PREPARATION FOR GYNAECOLOGIC OR PELVIC EXAMINATION

• Some women have mixed feelings about a vaginal or gynaecologic examination.
• A woman may fear the examination because she thinks it may be painful or it may show that something is wrong. She may also be embarrassed by physical exposure or questions the physician may ask.
• The nurses’ role in reassuring and relaxing the patient is very important.

Gynaecologic examination cont’d

• The purpose of a vaginal or pelvic examination is to examine the external genitalia and the pelvic organs for signs of irritation,growths, displacement or other abnormal conditions and to take vaginal smears.

Equipment

• Gown
• Draw sheet
• Examination tray
• Speculums of various sizes
• Lubricant jelly
• Applicators and glass slides
• Fixatives
• gloves

Procedure

• Protect the bed with draw sheet
• Assist patient to wear a gown
• Have the patient to empty her bladder before the examination
• Wash your hands and wear gloves
• Warm and lubricate the speculum
• Assist the patient into a lithotomy position and drape the patient.

Procedure cont’d

• The physician palpates the pelvic organs by inserting two fingers in the vagina, at the same time placing the other hand on the patient’s lower abdomen,
• The physician inspects the vagina and cervix after inserting the lubricated speculum.
• If the physician wants to take smears of vaginal or cervical secretions,applicators and glass slides are usually used

Procedure cont’d

• The nurse stays by the patient, helping her to relax
• After the examination,wipe traces of lubricating jelly from the perineum and adjust her position
• Provide her with sanitary pad if necessary
• Make patient comfortable
• Wash your hands and remove and dispose of gloves

Procedure cont’d

• If a biopsy has been taken, the patient may experience some bleeding, this should be minimal, if not the physician should be notified
• Label specimens and send them to the laboratory
• Document the procedure,date,time,the physicians name,type of specimen taken,
• Discard equipment

Gynaecological instruments

• Vaginal speculum
• Cuscus speculum
• Sims's speculum
• Dilators – in different sizes, the minimum size is ½ and the maximum size is 11/12, used to dilate the cervical os prior to evacuation operation.

Gynaecological instruments cont’d

• Green-armytage(uterine haemostatic forceps) used for haemostasis in lower uterine segment Caeserean section
• Vulsellum forceps-used to get hold of the anterior lip of the cervix

Hysterosalpingography(utero salpingography)

• Hysterosalpingography (HSG) is a radiologic procedure to investigate the shape of the uterine cavity and the shape and patency of the fallopian tubes.
• It entails the injection of a radio-opaque material into the cervical canal and usually fluoroscopy with image intensification

Hystero salpingography cont’d

• Uterine tumours,intrauterine adhesions,and developmental anomalies can be seen. Tubal obstruction caused by internal scarring, tumour or kinking also can be detected.
• A possible therapeutic effect of this test is that passage of dye through the tubes may clear mucous plugs, straighten kinked tubes or break up adhesions.

Hysterosalpingography cont’d

• contraindications
• Patients with infections of the vagina, cervix,or fallopian tubes, because there is risk of extending the infection
• Patients with suspected pregnancy,because contrast material might induce abortion

Procedure and patient care

• Before
• Determine pregnancy status of the patient
• Administer sedatives eg.diazepam(valium) or antispasmodics,if ordered before the test
• Tell the patient that no food or fluid restrictions are needed.
• Bowel cleansing may be needed, an enema or laxative may be given.

During

• After voiding the patient, is placed on the fluoroscopy table in the lithotomy position.
• With a speculum in the vagina,contrast material is injected through the cervix. The dye fills the entire upper genital tract(uterus and tubes)
• Fluoroscopy is performed and x-ray films are taken.

During

• This procedure is performed by a physician in approximately 15-30 minutes.
• Tell the patient that she may feel occasional, transient menstrual-type cramping and that she may have shoulder pain caused by subphrenic irritation from the dye as it leaks into the peritoneal cavity

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After

• Inform the patient that a vaginal discharge (sometimes)bloody may be present for 1-2 days after the test, may need vulval pads.
• Instruct the patient as to signs and symptoms of infection (eg fever,increased pulse rate pain)
• Some left over dye after the procedure may also come out of the vagina.

Abnormal findings

• Endometrial cancer ,polyps or hyperplasia
• Uterine fibroids
• Septate uterus
• Displaced IUD

Complications

• Infection, allergic reactions to the materials used.
• Intravasation of the material and if oil-based material is used ,embolisation. Air can also be accidentally instilled into the uterine cavity by the operator thus limiting the examination.

PAPANICOLAOU SMEAR(Pap smear, Pap test)

• A pap smear is taken to detect neoplastic cells in cervical and vaginal secretions.
• This test is based on the fact that normal cells and abnormal cervical and endometrial neoplastic cells are shed into the cervical and vaginal secretions.
• By examining these secretions microscopically, one can detect early cellular changes compatible with pre-malignant or an existing malignant condition

Pap smear cont’d

• Pap smear is 95% accurate in detecting cervical carcinoma, however, its accuracy in detection of endometrial carcinoma is only approximately 40%.
• In the past the cells were classified as :
• Class1-absence of abnormal cells
• Class 2-atypical cytology,but no evidence of malignancy

Pap smear cont’d

• Class 3-cytology suggestive of ,but not conclusive of malignancy
• Class4-cytology strongly suggestive of malignancy
• Class 5-cytology conclusive of malignancy

Pap smear

• Currently Pap smear reporting has been reclassified in terms of cervical intra epithelial neoplasia(CIN).
• This is a simple designation of the spectrum of intraepithelial dysplasia,which usually occurs before invasive cervical cancer.
• The subclasses of CIN are defined as follows:

Pap smear cont’d

• CIN 1-mild and mild to moderate dysplasia
• CIN 2-moderate and moderate to severe dysplasia
• CIN -3 severe dysplasia and carcinoma in situ
• A Pap smear may also be performed to follow some abnormalities eg. infertility

Pap smear cont’d

• An abnormal maturation index(MI) is characteristic of an oestrogen-progesterone imbalance.
• Pap smear should be part of the routine pelvic examination, which is usually performed once a year on women over 18years of age (or even earlier when the patient is sexually active)

Pap smear cont’d

• The American cancer society recommends that a Pap smear be taken annually for two negative examinations ,then repeated once every 3years until age 65 in asymptomatic women. More frequent testing may be indicated for patients with STIs, those with a family history of cervical cancer.

Contraindications

• Patients presently having routine normal menses because this can alter test interpretation.
• Patients with vaginal infections . Cellular changes that may be misinterpreted as dysplastic may transiently occur during these infections.

Interfering factors

• A delay in fixing a specimen allows the cells to dry which destroys the effectiveness of the stain, and makes cytologic interpretation difficult
• Using lubricating jelly on the speculum can alter the specimen
• Douching and tub bathing may wash away cellular deposits and interfere with the test results

Interfering factors

• Menstrual flow may alter test results
• Infections may interfere with hormonal cytology
• Drugs such as digitalis and tetracycline may alter the test results by affecting the squamous epithelium

Procedure and patient care

• Before
• Explain the procedure to the patient
• Instruct the patient not to douche or tub bathe during the 24hours before the Pap smear(some physicians prefer that patients refrain from sexual intercourse for 24-48hours before the test)
• Instruct the patient to empty her bladder before the examination

​

Procedure and patient care cont’d

• Tell the patient that no fasting or sedation is required.
• During
• The patient is placed in the lithotomy position
• A vaginal speculum is inserted to expose the cervix
• Material is collected from the cervical canal by rotating a moist,saline cotton swab or spatula within the cervical canal and in the squamo-columnar junction

Procedure and patient care cont’d�during

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• The cells are immediately wiped across a clean glass slide and fixed either by immersing the slide in equal parts of 95% alcohol and ether or by using a commercial spray.
• The secretions must be fixed before drying, because drying will distort the cells and make interpretation difficult

During cont’d

• The slide labelled with patient’s name,age and parity and with the date of her last menstrual period
• The patient’s medication history eg. oral contraceptives and the reason for the examination should be written on the laboratory request form
• Note that that a Pap smear is obtained by a nurse or a physician in approximately 10minutes.

Procedure and patient care�cont’d

• During

Tell the patient that no discomfort,except for insertion of the speculum, is associated with this procedure

After

Inform the patient when the results will be ready

Abnormal findings

• Cancer
• Infertility
• Sexually transmitted infections
• Reactive inflammatory changes
• Fungal infection
• Parasitic infection
• Herpes infection

TEACHING BREAST SELF-EXAMINATION (BSE)

• It is recommended that each woman examine her breasts monthly about one week following the menses,to determine if there are any lumps or nodules or any thickening.
• If the woman is post menopausal,she should examine her breasts on the same date each month.

Teaching breast self –examination cont’d

• The key is to note any change from the previous month.
• The flat of the hand rather than the finger tips, is used to perform breast palpation
• The woman should check the nipple for lumps,tenderness, discharge or any changes.
• The steps are as follows:

Step 1

• Careful examination of the breasts before a mirror for symmetry in size and shape, noting any puckering or dimpling of the skin or retraction of the nipple.

Step 2

• Arms raised overhead, again studying the breasts in the mirror for the same signs
• Step 3

Reclining on bed with flat pillow or folded bath towel under the shoulder, on the same side as breast to be examined

Step 4

• To examine the inner half of the breast, the arm is raised over the head, beginning at the breast bone and in a series of steps, the inner half of the breast is palpated
• Step 5

The area over the nipple is carefully palpated with the flat part of the fingers.

Step 6

• Examination of the lower inner half of the breast is completed
• Step 7

With arm down at side self-examination of breasts continue by carefully feeling the tissues which extend to the armpit.

Step 8

• The upper outer quadrant of the breast is examined with the flat part of the fingers
• Step 9

The lower outer quadrant of the breast is examined in successive stages with flat part of the fingers.

Breast self-examination cont’d

• Step 1: in the shower

-examine breasts during bath or shower

-keeping fingers flat, move gently over every part of each breast, use right hand to examine left hand for breast. Check for any lump, hard knot or thickening

Step 2:before a mirror

• Inspect breasts with arms at sides
• Raise arms high overhead
• Look for any changes in contour of each (a swelling, dimpling of skin, or changes in the nipple)
• Rest palms on hips and press down firmly to flex chest muscles. Left and right breast will not exactly match.

Step 3: lying down

• To examine left breast, put a pillow or folded towel under left shoulder
• Place left hand behind head(this distributes breast tissue more evenly on the chest)
• With right hand, fingers flat, press gently in small circular motions around an imaginary clock face.

Step 3 cont’d

• Begin at outermost top of left breast for 12’oclock then move to 1 o’clock and so on around the circle back to 12o’clock
• Move in an inch, toward the nipple and keep circling to examine every part of breast including the nipple. This requires at least three more circles.
• Repeat procedure on right breast, notice how the breast structure feels.

Step 4: nipple check

• Squeeze the nipple of each breast gently between thumb and index finger
• Any discharge, clear or bloody should be reported to the physician immediately.