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Obs and Gynae - Speculum exam

Indications

Heavy vaginal bleeding in first trimester pregnancy

Retained foreign body

Trauma

Female pelvic pain

Abnormal vaginal discharge

Post-menopausal bleeding

Contraindications (absolute in bold)

Minors (age <18 years)

Forensic investigation (preferably performed by sexual assault team)

Premature rupture of membranes (sterile procedure preferably performed by obs and gynae team)

Alternatives

No alternatives

Informed consent

Medical emergency

Consent is not required if the patient lacks capacity or is unable to consent

Brief verbal discussion is recommended if the situation allows

or

Verbal consent

Less complex non-emergency procedure with low risk of complications

Potential complications

Discomfort

Failure to identify cervix

Procedural hygiene

Standard precautions

PPE: apron, surgical mask, protective eyewear, non-sterile gloves

Area

Private bed space

Staff

Procedural clinician

Chaperone

Equipment

Cusco’s speculum (small, medium, large sizes according to patient habitus)

Good light source (preferably attached to speculum)

Lubricating jelly

Ring forceps or Kelly clamp

Gauze

Towel

Sheet

Absorbent pads

Positioning

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

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)

Medication

None

Sequence (speculum insertion)

Warm a metal speculum in warm water

Close speculum aligning the upper and lower blades

Lubricate the tip of the speculum

Observe the external genitalia and note any abnormalities

Part the labia with the non-dominant hand

Advance the speculum horizontally, with the handles at 9 o’clock (if right hand dominant)

As the speculum is advanced into the vaginal vault, gently rotate until the handles are at 6 o’clock

Direct the speculum inferiorly and posteriorly towards the posterior fornix

Gently open the speculum until the cervix is visualised

Lock the speculum into position by tightening the screw attached to the upper blade

Use gauze on long forceps to wipe away any secretions or blood

Observe cervix position, appearance, presence of discharge and any lesions or abnormalities

Take swabs if infection suspected

Release the lock and allow the speculum to partially close while removing it from the vagina

Offer the patient a towel or wipes

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

Post-procedure care

Discuss any findings with the patient after allowing her to re-dress

Document the procedure and findings

Tips

Leave the speculum open slightly on removal to prevent pinching of the vaginal walls

Discussion

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 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 STI testing with amplification assays (NAAT) and have greater sensitivity than cultures.

Peer review

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.

References

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O’Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

Carusi DA. The gynecologic history and pelvic examination. In: UpToDate. Waltham (MA): UpToDate. 2019 December 16. Available from: https://www.uptodate.com/contents/the-gynecologic-history-and-pelvic-examination

Corton MM. Williams gynecology. 2nd ed. New York: Mc-Graw Hill Medical; 2012.

McLean ME, Santiago-Rosado L. Plight of the pelvic exam. Emerg Med J. 2019;36(6):383-384. doi:10.1136/emermed-2019-208474

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/

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