How a Pelvic Exam is Performed

The client should not douche before the examination. On

the examination table the client should be lying in the
lithotomy position (lying flat on back), her thighs flexed
and abducted (knees up), her feet resting in stirrups for
support, and her buttocks extending slightly beyond the
edge of the examining table. A pillow should support her
head.

Relaxation is essential for an adequate examination. To

achieve it:
1. The client should be given an opportunity to empty her
bladder. An ideal solution would be to obtain the client's
urine test before beginning the exam. This way her bladder
has been emptied and you have her urine sample for
testing.
2. Drape her appropriately with a clean sheet or paper
drape. Some clients are more comfortable when a drape is
extended well over the thighs and knees. Others prefer to
watch both the practitioner and the examination itself and
object to drapes that obscure their view. Ask the client
which method she prefers.
3. The client's arms should be at her sides or folded across
her chest.
4. Explain in advance each step in the examination,
avoiding any sudden or unexpected movements.
5. Have warm hands and a warm speculum.
6. Monitor your examination when possible by watching
your client's face.

SET UP ALL SUPPLIES NEEDED.

Equipment should be within reach and should include a
good light source, a vaginal speculum of appropriate size,
and materials for bacteriologic cultures and Papanicolaou
smears (Pap smears), if these are to be done. Wear gloves.
Male examiners should be attended by female assistants.
Female examiners may or may not prefer to work alone but
should be similarly attended if the client is emotionally
disturbed or upset.
The examiner should be sitting comfortably between the
clients legs, low enough to obtain a good visiual of the
genitalia, but high enough to maintain visual eye contact
with the client's face for communication.

INSPECTING THE CLIENT'S EXTERNAL GENITALIA

The examiner should sit comfortably and inspect the mons
pubis, the labia and perineum. With a gloved hand,
separate the labia and inspect:
1. The labia minora.
2. The clitorus.
3. The urethral orifice.
4. The vaginal opening or introitus.
Itchy, small, red maculopapules suggest pediculosis pubis
(pubic lice). Look for nits and lice at the bases of the pubic
hair.
Enlarged clitoris in masculinizing conditions.
Lesions of the vulva.
Note any inflammation, ulceration of Skene's glands (e.g.,
from gonorrhea) is suspected, insert your index finger into
the vagina and milk the urethra gently from the inside
outward. Note any discharge from or about the urethral
orifice. If present, a culture should be taken.
If there is a history or appearance of labial swelling, check
Bartholin's glands. Insert your index finger into the vagina
near the posterior end of the introitus. Place your thumb
outside the posterior part of the labia majora. On each side
in turn palpate between your finger and thumb for swelling
or tenderness. Note any discharge exuding from the duct
opening of the gland. If present, culture it. Note any
surgical scars (episiotomy or other scars) and other
abnormalities.
Assess the support of the vaginal outlet. With the labia
separated by your middle and index finger; ask the client
to strain down. Note any bulging of the vaginal walls.

INTERNAL EXAM INSTRUCTIONS

Inspect the vagina and cervix next using a speculum. A
speculum is placed inside the vagina and opened. The
speculum is an instrument that holds the vaginal walls
apart and allows the examiner to see the cervix and vagina
and check for inflammation, infection, scars or growths.
There may be some feeling of pressure on the bladder or
rectum with the speculum in place. Select a speculum of
appropriate size, lubicate it and warm it with warm water.
(Other lubricants, such as K-Y Jelly, may interfere with
cytological or other studies but they may be used if no such
tests are planned.) By having your speculum ready during
assessment of the vaginal outlet, you can ease speculum
insertion and increase your efficiency by proceeding to the
next maneuver while the client is still straining down.
Place two fingers just inside or at the introitus and gently
press down on the perineal body. With your other hand
introduce the closed speculum past your fingers at a 45-
degree angle downward. The blades should be held
obliquely and the pressure exerted toward the posterior
vaginal wall in order to avoid the more sensitive anterior
wall and urethra. Be careful not to pull on the pubic hair or
to pinch the labia with the speculum.
After the speculum has entered the vagina, remove your
fingers from the introitus. Rotate the blades of the
speculum into a horizontal position maintaining the
pressure posteriorly.
Open the blades after full insertion and maneuver the
speculum so that the cervix comes into full view.
When the introitus is retroverted, the cervix points more
anteriorly than diagrammed. Position the speculum more
anteriorly, i.e., more horizontally, in order to bring the
cervix into view.
Inspect the cervix and its os. Note the color of the cervix,
its position, any ulcerations, nodules, masses, bleeding or
discharge. A normal cervix will appear pinkish in color. The
cervix will appear as purplish in color if a woman is
pregnant. Secure the speculum with the blades open by
tightening the thumb screw.

