Healthcare and Medicine Reference
Explain that slight discomfort is usual but reassure the patient
that the test only takes a few minutes. Be aware of both verbal
and non-verbal signs of distress or discomfort; if the patient
wishes the examination to be stopped, this must be respected
The patient should undress from the waist downwards. Position
the patient on the examination couch in a supine position.
The patient bends her knees, places her heels together and lets
her knees drop to either side (this is known as the lithotomy
position). Adjust the light source so that it illuminates the
Most speculums are plastic and disposable, but if a metal
Figure 23.2 The female reproductive tract.
speculum is used it may be warmed under running water. Apply
lubricant to the blades of the speculum.
Hold the speculum with your dominant hand, with the opening
mechanism pointing directly upwards and blades closed.
With your non-dominant hand, part the labia minora. Examine
the vulva and labia for abnormalities (e.g. erythema, ulceration,
warts and pigment changes).
Insert the speculum gently into the vagina; guide it towards
the base of the spine with the blades at approximately 45° to
the horizontal, adjusting the angle so the speculum passes with
Once the speculum is fully inserted warn the patient that they
will feel a stretching sensation and then slowly open the blades
to visualise the cervix including the SCJ. By ensuring that the
speculum is fully inserted you will open it at the vagina's widest
point and minimise discomfort.
Next minimise expansion so that although the cervix is seen,
Figure 23.3 Equipment required to perform a speculum examination.
the walls of the vagina are not stretched further than needed.
Use the thumbscrew to hold the speculum open.
Inspect the cervix. If necessary remove excessive secretions
Cytobrush and vial of preservative solution.
using a swab. The epithelium should be uniformly pink.
In some women (particularly those on oral contraceptives or
in pregnancy) more columnar epithelium will be visible as a
reddened area, known as an ectropion (a physiological change;
erosion is an inaccurate term and describes ulceration, which
would signify pathological change) (Figure 23.4).
Make note of any irregularity, friable tissue or ulceration.
Sponge forceps and swab.
Good light source.
Suitable chaperone (preferably a trained observer but a friend/
relative of the patient is acceptable if unavailable).
See Figure 23.3 for the equipment required to perform a speculum
To take a cervical smear
Liquid-based cytology (LBC) is the current recommended
Step by guide: inserting a speculum
Firstly, check that the procedure is indicated; do you know what
Insert the brush into the cervix. Gently rotate through fi ve
you are looking for?
Offer the patient a chaperone and document this in the notes. It
full turns to sample the SCJ/TZ, maintaining good contact
Remove the brush and detach its head or swill into the preserva-
is in your interest to have a chaperone present (obligatory for all
Ensure that the environment is appropriate (private, adequate
tive solution (as per hospital policy).
Label the vial with the patient's details.
Explain why the procedure is necessary and what is going to hap-
A small amount of bleeding after an examination is common so
pen, and gain informed consent. This intimate examination can
make the patient feel vulnerable. Be mindful of this; act in a pro-
fessional manner and treat the patient with respect and dignity.
Ensure that your shirt sleeves, tie/scarf will not obstruct your
examination. (Refer to your hospital policy regarding specifi c
infection control policy regarding watches/short sleeves.)
explain this to the patient; if there is excessive bleeding or you are
concerned about the appearance of the cervix, further referral is
If you have concerns regarding STIs or abnormal vaginal
discharge, microbiological swabs are indicated.