OBSTETRICS | Topic - OFFICE PROCEDURES

By Dr. Frances Janine B. Vera Cruz (May/10/2021)

TOPIC OUTLINE There are different sizes, small is used usually for
abused patients and nulliparous. Tas large
I. SPECULUM EXAMINATION naman for multiparous
II. PAP SMEAR
PROCEDURE PROPER
III. BIMANUAL EXAMINATION
IV. RECTOVAGINAL EXAMINATION 3. Tell the patient that she is going to be
V. RECTAL EXAM examined. Gently insert a finger of your other
VI. SAMPLEX hand just inside the vaginal introitus and apply
pressure downward.
 Inform the patient first that the procedure is
I. SPECULUM EXAMINATION uncomfortable
 Show first the speculum kasi minsan
(Please watch in youtube before reading for natatakot sila pag iniinsert bigla
better understanding. All that is color blue is  And make sure you insert tha speculum
coming from Bates pages 946-947) closed and along with the slit of the vagina
 Tell the patient to relax kasi the muscle will
Speculum examination- be more resistant if she is not relaxed
 Relaxation of the preineal and vulvar  When you insert, make sure that the pubic
structuresduring pregnancy may minimize, hair and the labia is properly separated
but not eliminate, discomfort from the para di mahila yung pubic hair, it is painful
speculum examination.  Avoid touching the clitoris, it is
 The increased vascularity of the vaginal uncomfortable
and cervical structures promotes friability,
so insert and open the speculum gently to
prevent tissue trauma.
 During the third trimester, perform this
examination only when necessary, as the
descent of the fetal parts into the pelvis
can makwe the examination very
uncomfortable
 (pg. 946 by Bates)

PREPARATION

1. Lubricate the speculum with water or water 4. Ask the woman to breathe slowly and to try
soluble lubricant. Advantage of using water is to consciously relax her muscles or the muscles
that a cold speculum can be warmed by of her buttocks. Wait until you feel the
rinsing in warm water, it can also be warmed relaxation. Use the fingers of that hand to
by holding it in your hand or under the lamp separate the labia minora so that the vaginal
for a few minutes. opening becomes clearly visible.

2. Select the appropriate size of speculum 5. Then slowly insert the speculum along the
and hold it in your hand with the index finger path of least resistance, often slightly
over the top of the proximal end of the downward, avoiding trauma to the urethra
anterior blade and the other fingers around and vaginal walls.
the handle.

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6. Some insert the speculum blades at an
oblique or horizontal, either ways avoid
touching the clitoris, catching pubic hair, or
pinching labial skin.

7. Insert the speculum the length of the

vaginal canal.

8. Open the speculum by pressing on the

thumb piece.

9. Sweep the speculum slowly upward slowly

until the cervix comes to view.

10. Gently reposition the speculum, if

necessary to locate the cervix.

11. Adjust the light source.

12. Once the cervix is visualized, manipulate

the speculum so that the cervix is well
exposed
C.) SURFACE CHARACTERISTICS-
13. Lock the speculum blades into place to Normally- should be smooth
stabilize the distal spread of the blades, and
adjust the proximal spread as needed. Nabothian cysts maybe observed as small,
white or yellow, raised, round areas on the
cervix. These are retention cysts of the
endocervical glands and are considered
What to observe: an expected findings.

CERVIX-inspect for color, position, size, surface Look for friable tissue, red patchy areas,
characteristics, discharge, and shape granular areas, and white patches that
and size of the os. could indicate cervicitis, infection or
carcinoma.
a) COLOR should be pink evenly distributed  Note for presence of any cervical polyps,
(bluish in pregnant women) which are bright red, soft, and fragile. They
b) POSITION- the anterior-posterior position of usually arise from the endocervical canal
the cervix correlates with the position of the
uterus,
*pointing anteriorly- indicates a c) SIZE & SHAPE-
retroverted uterus the os of the nulliparous woman is small
*pointing posteriorly- indicates a and round or oval.
anteverted uterus The os of a multiparous woman is usually a
*horizontal position- indicates a uterus in horizontal slit (an arc or a “smile) or maybe
mid position. irregular and stellate due to prior deliveries.
Cervical lacerations caused by trauma
 should be located in the midline from childbirth can produce lateral
 deviation to the left or right may indicate transverse, bilateral transverse or stellate
a pelvic mass, uterine adhesions or scarring. The inner portion of the cervix
pregnancy everts sllightly during pregnancy, called
ectropion, and appear as glandular friable
darker pink or red area inside the os.

