Obs and Gynae - Removal of products
Heavy vaginal bleeding in first trimester pregnancy
Contraindications (absolute in bold)
Minors (age <18 years)
Consent is not required if the patient lacks capacity or is unable to consent
Brief verbal discussion is recommended if the situation allows
Less complex non-emergency procedure with low risk of complications
Failure (to identify cervical os, remove products of conception or control bleeding)
PPE: apron, surgical mask, protective eyewear, non-sterile gloves
Private bed space
Cusco’s speculum (small, medium, large sizes according to patient habitus)
Good light source (preferably attached to speculum)
Ring forceps or Kelly clamp
Towel or sheet
Empty bladder prior to procedure
Bed facing away from the door
Supine with head elevated on a pillow
Removal of all clothing from the waist down
Place absorbent pads underneath patient
Towel or sheet to cover patient
Draw her heels up towards her bottom and put her ankles together
Relaxing the legs outwards (hips and knees flexed, hips abducted, knees dropped to sides)
Sequence (removal of products)
Insert the speculum (see vaginal speculum insertion guideline)
Empty vaginal vault by removing clots with forceps
Use gauze on sponge forceps to wipe away clots from the fornices and to clean the cervix
Remove any products seen within the cervical os with the forceps
Once the products have been removed, observe cervix briefly for further bleeding
Sequence (unable to identify cervix)
Withdraw the speculum and reinsert (rather than manipulating it)
Ask the patient to form her hands into fists and place them underneath her buttocks
Palpate the cervix with a gloved hand to identify position prior to reinsertion
Ask the patient to push or bear down (exert downwards pressure as in labour)
If vaginal wall laxity impairing view place a condom over the speculum, cutting the end off
Send products of conception for histopathology
Document the procedure and findings
Offer social work support
Monitoring for further bleeding:
Continuous cardiorespiratory monitoring
Pad checks every 30-60 minutes
Refer for urgent dilatation and curettage if ongoing heavy bleeding
Hypotension and bradycardia indicate cervical shock
Take care to avoid clamping the cervix while using forceps
The pelvic exam consists of a speculum examination during which the cervix and vaginal walls are visualised, with a bimanual examination for cervical motion tenderness, adnexal tenderness and pelvic mass.
While it is important to perform a speculum exam when it has diagnostic or therapeutic benefit, we should avoid unpleasant tests if they do not influence further investigation and treatment. The available evidence indicates that abnormal findings on pelvic exam are difficult to discern and subjective and often do not influence further management. We do not recommend performing a routine speculum exam for every female pelvic issue.
In early pregnancy, the pelvic exam cannot be used to rule out ectopic pregnancy for a patient presenting with vaginal bleeding or abdominal pain. For stable patients with minimal bleeding who have an ultrasound performed, the pelvic exam is unlikely to change disposition.
In non-pregnant patients, the pelvic exam is not generally required to assess for ovarian torsion or sexually transmitted infection. Neither condition can be excluded based on examination and suspicion of either will require further testing or empirical treatment.
Patient-collected vaginal swabs or urine specimens are accurate for sexually transmitted infection testing with amplification assays (NAAT) and have greater sensitivity than cultures.
This guideline has been reviewed and approved by the following expert groups:
Emergency Care Institute
Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.
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Linden JA, Grimmnitz B, Hagopian L, et al. Is the pelvic examination still crucial in patients presenting to the emergency department with vaginal bleeding or abdominal pain when an intrauterine pregnancy is identified on ultrasonography? A randomized controlled trial. Ann Emerg Med. 2017;70(6):825-834. doi:10.1016/j.annemergmed.2017.07.487
Christophe K. Speculations on the speculum: is a pelvic exam ever needed in the ED? 2019 Apr. Available at http://www.emdocs.net/speculations-on-the-speculum-is-a-pelvic-exam-ever-needed-in-the-ed/