Pelvic exam

This is my script for a pelvic examination. Everyone has their own, so feel free to chop and change it how you like.

Introduction:

  • “Hello, Mrs Jones, I’m Will Sloper, one of the doctors here, how are you doing today?”
  • “Can I check your date of birth quickly?”
  • “May I double check that you know what it is you’ve come here for today? Have you had one before?”
  • “Excellent, and do you understand why we do this test?”

o   Not a clue

  • “This exam is a routine test that we offer to all women over the age of 25, and it allows us to see whether there is a risk of cervical cancer further down the road. It’s not a test for cancer now, it just lets us intervene nice and early should we need to, alright?”
  • “Would you like me to explain what I’ll be doing?”

o   Yes

  • “There are two parts of today’s exam, the first is the smear test, and the other is a manual examination”
  • “For the smear test, I’ll use a soft little brush to take some cells from the cervix, so that we can send these cells off to the lab. To do this, I’ll gently insert a speculum, which will just hold the vaginal walls open so that I can see the cervix. It’ll be lubricated to make it more comfortable. Would you like to see the speculum beforehand?”

o   Yes

  • “Here’s an example, of course I’ll be using a sterile one in the examination itself”
  • “The second part of the exam is the manual exam. For this I’ll gently insert two fingers, with gloves on, into the vagina, and with the other hand I’ll press gently on your tummy. This will allow me to check that all of the reproductive organs are healthy. Is that alright?”
  • “Neither of the two parts should hurt, but they can be a little uncomfortable. It’s important that you know that you can say stop anytime, and I’ll stop straight away.”
  • “Having explained the procedures, do I have your consent to go ahead?”

Preparation:

  • “First of all do you need to go to the toilet? I will be pressing on your tummy”
  • “There will be a chaperone present, is that alright?”
  • “Would you like me to lock the door? The curtain will be drawn, but sometimes people walk in without knocking”
  • “Lastly, have you had any children?”

o   “Was that through normal delivery or Caesarean section?”

  • “Ok great, if you could head behind the curtain, and undress from the waist down, you can leave shoes and socks on if you’d prefer. If you lie on the bed, there’s a towel to cover yourself, and I’ll be in in a minute”

Wash hands

Get trolley ready:

  • Wipe with tissue and alcohol gel
  • Cover with tissue
  • Prepare the vial

o   Full name and DOB

o   Remove lid, discard seal

  • Place cytology brush on trolley
  • Squirt some lubricating jelly onto the trolley, and put the jelly down somewhere else
  • Select speculum and empty onto the trolley

o   Small if no children/caesarean

o   Medium if vaginal delivery

“Alright Mrs Jones, are you ready?”
Alcohol gel

1.       Abdominal examination

  • “Please could I ask you to slide your top up so I can have a look at your tummy first”
  • Visual inspection

o   Abdominal masses

o   Scars

o   Bruising

  • “Have you had any pain in this area?”
  • Abdominal examination

o   Press abdomen from umbilicus to pubic bone, across the width of the abdomen

o   Masses and tenderness

2.       Smear test

  • Put on gloves (NOW BE THINKING ABOUT WHAT YOU ARE TOUCHING)
  • Open the packet and assemble the speculum

o   Check it works

o   Apply a drop of lubricant to both sides but not the tip and spread with finger

  • Ask the chaperone to turn on the light
  • “Alright Mrs Jones, please could you bring your heels towards your bottom and let your knees flop out to either side”

o   “I’m just going to have a look before I do anything”

o   Inspect for signs of infection, genital warts etc

o   “Ok, I’m going to do the smear test now”

  • Part the labia with left thumb and index finger
  • With speculum horizontal, slowly insert towards the small of the back
  • When the lever reaches the inner thigh, turn so the mechanism is pointing upwards
  • When all the way in, turn left hand so that the thumb is in position to open the lever
  • With right thumb holding the base firmly in place, slowly open the speculum

o   Look inside as you do

o   When you can see the os, fix the speculum with the nut

  • If you cannot see the os, ask the patient:
  • “Mrs Jones may I ask you to put your hands under your bottom for me?”
  • Gently rotate speculum if necessary
  • Take cells

o   Insert the central bristles of the brush into the os and rotate clockwise five times

o   Push the brush to the bottom of the vial 10 times and swirl vigorously

  • Inspect brush to ensure no material is left
  • Throw the brush away
  • Ask chaperone to put lid on the vial, otherwise wait until the end to do so with non-gloved hands
  • Make sure the black lines are aligned
  • Remove speculum

o   Release nut while holding speculum open with left hand

o   Retract slowly until the blades are clear of the cervix

o   Let go of the speculum completely with the left hand and slowly remove the speculum with right hand

o   Dispose of speculum

  • “Alright Mrs Jones, I’ve finished the smear test, is it alright for me to do the manual examination now?”

