Vaginal Speculum Examination

Lydia Vandiver, RN, MS, SANE-A, SANE-P, CFN Albuquerque SANE Collaborative Introduction

• This module has been prepared for the sexual assault nurse examiner • This module is for vaginal/cervical inspection only-it is not considered a “pelvic exam” • This module covers speculum only-not the full forensic exam • Having a speculum to handle during review of this module is helpful What the SANE needs to know

• Anatomy • Equipment • Patient preparation and interactions • Positioning of the patient • Tips on performing speculum exam • Table manners • Challenges when doing exams Female Reproductive System

Figure 19-8(a) Female Reproductive System

Figure 19-8(b)

Needed Equipment/Supplies

• Gynecologic table with table sheet paper • Vaginal Speculums • Light source • Gloves • Drape • Warm water for “lubrication” • Condoms Adjunct equipment list

• Sexual Assault Evidence Kit • Assorted swabs: “Texas”, regular and nasopharyngeal type • Toluidine blue dye and related supplies • Chux • Camera/Colposcope Vaginal Speculum

• Medical tool for inspecting vaginal vault • Latin for “mirror” • Plural: specula or speculums • First generation dilator (speculum) cylinder type made of bamboo or gourd • Next generation of specula made of ebony or wood, then metal Historical Dilators/Specula Historical Dilators/Specula Roman vaginal dilator or speculum

Present name of speculum adopted in Roman era, made of bronze Vaginal Speculum Historical Facts

• Many centuries passed with little mention of the speculum

• Present day speculum developed by Dr. J. Marion Sims

• Early 1990’s transparent plastic specula first utilized Vaginal Speculum

• Consists of hollow cylinder with rounded ends • Divided into two hinged parts • Inserted into vagina to dilate for examination of vagina and cervix • Available in various sizes and types: (Graves, Pederson, Sims-metal; disposable plastic- contoured similar to Pederson) Purpose of Vaginal Speculum

• Allows for direct visualization of vaginal vault and cervix with supplemental light source for evaluation of injuries

• Allows for introduction of swabs for evidence collection Speculum Parts

Bills (Blades)

Adjustment levers

Light Source Sheath Speculum Adjustments

Adjustment lever to open bills of speculum; press clear tab, you will hear clicking sound as it opens Speculum Adjustments

Adjustment for increasing vertical diameter; push in, slide up Light Insertion Area Insert light source. Remove rubber band, cover light cable with plastic sheath Turn light source on as needed Vaginal speculum

• Be familiar with the type of speculum you will be using

• Vaginal specula come in a variety of sizes

• The light insertion area may also vary

• Some do not have light cable sheaths Patient Preparation

• Determine if patient has had previous speculum exam or surgeries • Convey respect and sensitivity • Explain procedure to patient • Show equipment to patient, demonstrate what part will be inserted • Have patient empty bladder prior to exam • Ask patient if she has questions or concerns Patient Preparation

• Speculum exams are not performed on prepubescent patients • If your SANE patient has never had a speculum exam you can defer and use other methods of examination that will be discussed during the SANE training Patient Positions

• Give patient choice of position for exam • Most common position is the lithotomy position • Lithotomy position is when the patient is supine with head elevated to comfort, foot rests (stirrups) are used • Use padded foot rests or give patient option of wearing socks Lithotomy position

• Patient will need to be instructed to move toward the examiner until her hips are on the edge of the exam table • Adjust the length and the width of the foot rests (stirrups) to patient comfort • Leave the patient covered until you are ready to do the genital examination • Speculum can be inserted with handle up or down Patient position

• Do not spread the patients legs for her • With the patient covered, allow her to relax her legs outward • You might hold your hands out to the position you would like her legs to be and ask that she move her knees outward to touch your hands Patient Instruction

• Explain that this is a medical exam • Ask that she let you know if anything is painful or if she needs to change position • Encourage her to keep her eyes open during the exam • Tell her you will keep her informed of your moves Lithotomy positioning Other Positions for Speculum Examination • Modified lithotomy with legs on table • This position is helpful if patient cannot flex her hips or knees • Dependent on patient comfort, one foot rest may be used • Speculum may need to be inserted with the handle up depending how patient is positioned on the table Other Positions for Speculum Examination • “Frog leg” position • This position is beneficial if patient is on a stretcher or bed without foot rests

• Speculum may need to inserted with the handle up Other Positions for Speculum Examination • Hips elevated position • Hips can be elevated on a folded blanket or inverted bedpan with padding • This technique can be used with any of the previously described positions • Depending on the elevation of the hips, the speculum can be inserted handle down or up • This position is helpful when the patient is on a bed or stretcher without the use of footrests Other Positions for Speculum Examination • Side lying position • This position should be used if patient cannot lie on her back • The woman lies on her side with knees bent, her top leg closer to her chest • The speculum can be inserted with the handle oriented to the patient’s back or front • Angle the speculum toward the small of the back Examiner position

• The examiner can sit in front of the patient • If the gynecological table has adjustable height control, adjust to level of comfort • Because of the position of the camera or the need to get equipment some examiners prefer to stand • The examination can also be conducted with the examiner standing at the patient’s side Draping for exam

