.<\/span><\/p>\n<hr \/>\n<h3><span style=\"text-decoration: underline; color: #003366;\">PROCEDURE<\/span><\/h3>\n<p><span style=\"color: #003366;\">&#8211; <span style=\"text-decoration: underline;\">Moisten<\/span> the other glove with <em>lubricant<\/em> or <em>water<\/em>.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; The examiner should perform the <em>bimanual examination<\/em> while <span style=\"color: #33cccc;\"><strong>standing<\/strong><\/span>.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Use the <span style=\"text-decoration: underline;\">non-examining hand<\/span> to spread the <em>external<\/em> 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 <em>laterally<\/em> and <em>ventrally<\/em>. Keep the labia spread until the examining fingers have been inserted to sufficient depth.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Examine with a relaxed wrist, with the forearm roughly horizontal.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; First insert about <span style=\"color: #33cccc;\"><strong>1\/3 of the middle finger<\/strong><\/span> past the posterior commissure, along the <span style=\"text-decoration: underline;\">posterior vaginal wall<\/span>. Make space for the index finger by exerting <span style=\"text-decoration: underline;\">perineal pressure<\/span>. Then, push the index finger past the middle finger. <em>Avoid pressure<\/em> on the urethra.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Keep the wrist <span style=\"text-decoration: underline;\">low<\/span>, the thumb away from the clitoris and upper legs, the little finger and ring finger <span style=\"text-decoration: underline;\">bent<\/span>.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Insert the <em>relaxed<\/em> fingers as deeply as possible into the vagina.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Place the palm of the external hand (<em>with the fingers held together<\/em>), transversely across the abdomen above the symphysis, to fix the uterus by <span style=\"text-decoration: underline;\">exerting pressure<\/span> on the abdominal contents.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Palpate first with just the fingers inside the vagina.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Try to locate the position of the cervix by making a circle around the cervix with the middle finger.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Determine the position of the cervix with respect to the vaginal axis.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Feel for:<\/span><\/p>\n<ul>\n<li style=\"list-style-type: none;\">\n<ul>\n<li><span style=\"color: #003366;\"><span style=\"color: #33cccc;\"><strong>Surface Irregularities:<\/strong><\/span> Nabothian cyst, polyp, carcinoma, laceration.<\/span><\/li>\n<li><span style=\"color: #003366;\"><span style=\"color: #33cccc;\"><strong>Consistency:<\/strong> <\/span>Very firm, firm-elastic, soft (<em>the tissue becomes tender and engorged with blood vessels at an early stage in the pregnancy<\/em>).<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><span style=\"color: #003366;\">&#8211; Feel towards the external orifice with a fingertip:<\/span><\/p>\n<ul>\n<li style=\"list-style-type: none;\">\n<ul>\n<li><span style=\"color: #003366;\">Open or closed.<\/span><\/li>\n<li><span style=\"color: #003366;\"><span style=\"color: #33cccc;\"><strong>Shape:<\/strong> <\/span>cleft-shaped, \u2018<em>pinpoint<\/em>\u2019.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><span style=\"color: #003366;\">&#8211; Hold the cervix between the spread fingers and move it from side to side. While doing this remove the hand from the abdomen.<\/span><\/p>\n<p><span style=\"color: #003366;\"><em>&#8211; Note the following: <\/em><\/span><\/p>\n<ul>\n<li style=\"list-style-type: none;\">\n<ul>\n<li><span style=\"color: #003366;\">Mobility<\/span><\/li>\n<li><span style=\"color: #003366;\">Tenderness (<em>extra-uterine pregnancy<\/em>).<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><span style=\"color: #003366;\">&#8211; Feel the fornices by moving two fingers next to each other from the lateral left side (<em>high up along the cervix<\/em>) via the posterior fornix, and then laterally to the right to the anterior fornix. <\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Note the following:<\/span><\/p>\n<ul>\n<li style=\"list-style-type: none;\">\n<ul>\n<li><span style=\"color: #003366;\">Shape and depth of the fornices.<\/span><\/li>\n<li><span style=\"color: #003366;\">Tenderness (<em>extra-uterine pregnancy<\/em>).<\/span><\/li>\n<li><span style=\"color: #003366;\">Consistency of the tissue.<\/span><\/li>\n<li><span style=\"color: #003366;\">Pulsating blood vessels next to the uterus.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><span style=\"color: #003366;\">&#8211; 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 <span style=\"color: #33cccc;\"><strong>size<\/strong><\/span>, <span style=\"color: #33cccc;\"><strong>shape<\/strong><\/span> and <span style=\"color: #33cccc;\"><strong>consistency<\/strong><\/span> can be determined. If the uterus is palpable between the two examining hands, then it is in the <span style=\"color: #33cccc;\"><strong>AVF<\/strong><\/span> (<em>anteversion\/anteflexion<\/em>) <span style=\"color: #33cccc;\"><strong>position<\/strong><\/span>.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Press the abdominal wall slowly and gradually inwards such that the fundus can be felt through the abdominal wall.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Move the fingers in the <span style=\"text-decoration: underline;\">anterior fornix<\/span>, or bilaterally in the <span style=\"text-decoration: underline;\">lateral fornix<\/span>, towards the external fingers so that pressure can be exerted on the uterus which is located in between (<em>to determine the position and consistency of the uterus<\/em>). <\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Note the following aspects of the uterus:<\/span><\/p>\n<ul>\n<li style=\"list-style-type: none;\">\n<ul>\n<li><span style=\"color: #003366;\">Position.<\/span><\/li>\n<li><span style=\"color: #003366;\">Mobility (<em>can move freely or fixed<\/em>).