3.       Bimanual exam

  • Apply a little gel to the index and middle fingers of the right hand
  • Part labia with left hand and insert the two fingers into the vagina, towards the small of the back, turning as they go in
  • Feel for the cervix

o   Try to get your fingertips underneath it into the posterior fornix

o   Push the cervix up with a steady pressure

  • “May I ask you to uncover your tummy please?”
  • Start at the umbilicus and press firmly down towards the pubic bone

o   Move down in increments until you feel the cervix moving onto your inside fingers

  • Assess the uterus for:
  • Size
  • Mobility
  • Pain
  • Position
  • Palpate the right adnexa
  • Place fingers in right lateral fornix
  • With outside hand press down the inside of the hip bone and work down in increments
  • Do the same for the left
  • Withdraw fingers and examine for blood
  • Remove gloves away from the patient
  • “Alright Mrs Jones that’s all finished”

o   Deal with vial if necessary

  • “Here’s some tissue to wipe away the gel, just pop them in the yellow bin when you’re done”
  • “I’ll let you get dressed in privacy, I’ll just wash my hands, and you let me know when you’re ready”

Clear trolley

Explanation of results:

  • “Alright, was that okay?”
  • “The smear test results will come in the post in about 2 weeks, and I’ll get a copy, as well as your GP”
  • “The vast majority of these tests are completely normal so there’s no need to worry in the mean time”
  • “In the examination everything felt healthy and normal, and sometimes there’s a little blood after a smear test. It shouldn’t be prolonged or painful, but if you have any worries then you can see your GP”
  • “Do you have any other questions for me?”
  • “Thank you for coming”

Mirena can’t have an IUD

I found it hard to remember the absolute contraindications to having an IUD or an IUS. Other than being male. So I came up with a rather gruesome story to remember it.

Mirena Wilson is pregnant. She goes to have an antenatal check up because she was very sick after her previous baby, and she’s recently started bleeding which she doesn’t understand. Unfortunately she’s so septic that the infection has spread into her pelvis and through her cervix, and now her baby has been infected, and so she undergoes a septic abortion. While investigating her the doctor finds that she has four simultaneous cancers, which he’s never seen all together before:

  • Gestational trophoblastic neoplasia
  • Cervical cancer
  • Endometrial cancer
  • Breast cancer

She says she knew about the cervical cancer and was waiting to have treatment, but the other things she’s very surprised by, because she thought they were just fibroids. The doctor explains that the infection was TB, also says she has a strangely shaped uterus so she slaps him.

Absolute contraindications to IUD/IUS:

  • Pregnancy
  • Puerperal Sepsis
  • Septic abortion
  • Gestational Trophoblastic Neoplasia
  • Unexplained PV bleed
  • Cervical Cancer awaiting treatment
  • Endometrial cancer
  • Uterine fibroids
  • PID or purulent cervicitis
  • Pelvic TB

Absolute contraindications to IUD:

  • Copper allergy
  • Wilson’s disease

Absolute contraindications to IUS:

  • Current breast cancer

Why can’t I have a diaphragm

Because I said so.

Also because of the following reasons. I’ve categorised them in two different ways, one’s with a mnemonic, and one’s a more ‘logical’ approach.

The Mnemonic


You can’t have a diaphragm because U CRAP HAIR, and you have far larger issues to think about

U – Uterovaginal prolapse


C – Cystocele 

R – Recurrent UTIs

A – Allergy to spermicide

P – Poor vaginal muscle tone

H – History of toxic shock syndrome

A – Abnormalities of the vagina (congenital)

I – Inadequate retropubic ledge

R – Rectocele



The logical route


I figured that there’s only really two reasons to not be allowed to use a diaphragm – either you’re going to get sick because of it, or it’s going to fall out.

Get Sick:

  • Recurrent UTI
  • History of TSS
  • Allergy to spermicide

Fall out

  • Abnormal anatomy
  • Cystocele
  • Rectocele
  • Poor vaginal muscle tone
  • Inadequate retropubic ledge
  • Uterovaginal prolapse

Obstetric History

I find it helpful to have an idea of what I’m looking for when I’m taking a history, as it helps me remember what questions to ask and why I’m asking them. Here I’ve put down the things to ask in an obstetric history, followed by some of the things you’re looking out for.

