Medical Student Tips - Using the Speculum
This started out as as reply to Graham's post, but as I got into it, I decided to make it a post of my own, and perhaps a series.
My most important tips for using the vaginal speculum:
- The patient's buttocks need to be extending a couple of inches beyond the end of the stretcher (particularly if the uterus is anteverted), otherwise you might not be able to maneuver the speculum into the proper angle to see the cervix. If it looks like they might not be scooted down far enough, then they aren't scooted down far enough. You can always have them scoot down more after you realize your mistake, but it's better to just position them properly before you begin.
- The patient has to be relaxed. If she's all tensed up and adducting her thighs, you shouldn't just try to force your way in. You've got to make her relax first. Act relaxed yourself, using gentle tones. Tell her to take a deep breath or two and let it out slowly. Take your time. Reassure her. If you can't gently separate her knees, she's not relaxed enough.
- Touch the inner thigh with your non-speculum hand before you touch the genital area, and tell her your intentions before you proceed. Don't just dive right in. A female instructor once asked me many years ago, "how would you like it if you were in that position and I just came up and grabbed your balls?" Hmmmm.
- You can push downward on the speculum with considerable force without causing unreasonable discomfort, but stay the heck away from the urethra. All the pressure should be directed inferiorly as you insert the speculum. I use my index finger to press down firmly on the inferior blade as I slide the speculum in. Torquing on the urethra with the speculum is as much of a no-no as using the upper incisors as a fulcrum for the laryngoscope. Just don't do it.
- You must find the cervix. If you don't, you're a failure.
Just kidding....sometimes it's not so easy. But don't give up, practice makes perfect.
Labels: tips
posted by scalpel at 1:50 PM
44 Comments:
As a girl and a doctor, can I add a couple things?
PLEASE warm the speculum--under warm running water works great. I actually have women say a few times a year,"nobody's ever done that before" when I have.
For most women, you can use the Pederson speculum (thinner one). Medium works for most women. If they're bigger, use the longer/large one. I can (maybe) think of a handful of occasions where I couldn't find a cervix with a medium or large Pederson.
Good tip. We use plastic speculums, so I didn't think about that one.
I should print this and give it to my OB.
I always appreciate docs who are kind enough to try and make me comfortable.
However, I do maintain that if men had to have pap smears and cervical checks, they would've found a better way than a speculum. In fact, I was talking about this very thing on my blog today.
M
Warm the speculum is rule #1 in my book!
As for speculum type and size: nullips and primps you can use a medium pederson, but for multips, you just have to go with the graves (medium should do, unless she's got a long vaginal canal) - it helps retract the vaginal walls back better, so you can better visualize the cervix.
Second-year med student here...my school pays people to let us man-handle (or woman-handle) them for these types of exams.
One of the female patients is 350+ lbs and had seven vaginal deliveries. We were all praying we wouldn't get her for our first pelvic...and guess who I got?
She was quite understanding, helped me a lot and made light of the situation ("You're gonna be up to your elbows, young lady!"). She even had her own extra-large speculum that the program director gifted her with last Christmas. Even so, the lateral walls of the vagina were STILL collapsing around the speculum somewhat. It took me the better part of ten minutes to find her cervix, although it felt more like ten hours.
Don't know if I will ever have a pelvic exam like that one ever again...
Next Wednesday I do the male genitalia exam...should be another fun-filled evening :)
Good God, I actually found Scalpel's instructions erotic....
(Man, I've been divorced toooo long....)
Good tips and as "the pelvic queen" in my ER, let me add some more:
Insert index finger first and press down on the inferior wall, advising women to let that muscle relax by just sinking their butt right into the gurney.
Then, find the darn cervix with your index finger BEFORE you insert speculum so you know where you are going.
If you still can't find the cervix have woman sit on the back of her hands - that little tilt is often all it takes.
Zelda - for your woman with lots of rugae or weak vaginal walls - you can solve this by sliding either a condom over the speculum and cutting off condom tip and then insert speculum. If no condoms you can use a glove finger but condoms are so much nicer.
Watch where you stick your thumb when doing the bimanuel exam. Two fingers in but tuck thumb down so you are not pressing on her clitoris. Common thing I see with newbie male students.
If you are not doing a PAP, remind patient that "this is not a PAP". Amazing how many think every pelvic is a pap.
