Clinical Examinations in OBG


Pap smear

Introduction, consent, empower



*Consent- informed consent VIC
Hi, my name is Lucy and I’m a fourth year student doctor…
First of all, congratulations for taking care of your health, and coming to do your pap test, it is a very important test.
Have you ever had this test done before? Do you remember what it involves?
Just to refresh your memory, there are 2 parts to the examination.
For the first part, I will be passing a speculum, an instrument with 2 bills (like a duck), inside your vagina, for examination. Then with a small brush, I will collect a sample from inside the vagina to send off to the labs for investigation.
For the second part of the examination (bimanual), I will be parting your labia and placing my 2 gloved fingers inside your vagina, and examine around the uterus, and the sides- the ovaries and ovarian ducts to feel for any abnormalities.
You may stop the examination at any time. Just simply raise your hand and say ‘stop’ and we can discuss any concerns, you may come back another day, or choose to see another clinician.
Do you have any questions?
Do you understand what this examination entails and are you happy to proceed?

Preparation: the Ls



Loo- you may need to go the bathroom before hand if you have a full bladder
Lump- place a pillow behind your lower back to tip the pelvis forwards
Lubricant- lubricate jelly in kidney dish
Light- place glove on lights to move later
[+] mirror if you want to look at your cervix


Clear Instructions




Firstly, I’ll just get you to remove any garments below your waist, including underwear. Here’s the drawsheets to help you.
(put on gloves sterilely)
Please lie down, pop the pillow behind you. And when you’re ready, lift the drawsheets. Now feet together, bring them closer to your bottom, and let your knees fall to the side.
(warm speculum with hands, hold correctly with bills between 2nd and 3rd fingers)
Now we will begin the first part of the examination. I will now rest the speculum against your vagina. Please take a deep breathe. On your breathe out, I will be placing this speculum inside.
(insert, hold top with left hand, lock in with screws; collect sample with both hands; use spatula and brush; fix slide with spray)
*cough if cannot find cervix; re-insert with 45 degrees down to relocate cervix;
Now for the second part of the examination… deep breath in and out…
(left hand on abdomen) Now I’m examining for any abnormal masses

N.B. 20% of females have retroverted uteruses


Conclusion



That concludes the examination, feel free to put your clothes back on.
Thank you for taking care of your health… everything appears to be normal on examination. However, do need to send results to the lab for further investigation. Results- back from lab in a week, will notify you when we receive them.
Pap smear register- may opt out. Things may change, and its good to test every 2 years. We will send you a reminder in around 2 years and 3 months if you forget.
Well done again for taking care of your health in participating in this very important examination.
*Tips back from CTA:
Be more confident and efficient
Wording of instructions- more professional
More pressure on abdomen in bimanual examination
Sterile fields and putting on gloves etc at the start





Investigations


Beta HCG- detects pregnancy 10-14 days post conception (ie before or on missed period)
Colposcopy- follows if abnormal cells are detected by Pap smear. The cervix and vagina are exposed by introducing a bivalve vaginal speculum, and inspected with a low-powered microscope. The colposcope is placed in front of the vagina and its focal length adjusted to examine the suspect part of the lower genital tract.

colp.jpg
Tip in Colp: focus on squamo-epithelial junction!
sej.jpg





CTG- accelerations and decelerations
GBS swab- for Group B Strep; identify need for antibiotics during birth; saves baby from potential sepsis
Ultrasound- detects pregnancy 5 weeks from LMP ie a week after missed period
Pap smear-
Vaginal sweep- alternative to inducing