Obstetric History:

Introduction:

  • wash hands
  • introduce yourself (+shake hands with patient)
  • explain why you’re there
  • check identity and parity
    • name
    • date of birth

Presenting Complaint

  • in patient’s own words, why they’ve come in 

History of Presenting Complaint

  • how long
  • onset – gradual or sudden
  • associated symptoms
    • pain?
      • site
      • onset
      • character
      • radiation
      • associated symptoms
      • timecourse
      • exacerbating and relieving factors
      • severity 1-10/10
    • any blood or protein in the urine?
    • any bleeding?
    • any high blood pressure?
  • have you noticed anything making it worse?
  • better?
  • was there anything you think triggered it?
  • have you had anything like it before?
    • any investigations?
    • diagnosis?
    • treatment?

Previous Reproductive History

  • Have you been pregnant before?
    • how many times
      • what year
      • how long was the gestation
      • what was the outcome
        • if live-birth, how are they now
          • were/are they breast/bottle/mixed fed?
  • How has this pregnancy been so far?
    • any problems?
      • have you noticed any bleeding in early pregnancy?
    • how far along are you?
      • when’s the estimated date of delivery?
        • was that confirmed on ultrasound?
        • when was your last menstrual period?
        • have you had scans?
          • any prenatal diagnostic tests?
        • have you felt the baby kicking?

Gynaecological History

  • Any previous gynaecological problems?
    • (have you had to see a gynaecologist before?)
  • When was your last period?
    • were your periods regular?
    • how heavy was the bleeding?
  • When was your last smear?
    • what was the result?
  • Were you using contraception prior to this pregnancy?
    • what were you using?
    • was it for contraception, or for problems with bleeding?

Previous Medical History

  • Do you have any long-term health conditions?
  • Do you see your GP for anything?
  • Have you been admitted to hospital for any reason?
  • Have you ever had any kind of surgery?

Previous Drug History

  • Do you take any regular medications?
  • Do you take any HRT (hormonal replacement therapy?)
  • Any over-the-counter supplements? (St. John’s Wort?)

Systems enquiry

  • Neuro
    • headaches
    • changes in vision
    • weakness
    • tingling
  • Resp
    • shortness of breath
    • cough
    • sputum/blood
  • Cardio
    • palpatations
    • chest pain
    • faints
    • feeling cold or clammy
  • GI
    • appetite
    • bowel movements 
    • abdo pain
  • GU
    • drinking enough
    • waterwork problems
    • frequency/urgency/retention
    • change in colour
    • pain
    • smell
  • MSK
    • joint pain
    • stiffness
    • muscle pain
  • General
    • fever
    • rash
    • jaundice
    • lethargy

Family History

  • Does anything run in the family that you know of?
    • heart disease
    • diabetes
    • thromboembolism
    • hypertension
  • Were there any complications with your mother during her pregnancy?
  • Any sisters who’ve been pregnant?
    • did they have any issues?

Social history

  • How is everything at home?
  • Who is at home with you?
    • do you feel like you have enough help at home?
    • do you receive any social support/do your other children have a social worker?
  • Any financial trouble?
  • Alcohol
  • Smoking
  • Drugs
  • Allergies

ICE

  • Are there any concerns that you have?
  • Do you have any questions for me?

Summary

  • So just to confirm… (1-2 sentence summary of what you’ve found out)

Conclusion

  • Thank you very much for talking to me
  • Wash hands
  • Present


What you’re looking out for:

Hypertension:

  • Chronic hypertension
    • present before 20 weeks
    • 3-5% of pregnancies
  • Pre-eclampsia
    • hypertension
    • proteinuria
    • oedema
  • HELLP syndrome
    • Haemolysis
    • Elevated liver enzymes
    • low platelets
  • Eclampsia
    • pre-eclampsia + convulsions

Diabetes:

  • Increased insulin requirements
  • Nephropathy may worsen, especially if HTN
  • Retinopathy may worsen
  • Infection risk
  • Pre eclampsia risk

Ectopic pregnancy:

  • positive pregnancy but lower B-hCG than expected
  • abdominopelvic pain
  • bleeding

Epilepsy:

  • 0.5% of pregnancies
  • Highest risk in puerperium
  • folate metabolism main concern

Sepsis:

  • Pelvic inflammatory disease
    • abdominopelvic pain
    • fever
    • discharge

Kidney Problems:

  • Higher risk of UTI
  • Hypertension
  • CKD
    • 1/30 pregnancies complicated by ckd
      • largely due to increased maternal age 
      • increased diabetes 
  • RISKS:
    • miscarriage
    • IUGR
    • preterm delivery
    • Foetal death

Anaemia:

