Healthcare and Medicine Reference
Specials: Obstetrics and Gynaecology
Caroline Fox 1 and Lucy Higgins 2
1 Birmingham Women's Hospital, Birmingham, UK
2 Maternal and Fetal Health Research Centre, University of Manchester, St Mary's Hospital, Manchester, UK
By the end of this chapter you should be able to:
understand the indications and contraindications for insertion of
vaginal speculum and bimanual examination
be aware of the relevant anatomy for these procedures
External urethral opening
describe the procedure of performing vaginal speculum
examination (with or without cervical smear)
describe the procedure of performing bimanual examination.
Figure 23.1 The vulva.
Vaginal speculum insertion with or
without cervical smear
Vu lv a —Bounded by the mons pubis, labia majora and perineum.
From anterior to posterior this contains the clitoris, external ure-
thral opening, labia minora and vaginal introitus (external open-
ing) - see Figure 23.1.
Allows visual inspection of the cervix and vaginal walls for the
diagnosing cervical/vaginal pathology (polyps, cancer, prolapse)
detecting pre-invasive cervical disease (National Cervical
Vagina —A muscular tube extending superoposteriorly from the
vaginal introitus to the uterus at the cervix. Superiorly the vagina
is described in terms of anterior, posterior and lateral fornices. The
superior aspect of the vagina is the widest part.
testing for lower genital tract infection including sexually trans-
mitted infections (STIs)
facilitating intrauterine instrumentation (e.g. IUCD, endometrial
investigating lower genital tract symptoms in pregnancy (e.g.
Cervix —Connects the uterine and vaginal cavities through the
internal and external os. The endocervical canal is lined by mucus-
secreting columnar epithelium whilst the vaginal surface is covered
by squamous epithelium to resist the acidity of the vagina. The
squamocolumnar junction (SCJ), is the area most susceptible to the
malignant change of cervical cancer.
bleeding, pain, discharge).
Refusal of consent.
Inability to take informed consent, unless to obtain information
that will prevent harm or death.
If the patient has never been sexually active they should be
Uterus —A pear-shaped muscular organ.
referred to a specialist. This also applies to paediatric patients.
Fallopian tubes —Arise from each cornu of the uterus and end at
Landmarks and anatomy
The female reproductive organs consist of the lower genital tract
(vulva, vagina, cervix) and the upper genital tract (uterus, fallopian
tubes and ovaries).
Ovaries —Each ovary is oval and lies lateral to the uterus.
See Figure 23.2 - the female reproductive tract.
Disposable examination gloves.
Cusco's bivalve speculum.