Now, Scalpel - how about some tips on how not to elcit erections in young men when doing exams?
For those of you practicing in a resource poor setting, an upside down bed pan under the sacrum does wonders for positioning when you don't have a bed with stirrups....wait, no, that's a dirty word now.... foot rests. Just remember that it's crazy uncomfortable, so only have her on it for as long as you have to.
To reiterate, it was said best in The Vagina Monologues, "Warm up the duck lips!" Even the plastic ones.
Zelda - If you get the chance again with a large SP, take all the time you can. Your patients will all weigh 400 lbs and NOT know where there ovaries are. That experienced SP is a life saver and a great source if you can get past the awkwardness. Even more so for your male classmates. They just need to chill.
Scalpel - you gonna give us little girls tips for prostate exams? You know, those of us that need to be elbow-deep just to find the bottom of the thing?
Great advice, night witch!
I would love to hear some tips for the male exam. Sorry to hijack the thread here scalpel :)
My classmate went to the Air Force Academy and was telling me about a "smokin' hot" female doc who did all the physicals for pilots in training. If any of the guys became aroused during the exam, she would administer a gentle flick with her index finger...
Me? I'm considering keeping ice packs in my coat pockets and frosting my hands down a bit before I begin! *evil grin*
Aim down. The cervix is lower than you think.
If you still can't find it, it may be right above the speculum. Pull it back a little and it will probably plop right down.
Those things look scarier then they actually feel going in, although not my idea of a fun time either! Some docs are definitely better at it then others. I admit to being a wimpette sometimes and have to be coaxed back down.
I am curious though...Scalpel or anyone else that has had this experience: What was it like for you the 1st time you had to insert one of those speculums into a woman for your first exam? Did you get it right the first time? Were you nervous? and do you practice on anything else first?
And why do medical people always comment about the 300 pounder and vag exams both on the blogs and TV? Is it because she isn't pleasing to the eye?
I know doctors are human and have their own thoughts and feelings. Also, what was wrong with her having 7 babies and doing a vag exam? Stretched out? does the speculum go in any easier? or extra stuff in the way?
You are right about the urethral area Scalpel!
It's scary and awkward the first few times....that's why I posted these tips. I don't recall practicing on mannequins or anything else first...I just observed someone else do it.
Morbidly obese women are technically more difficult to perform both speculum and bimanual examinations on. There is less room in between the thighs, so your elbows and shoulders are sometimes touching them, which makes you feel like you are climbing in waist deep. Occasionally assistants are required to retract the thigh fat so that you can approach the area of concern.
Their vaginas are not necessarily larger than slender women's, but there can be more vulvar tissue to displace, occasionally requiring the use of a larger speculum for that reason. And as stated, once the speculum is inserted, the vaginal tissue tends to collapse around the sides of the speculum, making visualization of the cervix more difficult.
Due to the large pannus, the bimanual examination is usually worthless.
"Now, Scalpel - how about some tips on how not to elicit erections in young men when doing exams?"
As far as I'm concerned, that's just the signal for "exam over."
"Scalpel - you gonna give us little girls tips for prostate exams?"
The main thing to remember is that even though you're barging through the back door, it's better to sneak around the corner. Retract one buttock with one hand and gently crook the index fingertip of your other hand along the lateral(3:00 or 9:00) aspect of the anus as you advance slowly to the DIP joint. Then you can slide your finger all the way inside. Try to make them relax too.
There are three types of male reactions to rectal exams: the guy who makes a show of protesting for a minute or so to display his heterosexuality, the nonprotesting older guy who has had so many rectal exams it just doesn't bother him anymore, and the friendly guy who bends over and spreads his butt cheeks widely apart before you even have your gloves on.
seaspray - bimanual exam on a skinny girl is still like trying to pick up raw oysters wearing boxing gloves.
As Scalpel was saying, a lot of collapsing tissue makes things hard to see. Now, I don't know how the guys feel, but I KNOW how uncomfortable pelvic exams are, and I know how not fun it is to be in the ER. For that, I want my pelvic exam to be as quick as it can be while still gaining the necessary information.
That means picking the right speculum and finding the cervix on the first go, which only happens if you're both lucky and good.
Then doing a bimanual. With a really big lady you're just not going to find her ovary. I'm not really convinced that you'd reliably find a tubo-ovarian abscess on some of my patients, and they hurt!