  • defined as less than 10.5 g/dl
  • haemodilution occurs in pregnancy as plasma volume increases by 50%
  • 2-3x increased iron requirement
    • 90% of pregnancy anaemia thought to be due to iron
  • 10-20x increased folate requirement
    • 5% of pregnancy anaemia thought to be due to folate
  • Sickle cell disease increased risk, as is thalassaemia

Auto-immune:

  • SLE – 1/1000
    • Lupus nephritis carries poor prognosis
      • high risk of miscarriage
      • IUGR
      • preterm delivery
      • IUD
      • transient neonatal lupus
      • maternal hypertension
    • symptoms may improve during pregnancy due to immunosuppression but often flare during pueperium

Asthma:

  • 1-4% of women of childbearing age
    • 1/3 have no change
    • 1/3 improve
    • 1/3 deteriorate
  • asthma doesn’t affect course of pregnancy unless poorly controlled:
    • small for gestational age
    • IUGR
    • preterm delivery
  • treatment is the same as in non-pregnant women

Hyperemesis gravidarum

  • 0.1-1% have persistent nausea and vomiting
  • weight loss
  • tachycardia
  • dehydration
  • fluid and electrolyte imbalance
  • postural hypotension
      • think about vitamin B1 deficiency (Wernicke’s encephalopathy)
      • hyponatraemia
      • malnutrition
      • thrombosis
      • psychological issues

IBD

  • 50% risk of Ulcerative colitis exacerbation in 1st and 2nd trimester
  • 75% of Crohn’s remains quiescent
    • improves in 1/3 of those with inactive disease at conception
    • may have puerperial flare
  • active disease at conception associated with
    • miscarriage
    • prematurity

Obesity

  • 1/5 pregnant women obese
  • risk of
    • pre-eclampsia
    • thromboembolism
    • diabetes
    • shoulder distocia (fat deposits on baby’s shoulders)
    • wound infection
    • resp infection
    • caesarean section
    • miscarriage
    • macrosomia
    • stillbirth
    • congenital abnormalities

Causes of death:

Direct

  • sepsis
  • pre-eclampsia
  • thromoembolism
  • amniotic embolism
  • early pregnancy death
  • haemorrhage
  • anaesthesia

Indirect

  • Cardiac disease
  • Neurological disease
  • Psychiatric causes
    • suicide
    • substance abuse
    • violence
  • Malignancy

Category X

Lots of drugs are a no-no in pregnancy. Here’s my way of remembering the teratogenic ones.

Pam is a very worried pregnant lady. She is sat at a cafe with her depressed parrot that suddenly has 3 seizures. She’s having miso soup because she’s on a low carb diet and he’s eating carrots.

  • pam – diazepam (anxiolytics)
  • paroxetine – antidepressants
  • seizures – carbamazepine, valproate, phenytoin
  • misoprostol
  • carbimazole
  • carrots – retinoids

A man called Danny, who is a well-known meth addict with a lisp approaches on a bicycle, holding a pack of cards. He says;

Lithen clothely, I am going to perform a magic trick”

Pam, remembering Danny’s last trick, puts tha’ lid on her soup and says, “It better not be a lame pencil trick again, that was just a fluke”

  • Androgen – danazol
  • methotrexate
  • cyclophosphamide
  • ace of spades – ace inhibitors
  • lithium
  • thalidomide
  • lame pencil – pencil-lame – penicillamine
  • fluconazole

He suddenly starts bleeding from one of his injection sites, starts glowing, and then screams “DIE ETHYL!” before collapsing on the ground and lying completely static.

  • warfarin
  • radioactive contrast
  • diethylstilbestrol
  • statins

Disclaimer: not all of them are listed here, and the evidence may change in the future! This paper:

describes how not all of them are absolutely contraindicated, but most of them are avoided if possible. Sometimes discontinuing the drug, such as psychotropics, is likely to lead to a worse outcome than continuing.

Category X drugs in pregnancy:

Known Teratogenic drugs:

  • ACE inhibitors
    • captopril
    • enalapril
    • lisinopril
  • Antidepressants
    • paroxetine
  • Antiepileptics
    • carbamazepine
    • phenytoin
    • valproate
  • Anxiolytics
    • diazepam
  • Alkylating agents
    • cyclophosphamide
  • Androgens
    • danazol
  • Antimetabolites
    • methotrexate
  • Carbimazole
  • Coumarins
    • warfarin
  • Oestrogens
    • diethylstilbestrol
  • Fluconazole
  • Lithium
  • Misoprostol
  • Oral contraceptives
  • Penicillamine
  • Retinoids
    • isotretinoin
  • Radioactive iodine
  • Thalidomide