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Gynaecological Examination - Coggle Diagram
Gynaecological Examination
Focused History
Presenting Complaint
HPCx
O&G history
Parity
LMP
Current contraceptive use
Irregular bleeding
Screening hx
Vaginal discharge
Preparation
Explain
exam / procedure steps
Obstain
consent
for exam /investigation
Discuss role of
chaperone
Clarify
how they should
prepare
- undressing
Direct to the
privacy area
for changing
Provide a blanket / gown as cover sheet
Offer opportunity for pt to
empty **
bladder**
Chaperone
Nurse of family member
Note in record that chaperone was offered
Record if chaperone was present / has be refused / was not available bu the pt was happy to proceed
Equipement
Exam room
PPE
Non sterile exam unless pregnant
Pregnant - Sterile gloves
Speculum
Lubricant jelly
Smear brush + container
Endocervical swap + container
Microbiology wap + container
Endometrial sampler + formula
General Inspection
End of Bed
Activity
Colour
Aids / Adjuncts
Medication
Vital Signs
Heigh / weight / BMI
General Exam
Signs of anaemia / jaundice
Signs of metastatic disease
Enlarged lymph nodes
Assessment of co-morbidities
Breast exam
Peripheral oedema
Pre-operative assessment
Chest ausculation - heart sounds
Abdominal Exam
Expose
Inspect
Distension
Scars
Skin changes
Stoma
Palpation
Quadrants
Superficial
Deep
Rebound / gaurding
Assessment of
Inguinal lymph nodes
Ascites
Hernias
Auscultation
Bowel sounds
Pelvic Exam
Position
Modified lithotomy position
Inspection of Vulval anatomy
Ulcers
Associated with genital herpes
Abnormal vaginal discharge
Candidiasis
Bacterial vaginosis
Chlamydia
Gonnorrhoea
Scarring
Surgery - episiotomy
Lichen sclerosis
Vaginal atrophy
Postmenopausal women
White lesions
Patchy / figure of 8 distribution
Lichen sclerosis
Mases
Bartholin's cyst
Vulval malignancy
Varicosities
Chronic venous disease
Obstruction in the pelvis eg malignancy
Female genital mutilation
Total / partial removal of clitorus and / or labia and/ or narrowing of vaginal introitus
Inspection for prolapse
Inspect for bulge visible protuding from vagina
Ask pt to cough as you inspect
Can exacerbate the lump and help confirm presence of prolapse / demonstrate stress urinary incontinenece
Palpation
Along length of labia majora feeling for any masses
Palpate bartholin's gland
Vaginal Inspection
Vaginal walls
Ulceration
Erosions
Vaginal atrophy
Foreign bodies
Discharge
Bleeding
Inspection of cervix
Identify cervical os
Inspect for erosions around the os
Cervical massess
Ulceration
Abnormal discharge
Coil threads
Speculum Insertion
Apply lubricant gel if not performing a smear test
Use your non-dominat hand (index finger and thumb) to seperate the labia
Gently inset the speculum atthe intoitus sideways (blades closde, angled downwards) using dominant hand
Once inserted, rotate speculum back 90° so that handle is facing upwards
Open the speculum blades slowly woth non-dominant hand until an optimal view of cervix is achieved
Tighten the locking nut / latch to fix the position of the blades with dominant hand
Sampling
Smear test
High vaginal wab
Endocervical swab
Endometrial sampling
Removing the Speculum
With non dominat hand, hold the blades of speculum
Loosed the locking nut or latch with your dominant hand
Ensures the blades do not snap shut when the locking nut is loosened
Gently retract speculum until past the cervix and inspecting the walls of the vagina
Remove with non-dominant hand
Gently remove by rotating while retracting
Speculum blades will close
Bimanual Examination - pelvic exam
Insertion
Carefully seperate labia using thumb and index finger of non-dominant hand
Gently inset gloved index and middle finge of dominat hand into vagina
Enter vagina with palm facing laterally and rotate 90 degrees so that palm is facing upwards