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  Make sure that the speculum is fully closed
d) DISCHARGE- when the blades pass thru the hymenal ring.
 Determine whether the discharge comes
from cervix or vaginal in origin and has  Note the odor of any vaginal discharge
only been deposited on the cervix. that has pooled in the posterior blade and
 Usual discharge is odorless, maybe obtain a specimen, if you already done so.
creamy or clear, maybe thick ,thin, or
stringy; and is often heavier at mid cycle  Deposit the speculum in the proper
or immediately before menstruation. container.
 The discharge of a bacterial or fungal
infection will more likely have an odor and
will vary in color from white to yellow, II. PAP SMEAR
green or gray.
 Obtain specimens for pap smear, HPV Method of cervical screening used to
testing, culture or other laboratory analysis detect potentially precancerous and
as indicated. cancerous processes in the cervix.

 Start at 21 y/o regardless of sexual activity

 For ages 21-29 y/o every 3 years
WITHDRAWING OF SPECULUM  Every 3 years for 30 to 64 y/o
 High risk patients are screened yearly
 unlock the speculum and remove  Stop at age 65
carefully so that you can inspect the
vaginal walls. Prcedure
Dapat naka close na sya ha before you • Clean discharges or blood first.
remove it. • Insert the speculum
 Note color, surface characteristics, Collect other vaginal specimens such as STI
relaxation, rugae, and secretions/ cultures, wet mount samples, or Group B strep
discharges. The color should be about the swabs
same color pink as the cervix or a little • Swipe on the squamo-columnar junction
lighter. For pregnant, normal color is (SCJ) then apply the smear on the slide (2
bluish color, deep rugae, and increased strokes)
milky white discharge (leukorrhea) Used for swiping:
*cotton swab
 the surface should be moist smooth or *Ayre’s spatula
rugated, and homogenous. Look for *Cervexbrush
cracks, lesions, bleeding, nodules and • Spray with fixative
swelling

 Secretions that maybe expected are

usually thin, clear or cloudy, and odorless.

 As you withdraw the speculum, the blades

will tend to close themselves. Avoid
pinching the cervix and vaginal walls.

 Maintain a downward pressure of the

speculum to avoid trauma to the urethra.
Hook your index finger over the anterior
blade as it is removed. Keep the thumb WET MOUNT KOH MOUNT
on the handle lever and control closing of Vag dsicharge +NSS Vag discharge + 10%
the speculum. Potassium hydroxide

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Can detect : (+) whiff test: muscles to relax. Gradually and gently insert
Pseudohyphae Fishy odor (seen in your fingers full length into the vagina.
Budding yeast bacterial vaginosis
Trichomonas and trichomoniasis) 4. Palpate the vaginal wall as you insert your
Clue cells fingers. It should be smooth, homogenous,
Can detect and non tender. Feel for cysts, nodules,
pseudohyphae and masses, or growths.
budding
5. Be careful where you place your thumb
during the bimanual examination. You can
WET MOUNT/ KOH tuck it into the palm of your hand, but that
• Spread the specimen on the slide. will cut down on the distance you can insert
Make 2 separate circles your fingers. Be aware of where the thumb is
and keep it from touching the clitoris, which
• One specimen with NSS the other with KOH. can produce discomfort.
• Place cover slip for each specimen.
• Write the name on the slide. 6. Locate the cervix with the palmar surface of
your fingers, feel its end, and run your fingers
 Make sure to collect the specimen first around its circumference to feel the fornices.
before writing the name in the specimen Feel the size, length, and shape, which
rightaway, baka makalimutan should correspond with your observations
from the speculum examination.

Cervix. Because of softening during pregnancy

III. BIMANUAL EXAMINATION (Hegar sign), cervix may be difficult to
identify. It may feel irregular if there is
Performing bimanual examination is much nabothian cysts and healed lacerations
easier during pregnancy due to pelvic floor from birth.
relaxation
To estimate the cervical length, palpate
the lateral surface of cervical tip to lateral
forix.. Prior to 34-36 weeks gesation, cervix
should retain its original length (3cm or
greater)

7. The consistency of the cervix in a non

pregnant woman will be firm, like the tip of
the nose, during pregnancy the cervix is
softer. Feel for nodules, hardness, and
roughness.