<\/span><\/li>\n<li><span style=\"color: #003366;\"><span style=\"color: #33cccc;\"><strong>Consistency:<\/strong><\/span> Softening lower uterine segment (<em>LUS<\/em>). <span style=\"text-decoration: underline;\">Hegar\u2019s sign<\/span> is positive if the cervix appears to be positioned \u2018<em>free<\/em>\u2019 from the uterus (<em>from 6th-7th week of pregnancy<\/em>)<\/span><\/li>\n<li><span style=\"color: #003366;\"><span style=\"color: #33cccc;\"><strong>Shape:<\/strong><\/span> In the first 12 weeks of pregnancy, the foetus often grows <span style=\"text-decoration: underline;\">asymmetrically<\/span>. This can result in a localised outward protrusion of the uterine fundus. This phenomenon is termed <span style=\"text-decoration: underline;\">Piskacek\u2019s sign<\/span>.<\/span><\/li>\n<li><span style=\"color: #003366;\"><span style=\"color: #33cccc;\"><strong>Size:<\/strong><\/span> This is indicated according to the number of pregnancy weeks or in centimetres. The uterine body of a non-pregnant uterus is about <span style=\"color: #33cccc;\"><strong>8 cm in size<\/strong><\/span>.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><span style=\"color: #003366;\">&#8211; Try to gain an impression of the <span style=\"text-decoration: underline;\">adnexa<\/span> and <span style=\"text-decoration: underline;\">parametria<\/span>.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Move the vaginal fingers high into the right lateral fornix and keep them still.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Move the palpating fingers of the external hand about <span style=\"color: #33cccc;\"><strong>3 cm<\/strong><\/span> medially to the level of the r<span style=\"text-decoration: underline;\">ight anterior iliac spine<\/span>, 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.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Spread the examining fingers slightly and move them in the lateral fornix towards the external fingertips.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Move the external hand in a sweeping manner towards the symphysis ensuring that the examining fingers follow the external fingers.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Pay attention to the woman\u2019s face.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Note the following:<\/span><\/p>\n<ul>\n<li style=\"list-style-type: none;\">\n<ul>\n<li><span style=\"color: #003366;\"><span style=\"color: #33cccc;\"><strong>Ovary:<\/strong> <\/span>Position, shape, size, consistency: mobility with respect to the uterus: tenderness.<\/span><\/li>\n<li><span style=\"color: #003366;\"><span style=\"color: #33cccc;\"><strong>Fallopian tubes:<\/strong><\/span> Normally not palpable.<\/span><\/li>\n<li><span style=\"color: #003366;\">Parametria.<\/span><\/li>\n<li><span style=\"color: #003366;\">Consistency (<em>succulent<\/em>).<\/span><\/li>\n<li><span style=\"color: #003366;\">Masses.<\/span><\/li>\n<li><span style=\"color: #003366;\">Tenderness.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><span style=\"color: #003366;\">&#8211; Repeat the examination in the <span style=\"text-decoration: underline;\">left lateral fornix<\/span> to assess the <span style=\"text-decoration: underline;\">left adnexa<\/span>.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; When removing the examining fingers, feel the vagina wall.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Remove the glove (<em>make a fist, slowly pull the cuff over it<\/em>).<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Inform the woman that the examination has been completed, and help her off the gynaecological examination table and ask her to get dressed again.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Offer a <span style=\"text-decoration: underline;\">sanitary towel<\/span> if there is <em>discharge<\/em> or <em>blood loss<\/em>.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; Once the woman is dressed, tell her about the <span style=\"color: #33cccc;\"><strong>findings<\/strong><\/span> of the examination.<\/span><\/p>\n<p><span style=\"color: #003366;\">&#8211; 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:<\/span><\/p>\n<ul>\n<li style=\"list-style-type: none;\">\n<ul>\n<li><span style=\"color: #003366;\">This loss of blood is more than the blood loss at the end of one of her normal menstrual periods.<\/span><\/li>\n<li><span style=\"color: #003366;\">The blood loss persists more than 48 hours.<\/span><\/li>\n<li><span style=\"color: #003366;\">Pain symptoms occur during the blood loss.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><span style=\"color: #003366;\">&#8211; <span style=\"text-decoration: underline;\">Clean<\/span> the materials used and place these in the disinfectant.<\/span><\/p>\n<hr \/>\n<p><span style=\"color: #003366;\">Significant diagnostic difficulties can be encountered during the interpretation of abnormalities of the <span style=\"color: #33cccc;\"><strong>uterus<\/strong><\/span>, <span style=\"color: #33cccc;\"><strong>adnexa<\/strong><\/span> and <span style=\"color: #33cccc;\"><strong>parametria<\/strong><\/span> in the early stages of pregnancy. An <span style=\"text-decoration: underline;\">ultrasound scan<\/span> may then be indicated.<\/span><\/p>\n<p>&nbsp;<\/p>\n<p><span style=\"color: #003366;\">After the first trimester, bimanual examination of the adnexa is <em>less reliable<\/em>. 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.<\/span><\/p>\n<hr \/>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>PROCEDURE &#8211; Switch on the light source and direct this on the vulva. &#8211; Sit on a stool. &#8211; Put gloves on. &#8211; Inspect the vulva and the mons pubis and note: Anatomical development of the vulva. Pubic hair pattern. Symptoms of inflammation. Swellings. Skin lesions. Colour. Discharge. &#8211; Spread out the labia by placing [&hellip;]<\/p>\n","protected":false},"author":83,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[56],"tags":[138],"class_list":["post-1692","post","type-post","status-publish","format-standard","hentry","category-first-check-up","tag-obstetrics"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Inspection Of The External Genitals - Qpercom | Skills in Medicine<\/title>\n<meta name=\"description\" content=\"Online Mock OSCEs with examiners, patient actors, instant results and personalised feedback. 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