Pelvic examination

1. Pelvic examination Modified by: Dr/Amaal Rayan

2. 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. objectives

3. 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 Indications of pelvic exam

4. 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 When to have a pelvic exam:

5. 1-PV

6. 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

7. 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.

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

9. 2- Examination . 􀂃 Ask the patient to cough (urinary incontinence) 􀂃 Ask the patient to bear down (uterine prolapse). .

10. 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.

11. 8- Palpation: • Palpate anterior ,posterior and lateral walls of vagina ? • obliterated or bulging due to a pelvic swelling mass, cyst or foreign bodies.

12. 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.”

13. 2-Speculum exam

14. 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. Preparation

15. Gloves • Speculum • Lubricating jelly • Examination couch and a ‘modesty sheet’ • Adequate lighting • Ensure speculum is warmed and all equipment is in working order Equipment

16. Inspection • Hair distribution • Vulval skin • Look at the perineum for scars/tears • Gently part labia – inspect urethra • Look for discharge, prolapse, ulcers, warts

20. Visualisation of Cervix • Inspect for: • Discharge • Warts • Tumours • Size of cervical os • Bleeding

21. Ask the patient to cough: • Rectocele • Cystocele • Liquor Findings

22. Taking a Cervical Smear

23. 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 Indications of cervical smear

24. 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)

25. 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.

26. 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. Concluding Cervical Smear

27. 3-Bimanual examination

28. BimanualExamination • 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

29. 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

30. 4-Examination during labor

31. 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 Examination during labor

32. 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

33. 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

34. Thank you