For me, big ladies are tough in the knowing you did your job right and didn't miss anything. Tiny little 15 year old nullis are scary because you know you have to do your job right and you don't want to scar them for life.
Thanks Scalpel and Ruby Girl med!
I had 2 c-sections because My babies were 10lbs,10 oz -23 inches and 10lbs, 6oz 21 inches. 2nd one probably would've been larger but they took him on my due date.
My girlfriend delivered her 10 pounder vaginally! The nurse told me about another woman who delivered a 12 pounder vaginally! That was when I was in the hospital for my first one and I got depressed because after an extremely long labor (understatement)they had to do the C-section and so I thought I failed because I couldn't do it naturally.
As I said some docs are better than others at exams but this one time my reg OBGYN did hurt me and he assured me he was using the smallest speculum and so I don't know why that happened. He was always good at it too. I guess like in any profession...you have good days and bad days.
O.k., I have another question and I KNOW I am NOT the only woman that has ever wondered this....
What are you male docs thinking as you approach a naked woman to do the exam?
My favorite acronym which someone said in medblog Addict's post?
OBGYN-Oh boy got you naked! :)
My girlfriend asked me a long time ago if I thought docs thought certain things and I said"Oh no-o-o-o, they're doctors, they are just doing their jobs. Besides, they see so many that they don't think anything about it." Not long after that she read about her OBGYN losing his license, etc because he was up on charges for doing inappropriate things with his pts. I felt bad that I blew her off but she never told me the comments he made about her bajingo either!
I have been around naked male pts in the ER and have always been aware that is their schwing schwong but I tuned that out and just saw the patient. Same with seeing women's breasts when they are getting the EKG's, I see but I don't look...if that makes any sense. Just go to a different level.
Plus, I am thinking that in a pelvic exam...you are wanting to do everything right and you are gathering information and therefore in science mode.
I have female friends that prefer and are more comfortable with female docs doing their exams and yet for some reason I prefer male docs. I guess I am more used to it. It doesn't bother me at all that they are male because I am not thinking that way.
And actually, I would think female docs know exactly how you feel because they have felt it too, yet except for one...all my docs are males.
I have one more question but wrestling with it and have to think about it. Unless of course someone can read between the lines and just answer it. :)
"What are you male docs thinking as you approach a naked woman to do the exam?"
I'm hoping that I don't need a machete to clear the path for the speculum.
wrong. just wrong. (to the machete comment)
We usually aren't thinking about much of anything except what we're looking for. I'll admit there are times I'm disgusted, and I'll even admit to having the extremely rare, and very brief thought that I can't print here.
Honestly, though, vaginas are in general not attractive organs. So, those few, fleeting moments of that "other" thought are usually not about what specifically I'm looking at, but that "this patient's hot, and I'm looking at her naked...", I'm uncomfortable for a moment, then it passes, and the exam continues.
(alright guys, back me up here, don't make me realize I'm a creep...)
The thougt goes like this, "What a lovely attractive person this is who happens to be naked in front of me. What a very pretty ____ (face, arms, six pack, behind, tattoo...that's about the whole list, because bits is just not attractive....don't care if Michelangelo sculpted them, bits is gross if you're not on a very personal basis with their owners.)
Of course the very pretty part comes rapidly followed by "Oh look, he's _______. (arrested, drunk, high, belligerent, vomiting on my shoes)
LOL!!! ROFL YOU "almost" got me with a nasal lavage scalpel! That's two days in a row I've choked on a beverage reading a comment. it's been awhile but it's the unexpected that always gets me. ;)
Hibgia - "Honestly, though, vaginas are in general not attractive organs."
I am holding back here! ;)
Still I would think that just "because" they are what they are that would be the attraction.
But I am curious...what organ IS more attractive? The heart, liver, or kidney, etc.? I think Dr Schwab has mentioned some tiny little organ being blue (I could be wrong) but if there is a blue organ then that would have to be the attractive one in my book. ;)
Your candor is appreciated and your human, with eyes that take in information. It's what you do with the info that makes the difference. :)
I was going to say "use my sword" but I thought that might be misconstrued.