8. Note the position of the cervix as discussed

in the speculum examination. The cervix
should be in the middle and maybe pointing
1. Inform!!!!!! the woman you are going to anteriorly or posteriorly.
examine her internally with your fingers.
9. Grasp the cervix gently between your fingers
2. With your gloved finger lubricate the index and move it from side to side.
and middle finger of your examining hand.
10. Observe the patient for any expression of
3. Insert the tips of the gloved index and pain or discomfort with movement (cervical
middle fingers into the vaginal opening and motion tenderness)
press downward, again waiting for the

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 11. The cervix should move 1-2 cm in each
direction with minimal or no discomfort.
Painful cervical movement- suggest a PID, 17. Palpate the uterus for size, shape, and
inflammatory process or ruptured tubal contour. It should be pear shape and 5.5 to
pregnancy. 8 cm long, although it is larger in all
dimensions in multiparous women. Take note
Palpate the cervical os. This may be easier if the that the uterus becomes an abdominal
patient moves her heels close to her organ at 12 weeks
buttocks, shortens vagina and places her
closed fists under her buttocks to tip the  A uterus larger than expected in a
pelvis upward, which makes the cervices woman of childbearing age is indicative
easier to palpate. of pregnancy or tumor
The externol os- may be open to admit a
fingertip of a multiparous woman  The contour should be rounded, and
The internal os (the narrow passage bet. walls should feel firm and smooth in a
Endocervical canal and the uterine cavity- non-pregnant woman
should be close until late pregnancy
 Gently move the uterus between the
intra-vaginal hand and abdominal hand
UTERUS to asses for mobility and tenderness and
12. Palpate the uterus. Place the palmar masses
surface of your other hand on the
abdominal midline, midway between the  The uterus should be mobile in the
umbilicus and the symphysis pubis. Palpate anteroposterior plane
for the uterine size, shape, consistency, and
position.  A fixed (not moving) uterus indicates
adhesions. Tenderness on movement
13. Place the intravaginal fingers in the suggests a pelvic inflammatory process
anterior fornix. or ruptured tubal pregnancy.

14. Slowly slide the abdominal hand towards  Palpate the adnexal areas and ovaries.
the pubis, pressing downward and forward (You have right and left adnexa, present
with the flat surface of your fingers. here are your broad ligaments, fallopian
tube, and ovary). Place the fingers of
15. At the same time, push inward and your abdominal hand on the right lower
upward with the fingertips of the quadrant. With the intravaginal hand
intravaginal hand while you push facing upward place both fingers in the
downward on the cervix with the backs of right lateral fornix. Check for ovarian
your fingers. masses or ectopic pregnancy. If there is
tenderness it can be PID or ruptured
Note: Think of it as trying to bring your two ectopic pregnancy. But in my
hands together as you press down on the experience if it just a 3cm mass you
cervix. cannot feel it, you can only feel 4-5cm
masses.
16. Confirm the location and position of the
uterus by comparing your inspection  Press the intravaginal fingers deeply
findings with your palpation findings. The inward and upward toward the
uterus should be located in the midline abdominal hand, while sweeping the
regardless of its position. flat surface of the fingers of the
abdominal hand deeply inward and
Note: Deviation to the right or left is indicative obliquely downward toward the
of possible adhesions, pelvic masses, or symphysis pubis.
pregnancy.

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  Palpate the entire area by firmly IV. RECTOVAGINAL EXAMINATION
pressing the abdominal hand and
intravaginal fingers together. Repeat  The rectovaginal exam is an important
the maneuver on the left side part of the pelvic examination

 The ovaries if palpable should feel firm,  It allows you to reach almost 2.5 cm
smooth, ovoid, and approximately 3 x 2 (1inch) higher into the pelvis, which
x 1 cm in size enables you to better evaluate the
pelvic organs and structures
ADNEXA
 You are also palpating for adnexal  As you complete the bimanual
masses, and if any are found they examination, withdraw your examining
should be characterized by size, shape, fingers, change gloves and lubricates
location , consistently and tenderness fingers.

