PELVIC EXAMINATION
This is from a Medical School Site on How to do this exam
A. Preparation
1. Explain procedures and purpose.
a) "I will now aid you in getting positioned for the pelvic exam."
b) "I will also prepare the supplies needed during the exam."
2. Position patient.
a) Raise head of exam table to 45 angle.
(1) Allows eye contact with patient.
(a) Examiner-patient eye contact is reassuring to patient.
(b) Allows examiner opportunity to read patients facial expression which
may indicate questions, discomfort, comprehension, etc.
(c) Patient can observe when examiner is about to make physical contact
and is prepared.
(d) Reduces anxiety and spasmodic muscle reaction.
(2) Relaxes abdominal muscles for easier palpation.
(3) Allows patient to utilize mirror to observe pelvic exam if desired.
3. Position heels.
a) Ask patient to place her heels in the heel rests.
b) Adjust length and angle of heel rests for patient comfort.
4. Position hips.
a) Examiner should sit at end of exam table.
b) Place hand at the end of exam table with palm facing away from patient.
c) Drape should be between patient's hip and your hand.
d) Ask patient to move her hips down to the end of table until the back of
her thigh touches the back of your hand.
e) Ask patient to stop when her thigh touches the back of your hand.
5. Position knees.
a) Place your hands on either side of patient's draped knees. Extend
hands out to where knees should be positioned.
b) Ask patient to relax her knees outward until they meet your hands.
c) Use the width of patient's shoulders as a guide to how far apart knees
should be extended.
6. Adjust examining light and position rolling stool.
7. Undrape vulva.
B. External Genitalia Exam
1. Explain procedures and purpose.
a) "I will be examining the outer vaginal area, urethra, vaginal opening,
and several glands."
(1) As you maintain contact, rotate your hand downward toward introitus
(vaginal opening).
(2) Rest your hand on inner thigh between exam maneuvers to prevent
breaking contact completely.
(a) Prevents `touch-remove-touch' action which is disconcerting to
the patient.
(b) Reduces spasmodic muscle reactions.
(3) Always keep the elbow in close to the body. An elbow and arm
extended outward can tire examiners hand and shoulder.
2. Examine outer genitalia
a) Inform the patient that you are about to touch her inner thigh with
the back of your hand, then touch her thigh.
b) Examine vulva for following:
(1) Masses/lesions,
(2) Lice/nits
(3) Inflammation, swelling
3. Examine outer labia and inner labia.
a) Using index and middle finger, palpate labia majora with a firm but
gentle circular motion. Move down both labia simultaneously, starting at the
top (at the clitoris)
b) Separate labia majora and minora - inspect between.
c) Repeat (a) on the labia minora.
d) Maintain contact for exam continuity.
4.Examine labia for following:
a) Lesions/masses
b) Inflammation
c) Swelling
d) Discharge
5. Inspect clitoris
a) Place one finger on either side of the prepuce (hood) of clitoris
(prepuce).
b) Shift fingers upward to lift prepuce back exposing clitoris for visual
inspection.
c) Inspect for erythema, hygiene, lesions, swelling, masses, scars etc.
d) Release prepuce to recover clitoris.
6.While doing the other parts of the examination, observe the anus for the
following:
a) Skin tags, hemorrhoids
b) Fissures, excoriation, inflammation
c) Sexual trauma
7. Locate cervix/examine Bartholin's glands.
a) Explain procedures and purpose
(1) "I am going to insert one finger into your vagina to locate your
cervix and to examine some glands."
b)Touch back of examining hand to patient's thigh. Use `peace sign' to
open labia. (Peace sign: with index and middle fingers of non dominant hand,
separate the labia from below so the introitus can be visualized.)
c) Insert index finger, palmer surface up
d) Follow posterior vaginal wall to locate cervix (it feels like the end of
a nose, with a dimple.)
8. Examine the Bartholin's glands
a) Rotate internal finger
b)Palpate just inside the vaginal opening at 5:00 o'clock between the thumb
and index finger to examine patient's left Bartholin's (vestibular) gland,
then palpate at 7:00 for right gland.
c) Any swelling or inflammation indicates infection.
Conclude this portion of the exam with a reassuring statement.
"Everything is normal."
C. Speculum Exam
1. Explain procedures and purpose.
a) "I am going to inspect the vagina and cervix by using an instrument
called the speculum."
b) "If you are uncomfortable at any time, please let me know."
2. Lubricate the speculum with warm water.
3. Position speculum in hand.
a) Inform the patient that you are touching the inner thigh with the back
of your hand.
b) Touch speculum to inner thigh to warn patient of temperature.
4. Using index and middle finger of non dominant hand, separate labia from
below so introitus can be visualized (peace sign).
5. Insert speculum in an oblique (45 angle) into introitus.
6. Insert in a posterior angle toward rectum.
7. Always apply pressure downward (posteriorly) during insertion. Never apply
pressure upward (anteriorly) during insertion.
a) Urethra could be pressed against pubic bone causing pain or discomfort
to patient.
b) Most cervices are in a midline or posterior position.
8. Rotate bills to a horizontal position.
9. Grasp handle with non-dominant hand.
a) Remove the index and middle fingers of dominate hand from bills of
speculum.
10. Insert the speculum until flush against perineum.
Place dominant index finger at top bill base to maintain posterior angle of
bills.