OBTAINING SPECIMEN SAMPLES

If you are going to obtain specimens for cervical cytology
(Papanicolaou smears, also known as a pap smear). Take
these steps in order:
1. The Endocervical Swab: Moisten the end of a cotton
applicator stick with saline and insert it into the os of the
cervix. Roll it between your thumb and index finger,
clockwise and counter clockwise. Remove it.
Smear a glass slide with the cotton swab, gently in a
painting motion. (Rubbing hard on the slide will destroy the
cells.) Place the slide into the ether-alcohol fixative at
once.
2. Cervical Scrape: Place the longer end of the scraper on
the os of the cervix. Press, turn and scrape. Smear on a
second slide as before.
3. Vaginal Pool: Roll a cotton applicator stick on the floor of
the vagina below the cervix. Prepare a third slide as
before. If the client has an infection or a discharge from
the cervix or the vagina, this would be a good time to take
a sample with a cotton swab for analysis.
If the cervix has been removed, do a vaginal pool and
scrape from the cuff of the vagina.

VAGINAL INSPECTION
Do a vaginal examination. Withdraw the speculum slowly
while observing the vagina. As the speculum clears the
cervix, release the thumb screw and maintain the speculum
in its open position with your thumb. Close the blades as
the speculum emerges from the introitus, avoiding both
excessive stretching and pinching of the mucosa. During
the withdrawal, inspect the vaginal mucosa, noting its
color, inflammation, discharge, ulcers or masses.

BIMANUAL INSPECTION
Perform a bimanual examination. From a standing position,
introduce the index and middle finger of your gloved and
lubricated hand into the vagina, again exerting pressure
primarily posteriorly. Your thumb should be abducted, your
ring and little fingers flexed into your palm. Note any
nodularity or tenderness in the vaginal wall, including the
region of the urethra and bladder anteriorly.
Identify the cervix, noting its position, shape, size,
consistency, regularity, mobility and tenderness. Palpate
the fornix around the cervix. Note that during pregnancy,
the cervix will be softer in consistency (like palpating your
lips) as compared to nonpregnancy (like the end of your
nose).
Place your abdominal hand about midway between the
umbilicus and symphysis pubis and press downward toward
the pelvic hand. Your pelvic hand should be kept in a
straight line with your forarm, and inward pressure exerted
on the perineum by your flexed fingers. Support and
stabilize your arm by resting your elbow either on your hip
or on your knee which is elevated by placing your foot on a
stool. Identify the uterus between your hands and not its
size, shape, consistency, mobility, tenderness and masses.
This procedure may cause some discomfort for the client.
Uterine enlargement suggests pregnancy, benign or
malignant tumors.
Place your abdominal hand on the right lower quadrant,
your pelvic hand in the right lateral fornix. Maneuver your
abdominal hand downward, and using your pelvic hand for
palpation, identify the right ovary and nay masses in the
adnexa. Three to five years after menopause, the ovaries
have usually atrophied and are no longer palpable. If you
can feel an ovary in a post-menopausal woman, suspect an
ovarian tumor. Note the size, shape, consistency, mobility
and tenderness of any palpable organs or masses. The
normal ovary is somewhat tender. Repeat the procedure on
the left side.
Vaginal-Rectal Exam: Withdraw your fingers, removing your
gloves and throwing them away. Reglove using fresh, clean
gloves. Place lubricant (K-Y Jelly) on internal exam glove.
Then slowly reintroduce your index finger into the vagina,
your middle finger into the rectum. Ask the client to strain
down as you do this so that her anal sphincter will relax.
Tell her that this examination may make her feel as if she
has to move her bowels - but, she won't. Repeat the
maneuvers of the bimanual examination, giving special
attention to the region behind the cervix which may be
accessible only to the rectal finger. In addition, try to push
the uterus backward with your abdominal hand so that
your rectal finger can explore as much of the posterior
uterine surface as possible. Check the rectum itself and
other nearby structures for any abnormalities.

AFTER EXAMINATION
After the examination, wipe off the external genitalia and
anus or offer the client some tissue with which to do it
herself.