Healthcare and Medicine Reference
Specifi c requirements
For investigation of vaginal wall or uterine prolapse, a Simm's spec-
ulum allows better inspection of the vaginal walls. This is usually
performed in the left lateral position.
Bimanual examination of the pelvis
Evaluation of pelvic masses (fi broids, malignancy).
Evaluation of pelvic pain (pelvic infection, endometriosis).
As for speculum examination.
Rarely performed in later stages of pregnancy, although a digital
examination is useful to assess the cervix for diagnosis of labour.
Any kind of digital examination is contraindicated in antepartum
haemorrhage, until placenta praevia is excluded.
Caution is necessary if an ectopic pregnancy is suspected, as too
vigorous examination can cause rupture. If in doubt perform a
speculum examination only.
Figure 23.4 Cervix with small ectropion, the reddened area visible mainly
on the upper lip of the cervix.
Landmarks and anatomy
As for speculum examination. In addition, locate the anterior supe-
rior iliac spines and iliac crests.
Endocervical (two separate swabs: one chlamydia swab and a
routine microbiology swab for gonorrhoea). Ensure two full
turns of the swab against the endocervix before removal.
Posterior fornix/high vaginal swab: routine microbiology
swab. This is also the site for a fetal fi bronectin test in threat-
ened preterm labour.
To withdraw the speculum, loosen the thumbscrew but keep the
Drapes etc. as for speculum examination.
Step-by-step guide: bimanual examination of the
Firstly, check that the procedure is indicated; do you know what
blades slightly parted. This will prevent tissue being trapped and
allow visualisation of the vaginal walls. Before removing the tip,
close the blades completely.
If you suspect an STI, take a urethral swab for gonorrhoea and
you are looking for?
Explain why the procedure is necessary, what will happen and
A bimanual examination may be indicated; otherwise replace
gain informed consent. Perform abdominal palpation.
Explain that whilst slight discomfort is usual, the examination
the drape, providing tissues and privacy for the patient.
should not be painful and will last only a few minutes. Always
perform abdominal palpation fi rst.
The patient lies in the lithotomy position as for a speculum exam-
A trained chaperone supports the patient, assists the practitioner
and witnesses that all actions were necessary, appropriate and with
consent. It is accepted practice that all doctors should conduct inti-
mate examinations in the presence of a chaperone, by not doing so
you expose yourself to unnecessary risk.
ination. Ensure that the abdomen is exposed for examination.
With the non-dominant hand, part the labia minora, again
noting any visible lesions.
Lubricate the index and middle fi nger of the dominant hand and
then insert through the vaginal introitus and rotate so that the
fi nger pulps face superiorly.
Advance the examining fi ngers to the cervix.
Palpate the cervix for any irregularities. Note any pain on
If visualisation of the cervical os is diffi cult you can withdraw the
movement of the cervix (excitation).
Push the cervix superiorly, and place the non-dominant hand
speculum slightly, ask the patient to place her fi sts at the base of
her spine then reinsert the speculum and open the blades again.
Alternatively, a longer speculum may be required.
If applicable you can allow the patient's skirt to remain. This
suprapubically gently pushing down to feel the uterus between
both hands. Try to assess size and regularity of the uterus
(a bulky irregular uterus suggests the presence of fi broids),
mobility (immobility suggests adhesions from malignancy,
pelvic infection, endometriosis or previous surgery). Note any
reduces exposure and perhaps anxiety.
LBC enables a smear to be taken despite the presence of
small amounts of blood; however, some women will be more
comfortable being examined when they are not menstruating.