Pelvic Exam II: Speculum Exam

The speculum exam begins immediately after the end of the external genitalia exam; therefore, the patient already has provided a history and is in the modified lithotomy position. Make sure the patient is seated at the end of the table, as the speculum cannot be fully inserted any other way.

1. Preparation

1. Lay out the supplies for the Pap test.
2. Label the liquid cytology canister with the patient's information.
3. Unscrew the lid of the canister until it is resting on top and can be lifted off.
4. Place the speculum in your non-dominant hand and position your index finger above the bills, your middle finger below the bills, and your thumb on the back of the speculum (Figure 4).
5. Use your dominant hand to spread the water-based lubricant (or warm water, otherwise) on the outside of the bills.
6. Introduce the speculum and let the patient know what to expect: "This is a speculum. These are the bills, which I will be placing into your vagina to view your cervix and take some samples. This is the handle, which will not be inserted."

Figure 4. How to hold a plastic speculum.

2. Insertion

1. As always, introduce your touch to the patient before beginning the exam.
2. Let the patient know you are about to place the back of your hand on the patient's thigh and will then begin the exam.
3. Place the back of your hand on the inside of the patient's thigh, over the drape, then begin to examine: this prepares the patient and starts with non-invasive contact, which may help put the patient at ease.
4. Using the pads of the index and middle finger of your dominant hand, separate the labia minora just above the perineum to get a clear view of the vaginal introitus.
5. Guide the patient through a relaxation technique: "I'm going to teach you how to make this more comfortable for yourself. Please take a deep breath in, and as you exhale, bear down as if you are making a bowel movement. (If the patient doesn't understand this, ask the patient to push against your fingers.)"
6. As the patient bears down, the vaginal introitus opens. Let the patient know, "You'll feel me inserting the speculum."
7. Smoothly insert the speculum about halfway into the vagina at an oblique angle (roughly 45°), angling the bills below where the cervix is expected to be (based on the digital exam) while maintaining posterior pressure.
8. Use the first two fingers of your dominant hand to clear the labia on one side, so the labia are not tugged along with the speculum.
9. Use your dominant hand to clear the labia on the other side.
10. Bring your non-dominant hand to the bottom handle of the speculum, rotate the speculum flat, and insert fully, until the handle is flush against the patient's pelvis and perpendicular to the floor.
11. Place one finger of your dominant hand inside the bills of the speculum, and use the finger to apply strong posterior pressure as your non-dominant hand pulls down on the handle of the speculum at the same time. Apply enough posterior pressure so space in the vagina can be seen above the speculum.
12. Place the thumb of your non-dominant hand on the thumb lever, and smoothly depress.
13. Do not continue to depress once resistance is met, or you may open the bills too far and cause the patient discomfort.
14. Hold the speculum steady and check to see if the cervix has been located.

3. Pap test

1. If there is enough discharge on the face of the cervix to obscure the os and interfere with specimen collection, use a large cotton-tipped swab to gently clear excess cervical mucous.
2. Use your dominant hand to pick up the spatula (or have the chaperone hand it to you).
3. Insert the spatula into the vagina, being careful not to let it touch the walls, until the long end rests in the os and the depression and short end are pressed against the squamocolumnar junction.
4. Rotate 360°, maintaining consistent pressure and contact with the exocervix.
5. Remove the spatula, being careful not to touch the walls of the vagina.
6. Place the spatula into the open canister and thoroughly rinse by swirling vigorously in the liquid (different brands of liquid-based cytology recommend swirling for different lengths of time; be familiar with the manufacturer's recommendation before beginning).
7. Discard the spatula, or place it back on the tray.
8. Use your dominant hand to pick up the endocervical brush.
9. Insert the endocervical brush into the vagina, being careful not to let it touch the walls, and gently insert it into the os until only the bottom bristles are exposed.
10. Slowly rotate 180° in one direction. Do not over-rotate.
11. If using a cervical broom, rather than an endocervical brush and spatula, insert the broom until the center bristles are in the os and the shorter bristles rest on the squamocolumnar junction, then rotate five full times in one direction before removing.
12. Remove the brush, being careful not to touch the walls of the vagina.
13. Place the endocervical brush into the open canister and thoroughly rinse by swirling vigorously and pressing it repeatedly against the sides of the canister to release material.
14. Discard the endocervical brush.
15. Replace and tighten the lid of the cytology canister.

4. Removing the speculum

1. Place your non-dominant thumb on the thumb lever and maintain pressure while releasing the locking mechanism.
2. Continue to hold the thumb lever down, and remove the speculum to about an inch out to allow the cervix to clear the tip of the bills.
3. Completely remove your thumb from the lever and place it on the handle of the speculum.
4. Rotate the speculum 45° while smoothly removing it the rest of the way out, allowing the vaginal walls to close the bills.
5. Place your dominant hand underneath the speculum to catch any discharge.
6. Discard the plastic speculum, if disposable.