Even funnier and yeah...could've been misconstrued! :)
More tips -
ALWAYS have all of the supplies you think you will need out and usable. The faster you can do this, the better. I never even screw the speculum open, my assistant has everything ready and I'm done collecting pap/cultures/whatever within 20 seconds. Speculum out as soon as possible.
Lube is your friend.
Ask the patient to try to sink her butt down. This relaxes her pelvic floor and provides distraction, both of which are good things.
For the bimanual exam - move the cervix without asking if it hurts. Then ask the question while your hand remains perfectly still. Then ask again while moving the cervix. Helps to differentiate between real and not real pelvic pain (similar to pushing of the abdomin with the stethoscope).
For the really fat folks, the only way to get a pap (because you CAN'T see the damn cervix, despite using every trick in the book) is to do the bimanual and find the cervix like you're doing a cervical exam in labor. With your hand still in place, insert a cytobrush into the os.
For the gyns, doing a D&C on a large women can be challenging. The lighted right-angle abdominal retractors and malleables are god-sends. I successfully did a D&C on a women with a BMI of 93 last month using those, along with plentiful cussing.
seaspray,
Re: "attractive" organs, I think it was the gallbladder that Dr. Schwab described as being robin's egg blue in a sea of otherwise nondescriptly colored organs. Another awesome medblogger I read regularly.
Thanks Medrecgal - Yes Dr S. is another awesome blogger and turned me into a surgical groupie!
Robins egg blue....What a BEAUTIFUL color! I wonder what God was thinking when he painted that organ? :)
I''m SeaSpray! Sorry forgot I was blogging under my alter ego. :)
Night Witch, I think I'm one of those women who thinks all exams are paps... maybe I haven't had anything else, so I don't know.
I didn't know how well I had it with my (male) doctor giving me my yearly pap smears until I had a midwife give me a pap (pelvic exam?) after I got pregnant. She was very rough (I jumped a lot during it), the instruments were cold, and she didn't give me time relax.
I agree 100% about touching a woman with your hand first... I find that not being touched first makes me jump and tense up.
A surgical groupie...LOL! I was one long before blogs existed. LONG story behind that comment...but let's just say some previous OR experience left me with much interest!
I would rather have a pelvic exam weekly thanhave to go to the dentist twice a year! Anyone else feel the same way?
BTW...touching the thigh as a "warning" is a good move. I know then that it is coming and to relax.
Oh Surgeon in my dreams...you're a girl after my own heart! Except that I would rather have a pelvic exam twice a day than a dental exam twice in my LIFETIME!
Yes people- I DO have teeth! I manage to suck it up somehow and not whimper or bite too much...but it is ONLY by the grace of God!
Once, before getting in the dental chair I blurted out to him that I would rather get a pap then go to the dentist! He then told me to lie back and he would accommodate me...but he lied! He worked on my teeth...and I never trusted him again! ;)
Years later when I had to switch dentists, I warned the new guy to be nice or I'll bite to which he retorted, "That's alright...I'll bite you back!"
Needless to say, I still whimper but never bite him...but I've THOUGHT about it! ;)
Heck I'm one of these people where "anticipation" is everything. If you just look at me with intent...I feel it! Kind of like feel the tickle before the touch.
Seriously though...thank you to all the dentists out there. What would we look and feel like without you? :)
P.S. Thanks for the blogroll Scalpel. I guess you LIKE headaches? ;)
I've got one to add to this - when one (namely me) says, "Please use the little one," and the MD looks at you like, "Thank you, I know what I'm doing," and uses the bigger one. . . I felt like suggesting, "and now, I will do your lower GI - give me that thing!" Trust us, we know our own bodies.
I had opportunity yesterday to wish I had printed this one out and handed it to my Gyn...
FYI - I linked to you in the post about my experience at http://medicine-animals-and-a-dream.blogspot.com/2007/10/pap-smears-pcos-ambush-of-rectum.html
Fell free to remove the link - I just wanted you to know and I couldn't find an email address.
Hello, I have a question regarding pap exams. Is it possible for a male doc to know that he has turned the female patient on with the finger exam? Every single time this happens to me and I try very hard for it not to. I have had other obgyn male doc before and it never happend with him, only with this certain male doc. Is it possible that he is trying to turn me on and it's not me, but him? Any input is appreciated, thanks.
BRN: Good God, I actually found Scalpel's instructions erotic....