Lubraicate gloved index and middle fingers of dominant hand
Palpation
Vaginal walls
Irregularities
Massess
Cervix
Position
Consistency
Cervical motion tenderness
Fornices
Masses
Watch patient's face
Assessment of Uterus
Place non-dominat hand on anterior of abdominal wall
Place two dominant hand's fingers into posterior fornix
Push upwards with internal finger whilst simultaneously palpating lower abdomen with non dominant hand
Should feel uterus between hands
Assess various characteristics of the uterus
Size
Should be approx orange sized in average female
Shape
May be distorted by masses - large fibroids
Position
Anteverted or retroverted
Surface characteristics
Smooth // nodular
Tenderness
Inflammation
Mobility
Fixed or mobile
Assessment of Adnexa
Area including ovaries and fallopian tubes
Position internal fingers in right lateral fornix
Position external hand onto righ iliac fossa
Perform deep palpation of right iliac fossa whilst moving internal fingers upwards and laterally to the right
Feel for palpable masses, noting size and shape
Repeat adnexal assessment on the left
Withdraw and inspect fingers for blood / discharge
Additional Investigations
PR exam
If pelvic mass or endometriotic nodules palpated
Bedsides
Urine dipstick
Urine BHCG
US assessment of pelvis
Completion
Cover patient with sheet
Exaplin procedure is complete
Provide pt with tissue to remove excess gel / pad if excess bleeding
Leave examination space providing privacy for pt to get dresses
Dispose of all used equipement in clinical waste bin
Remove gloves and perform hand hygiene
Finishing consultation
Label specimens and complete forms
Discuss exam findings with pt
Inform pt of when and how to expect results
Document examination performed and clinical findings
Tools
Speculums
Types
Cusco's
Sims
Assess for prolapse
Sizes
:yellow_heart: Yellow Small
Menopausal women
🩷 Pink medium
Starting point for women of childbearing age
💙 Broad
💚 Long
Insertion
Apply lubricant gel if not performing a smear test
Use your non-dominat hand (index finger and thumb) to seperate the labia
Gently inset the speculum atthe intoitus sideways (blades closde, angled downwards) using dominant hand
Once inserted, rotate speculum back 90° so that handle is facing upwards
Open the speculum blades slowly woth non-dominant hand until an optimal view of cervix is achieved
Tighten the locking nut / latch to fix the position of the blades with dominant hand
Smear
Protocol
Check expiry daye on Thin Prep pot
Remove plastic seal
Open specimen containt
Testing / Sampling
Smear taking
Rotate brush 360 degress five times in the cervical os
Dab brush on the bottom of the pot 10 times
Close the lid of the pot matching up the black lines
Insert endocervical brush gently into external os
High Vaginal Swab
Microbiological Assessment
Beta haemolytic streptococci
Trichomonas vaginalis
Bacterial vaginosis
Vaginal candidiasis
Take microbiology swab
Rotate swab for 10-15 seconds in posterior fornix ensuring you swab any discharge present
With speculum in situ, pass tip of swab through the speculum to the fosterior fornix of the vagina
Remove sab and inset into tube from which it was removed
Secure the swab into the tube
Endocervical Swab
Nucleic acid amplification test (NAAT) for detection of chlamydia trachomatis and neisseria gonorrhoea
Remove the thin endocervical swab from packet
With speculum in situ, pass tip of swab through the speculum to the cervical os
Insert the swab gently into the cervical os
Rotate swab for 10-15 seconds in the endocervix
Remove swab and open the NAAT test tube from packet
Insert swab into NAAT test tube and snap the swab against the side of the tub along indicated black line
Screw lid onto NAAT test tube
Assistant may be helpful to open NAAT test tube
Important not to spill any fluid from test tube
Endometrial Sampling - Pipelle Biopsy