• Leave patient covered as they assume chosen position • Let patient drop legs to side in relaxed position prior to exposing • Expose genital area, leaving legs covered • Position drape so the patient’s face can be visualized, maintain frequent eye contact Interacting with the patient during the examination • Initially touch the patient in a neutral spot, such as the thigh, before touching the genitals. • Explain each step during the exam: “I’ll be inserting the speculum now, you will feel some pressure.” “I’m going to touch you now.” • Include the patient in any discussion about her exam. Drape the patient to protect her modesty and keep her warm Visual assessment, photography, evidence collection and Toluidine Blue dye of external genitalia need to be done prior to the speculum exam. These skills will be presented at the SANE training. The Speculum Examination

• The SANE exam is not a pelvic exam or Pap smear – Use the smallest size speculum possible that still permits adequate visualization. – The patient is often uncomfortable from genital trauma, anxiety, or a combination of both. – Allow patient to see speculum; demonstrate how little of the speculum is actually inserted. Place two fingers at the lower part of the vaginal opening. Apply downward and outward pressure. Instruct patient to relax the pelvic muscle. Deep breathing will help with relaxation. Hold speculum so that the bills do not separate. The top finger can be used to help control speculum Hold speculum sideways at about a 45% angle and insert speculum toward the small of the back. Warm water may be used for “lubrication” if necessary. Lubricating jellies can interfere with evidence collection. Avoid contact with the anterior structures. Pressure on the urethra can cause discomfort. As speculum is inserted, turn it so that the bills are horizontal. Press lower bill uniformly against the posterior vaginal wall. Maintain separation preventing the labia minora from being pulled in. Hold the speculum so that the bills do not separate. Ongoing Observations

• Watch the patients facial expression and demeanor for signs of discomfort. • Monitor her response to your touch. • Note for tension of legs, movement of the feet or lifting of buttocks. • If she closes her eyes, encourage her to keep them open. As speculum is inserted, observe vaginal walls for changes from rugated to smooth. Position speculum with the handle in a vertical position. Insert until the handle is almost flush with the perineum. Finding the cervix

• Observe the characteristics of the vaginal vault as the speculum is inserted • The rugae will disappear and the vaginal vault will smooth out • The cervical os may be visible through the bills of the speculum • Reposition the speculum at the correct angle Observe how cervical os is visible through the bills of the speculum and angle the tip in that direction. Challenges

• If you have difficulty finding the cervix, withdraw slightly with the bills closed and reposition the angle of the speculum. • Occasionally the cervix may be anteverted vs retroverted. • The speculum may also be inserted too deep causing the cervix to be pushed up, down or to the side. Separate the bills of the speculum and observe the cervix and vaginal walls for injury or discharge. Take photographs. Challenges

• Secretions may obstruct visualization of the cervical os. • Blood, clots, mucous, or other discharge may be present in the vaginal vault. • Use swabs as appropriate to remove or absorb the blood or mucous. • Consider drying the swabs for evidence Collect evidence swabs Speculum Removal

• Verbalize the procedure to the patient. • Be careful that the speculum is removed gently. • Do not attempt to close the bills while they are on the cervix • Open bills slightly until free of cervix, then rotate the speculum slightly and withdraw past the cervix. Speculum Removal

• If the walls have collapsed, rotate the speculum back and forth slightly as you close the bills to avoid pinching. • Keep speculum closed during withdrawal • Continue to maintain downward pressure to avoid irritation of urethra Assure that the cervix is not pinched between the bills prior to removing the speculum. Close the bills of the speculum before removal. Again, avoid contact with the anterior structures. Challenges

• Occasionally visualization of the cervix may be difficult because the walls collapse inward once the speculum is open. • Remove the speculum and place a condom over the speculum and cut off the end of the condom. • Use a condom of a neutral color so the light is not absorbed when taking photographs of the cervix. A colored condom was use for this demonstration, so the technique could be visualized. Challenges

• Depending on the patient position, there may not be room to insert the speculum in the handle down position. • The speculum may be inserted with the handle up. • Remember to angle the speculum toward the small of the back. • The handle up position can be used as a matter of personal preference. Note that the speculum is being angled toward the spine. This technique allows for the examiner to position themselves comfortably at the patients side. Challenges

• Visualization and photography of the vaginal walls may be necessary if the patient complains of pain with swab collection or speculum insertion. • Use the lever for increasing the vertical diameter of the speculum and angle the speculum to the right or left to visualize the vaginal wall and photograph the concerning areas. Speculum Adjustments

Adjustment for increasing vertical diameter; push in, slide up Increase the vertical diameter after insertion of the speculum. Angle the speculum slightly, inspect and photograph the vaginal wall. Table manners

• Cover genital area when changing gloves, getting additional equipment, or if exam is paused for any reason • Keep patient informed of your moves • Explain procedures and steps of the exam as you do them • Allow for breaks if needed • Change gloves often Table manners

• Avoid medical terminology that might not be understood or language that has painful, violent or sexual connotations: • Speculum “bills” rather than “blades” • “Footrests” instead of “stirrups” • “Exam table” not “bed” • “Relax your legs open” not “spread your legs” • “Insert” or “place” not “stick it in” • “Examine” not “feel” or “palpate” Table manners

• Avoid pushing the patient’s legs apart, instruct her how you need them positioned. • If patient is receptive, point out anatomy and explain anatomical terms, such as cervical os, hymen and urethra. • Review the photos with the patient if she would like to see them. • Don’t forget to remind patient to scoot back before sitting up or she’ll fall off! Gaining Proficiency

• Practice makes perfect! • Be familiar with your equipment. • Practice on manikins. • Practice on other SANEs. • Participate in a genital skills lab. • Do exams at Public Health, in the Emergency Room, at your OB/Gyn office Thank you for your participation.

During the SANE training you will have the opportunity to learn more!