11. Open and position speculum.
a) Place thumb on thumb rest of speculum.
b) Apply pressure on thumb rest to open bills.
c) Open bills to aperture of approximately 2cm.
d) Cervix should position itself between bills and be visible.
12. Techniques to use if cervix is not visualized.
a) Do not shift plane or angle with speculurn inserted and opened.
(1) This could be painful or uncomfortable to patient.
(2) This is not an appropriate technique to locate cervix.
b) Reangle closed speculum.
(1) Remove speculum about 2cm, to prevent bills from closing on cervix,
then release thumb pressure.
(2) Pull bills out about 70% and reposition at new angle and/ or plane.
(3) Reopen the bills.
c) If cervix is still not seen, pull back speculum about 2cm, then
release thumb pressure. Pull back speculum completely.
(1) Remove speculum completely.
(2) Insert index finger, palmar surface down.
(3) Follow vaginal floor to cervix.
(4) Note angle and depth of finger insertion.
(5) Reintroduce speculum.
13. Secure speculum bills into position.
a) Plastic speculum - move thumb rest upward until it clicks into first
position.
b) Metal speculum - tighten nut to maintain aperture, approximately 1-2cm.
c) Do not open bills to full aperture as this is too wide
14. Observe vaginal walls and remove speculum.
a) Place thumb of dominant hand on thumb rest. Grasp handles in hand.
b)Maintain pressure on thumb rest with thumb to prevent bills from closing
on cervix.
c) Release secured position.
(1) Plastic speculum - push downward on thumb rest ledge until first
position is unclicked.
(2) Metal speculum - maintain pressure on thumb rest.
Loosen nut with nondominant hand.
d) Remove speculum about 2cm, or until bills are past cervix, Then remove
thumb from thumb rest.
e) Rotate speculum clockwise to observe the vaginal walls as
removing speculum.
f) Remove speculum applying posterior pressure on pelvic floor.
(1) Vaginal walls will close bills naturally.
(2) Remove bills on an oblique (45) angle.
(3) Avoid pulling pubic hair or pinching labia.
g) Rotate back of hand to touch the inner thigh. Break physical'' contact
with patient.
h) Discard speculum or place in container provided.
Conclude exam with a reassuring statement
"Everything is normal."
D. Bi-Manual Exam
1. Explain procedures and purpose.
a) "I am going to insert two fingers into the vagina. I will palpate the
abdomen with my free hand and examine the cervix, uterus and ovaries."
b) "Please let me know if you feel any discomfort."'
2. Lubricate and insert examining fingers.
a) Apply a small amount of powder or lubricant to reduce pull on skin.
b) Drop lubricant on index and middle finger. Do not touch opening of
lubricant applicator, this avoids contamination
(1) Place dominant foot on foot shelf on bottom of table end.
(2) Have patient pull gathered drape above her navel.
(3) Inform the patient that you are going to touch her thigh.
c) Use the `peace sign' with non dominant hand. Insert index and middle
finger of dominant hand palmar surface up.
d) Follow vaginal floor until cervix is located.
(1) Recall angle and depth of speculum insertion to aid location.
(2) Cervix feels like the tip of the nose with a (dimple) as in the
center.
(3) Try not to lean on the patient.
3. Palpate cervix and anterior uterine surfaces.
a) Position cervix between the index and middle finger.
(1) Rock cervix gently and note mobility.
(a) Note patient's face for discomfort.
(b) Ask patient if she feels any discomfort.
b) Rotate index finger around cervix.
(1) Note size, shape, and consistency
c) Place two fingers under cervix. Gently push up on cervix attempting to
tilt uterus upward.
d) Assess anterior uterine surface.
(1) Place non-dominant hand on abdomen below navel.
(2) Palpate with the flats of three fingers downward toward hairline.
(3) Uterus should be palpated between internal examining fingers and
external palpating hand.
4. Palpate adnexa.
a) Position examining fingers.
(1) Remove fingers 70%, reinsert into patient's right fornix.
(a) Fingers should, be palmar surface up .
(b) Assess fornix for masses or irregularities as inserting fingers.
(2) Internal fingers should be used to evaluate ovaries.
(a) Use flats of fingers to assess ovary.
(b) Fingers should be protruding upward slightly.
b) Ovary Characteristics.
(1) A normal ovary is oval in shape and pliable, and approximately
2-4cm.
(a) An ovary is very mobile, evasive and often not palpable.
(b) Palpate an ovary gently! Ovaries are extremely sensitive, comparable
to a testicle
(c) Normal fallopian tubes are rarely palpable.
(d) Ovary palpation and assessment.
(2) Use other hand to palpate externally.
(a) Use powder or lubricant to reduce pull.
(b) Locate hip bone, move inward toward navel 3cm.
(c) Sweep external hand towards hairline in a diagonal line.
(d) Repeat sweeping motions, if necessary.
(3) Ovary should be swept down by external hand, so it will move across
the internal fingers for a brief assessment.
(4) Remove fingers from vagina, reinsert into left fornix to assess
remaining ovary.
(5) Never sweep internal fingers across cervix to reposition, this .could
cause discomfort to patient.
5. Remove examining fingers.
a) While removing fingers, rotate back of hand to press against the inner
thigh.
b) Break physical contact with patient.
c) Remove gloves away from patient.
Conclude exam with reassuring statement.
"Everything is normal.”
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