Probably the paragraph on getting the woman to relax. ;)
Reading what these male physicians say about pelvic exams has been a, um, enlightening, if not discouraging, experience. They put one fear to rest but confirm another fear. I may never submit to a pelvic exam again!
Maybe I can find a female gynecologist. The only problem with those is that they're never available when you really need them.
Night witch said:
"If you are not doing a PAP, remind patient that "this is not a PAP". Amazing how many think every pelvic is a pap."
May I suggest if you are in there anyway do the woman a favour and take one. It will only take a few moments.
Also, what is it with American's an their annual pelvics? It is certainly NOT the practice in the rest of the world...
P.S Thought I better clarify that:
(a) The American College of Obstetricians and Gynecologists suggest you have an annual exam
(b) The Alliance for the Prevention of Cervical Cancer suggests 3 - 5 yearly intervals
(c) The Australian Government (Department of Health and Ageing) suggests every 2 years
(d) The New Zeland Government suggests every 3 years
(e) The Royal Australian and New Zealand College of Obstetricians and Gynecologists suggest every 2 years in Australia (as it is the Australian Government national policy) and every 3 years in New Zealand (as it is the New Zealand Government national policy)
(f) The College of Family Physicians of Canada suggests every 3 years
(g) The Nordic Federation of Societies of Obstetrics and Gynecology suggests every 3 years
(h) The Royal College of Obstetricians and Gynecologists suggests every 3 years up until age 50, and then every 5 years till age 64
Keep in mind that it is widely acknowledged that most cases of cervical cancer take up to 10 years to develop.
Performing bimanual/DREs during a pelvic on an asymptomatic woman are old hat.
http://www.racgp.org.au/Content/NavigationMenu/Publications/AustralianFamilyPhys/2006issues/afp200611/20061103stewart.pdf
It's time to re-think these archaic practices...
http://www.racgp.org.au/Content/
NavigationMenu/Publications/
AustralianFamilyPhys/2006issues/
afp200611/20061103stewart.pdf
Dear Doctor... if your patient is crying out in pain during a speculum exam... I suggest you STOP doing the exam. Something isn't right. I never knew that this exam could hurt until my last exam with a gyno (female type). She was a heartless bitch and I'm now scarred for life. It's important for you doc types to know that that there is a think line between medical care and abuse. If you are careless you'll step over the line... but lucky for you your MD will protect you from charges... but what protects your patient?
What a funny blog- it made me laugh more than once :) RN myself, seen this, done that, but pelvic exams are never fun, that's why I go ONLY when I am due to have pap smear or something else comes up. But I enjoyed this one and will definitely print it out for my ob-gyn.
Could somebody tell me where I can find written and creal instructions about how I can obtain smear for a Pap-test?No matter how many times I have done it, I never feel quite sure about this and I think I am doing something wrong (although no complaints ever reached my ears).
Hi Scalpel:
I had a pap smear done and when the Dr took out the speculum, there was a lot of blood on the speculum. Im so scared now. It's probably just a tear to the vaginal lining but can the speculum be inserted too far in and cause damange to the cervix or uterus or other reproductive organ in that area?
Dont think the bleeding was from the actual pap test, because when the Dr took out the speculum, she was suprised that there was blood on it (the tip of the speculum was full of blood) whereas the pap test didnt result in blood.
I had no pain, the spotting stopped after 3 days and it was brown blood, so should be old blood, still have minor pain/cramp on lower ab. What should i do? should i see another Dr and get them checked agagin using a speculum again to see if there is a damage? im so scared.
Im planning to have children in a years time, im scared that this incident have damaged my reproductive organ or scarred it and would make me infertile.
Btw, im in Australia, so the pap test was done by GP rather than specialist. I hate this GP system.
Thanks
TTT
I have a question,please? I hope this thread is not too old get an answer. Is a child speculum used on a sexually active woman in her 20's? Also, what are the chances of a woman breaking a speculum with the tighting of vaginia if she gets tense during the exam?
Hi Scalpel,
I hope this blog isn't too old either! Nearly all the blogs are about inserting the speculum, can you please give us some tips about taking it out? Should the 'bills' be kept open after you clear the cervix and come right up to the introitus? or should you just close it soon after it clears the cervix? Hope you are still checking these blogs!! Totally enjoyed them! Thanks. ;)
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