 The Adnexa are often difficult to  We usually do rectovaginal examination

palpate of their location and position for cases of gynecologic patients with
and the presence of excess adipose any kind of cancer, either endometrial,
tissue in some women. cervical or ovarian

 Tell the patient that she may feel the

DIFFERENT TYPES OF UTERUS urgency of a bowel movement. Assure
A. Anteverted Uterus –this is the her that she will not have one, and ask
relationship of your uterus with your her to breathe slowly and consciously try
vaginal canal to relax her sphincter, rectum, and
B. Anteflexed Uterus – this is the buttocks, because tightening the
relationship of your uterine body to muscles makes the examination more
your cervix, it is going to the bladder uncomfortable for her.
 If the uterus is anteverted or
anteflexed your cervix is Anal sphincter
posterior, the uterus is leaning  Place your index finger into the vagina,
more on your bladder then press your middle finger against the
C. Retroverted Uterus – uterus is leaning anus and ask the patient to bear down.
more on your rectal area so your cervix
is anterior  Slips the tip of the finger into the rectum
D. Retroflexed Uterus just pass the sphincter. Palpate the area
E. Midposition of Uterus of the anorectal junction and just above
it

 Ask the woman to tighten and relax her

anal sphincter. Observe sphincter tone.
An extremely tight sphincter maybe the
result of anxiety about the examination;

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 maybe caused by scarring or may Adnexa
indicate spasticity caused by fissures,  Same manuevers use in bimanual exam,
lesions, or inflammation with the middle finger in the rectum
 Palpate the right and left adnexa. The
 A lax sphincter suggest neurologic corpus luteum may be palpable as a
deficit, whereas an absent sphincter small nodule on the affected varies
may result from improper repair of third during the first weeks after conception.
degree perineal laceration after or After the first trimester, adnexal masses
previous childbirth or trauma become difficult to feel.

 3rd or 4th degree lacerations the anal

sphincter ring is cut, so you have to Stool
look for each end and connect it back  As you withdraw your fingers, rotate the
to avoid lax sphincter. rectal fingers to evaluate the post rectal
wall just as for the anterior wall, check
for bleeding
Rectal walls and rectovaginal septum
 Slide both your vaginal and rectal  Gently remove your examining fingers
fingers in as far as they will go, then ask and observe for secretions and stool.
the woman to bear down. This will bring Note the color and presence of any
an additional cm within reach of your blood
fingers. Rotate the rectal fingers to  Prepare a specimen for occult blood
explore the anterior rectal wall for testing, if indicated. Unless the woman is
masses, polyps, nodules, stricture, unable to, let her wipe off the
irregularities and tenderness lubricating gel herself

 The wall should feel smooth and

uninterrupted. Palpate the
V. RECTAL EXAMINATION
rectovaginal septum along the anterior
wall for thickness, tone, and nodules  Inspect for external hemorrhoids. if
you may fell the uterine body and present, note their size, location, and
occasionally the uterine fundus in a any evidence of thrombosis
retroflexed uterus
 May be indicated to determine the
Uterus presence or absence of the uterus or
 Press firmly and deeply downward with the presence of a foreign body in the
the abdominal hand just above the vagina
symphysis pubis while you position the
vaginal finger in the posterior vaginal  Parent/ guardian can assist and offer
fornix, and press strongly upward reassurance to the child
against the posterior side of the cervix
(posterior vaginal fornix is longer than  Maybe performed lying on her back,
the anterior) feet held together and knees bent up
on the abdomen
 Palpate as much of the posterior side
of the uterus as possible, confirming  Most prefer index finger, not mandatory
your findings from the vaginal
examination regarding location,
position, size, shape, contour,
consistency, and tenderness of the
uterus

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 VI. SAMPLEX

TRUE OR FALSE
1. A mobile uterus indicates adhesions –
2. Anteverted uterus is the relationship of
your uterine body to your cervix –
3. In Anteflexed uterus your cervix is
posterior, the uterus is leaning more on
your rectum –
4. The posterior vaginal fornix is longer
than the anterior vaginal fornix –
5. A lax sphincter suggest neurologic
deficit -

1. What particular part of the cervix will you

collect specimen for pap smear?
2. A cervix that is pointing anteriorly indicates
what kind of uterus?
3. At what age thus pap smear adviced to be
started?
4. What is mixed in a KOH mount?
5. In pap smear, fishy odor usually is indicative
of?

ANSWERS:
1. false (fixed not mobile)
2. false (Anteflexed not anteverted)
3. false (bladder not rectum)
4. True
5. True

1. Squamo-columnar Junction
2. Retroverted uterus (while posterior
pointing cervix indicates anteroverted
uterus; note they are opposite. When your
cervis is anterior, your uterus is posterior or
retroverted; and vice versa)
3. 21 years old
4. 10% Potassium hydroxide (while for wet
mount, it is NSS)
5. bacterial vaginosis and trichomoniasis

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