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M Cervical Erosion

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              GYNAECOLOGICAL EXAMINATION
1.    Introduce yourself

2.    Obtain consent

3.    Ensure a chaperone is present – and document the name of the chaperone

4.    Wash your hands

5.    General Examination
      General comments on the patient’s condition from the end of the bed

6.    Abdominal Examination
      Standard abdominal examination with the addition of
       Palpation of uterus
       Auscultation of foetal heart sounds (with Doppler at 10wks and with stethoscope at
         25wks gestation)

         EXPLAIN TO PATIENT THAT INTERNAL EXAMINATION WITH
          YOUR FINGERS IS NEEDED + GET ADDITIONAL CONSENT

7.    Position/ exposure of patient
       Allow patient to undress in privacy
       Patient exposed from waist down – cover their pelvis with a sheet.
       Patient lies supine, with hips and knees flexed, heel together
       Thighs adducted
       Ensure good lighting

8.    Wash your hands again and put gloves on

9.    Inspection of vulva
      Maintain intermittent eye contact with patient throughout whole examination

      Looking at:
       Swellings
       Inflammation
       Ulceration
       Warts
       Discharge
       Prolapse
       Pubic hair distribution – a measure of sexual development

10.   Speculum examination (vaginal and cervical examination)
      Explain you are going to look at the cervix and vagina by inserting a speculum
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      Includes taking a cervical smear and triple swabs if necessary at this stage

       Gently separate labia
       Slowly insert a lubricated and warmed bi-valve speculum into the vagina

         Part labia with the fingers of your left hand
         Make sure the speculum blades are closed before inserting
         Insert speculum sideways
         Then turn the speculum through 90˚ once the tip has entered the vagina
         Gently open blades under direct supervision to expose cervix
         Once visualised cervix tighten ratchet on speculum to secure position

       Inspect cervix and upper vagina

       The position of cervix relates to position of uterus
                    o Posterior cervix = anteverted uterus
                    o Anterior cervix = retroverted uterus
       Cervical os should be round if nulliparous/ but slit-like after childbirth
       Cervix should project about 1-3cm into vagina
       Surface of cervix should be pink, smooth and regular

11.   Cervical Smear
       Insert the long bristles in the centre of the cervical brush into the endo-cervical canal

      To collect cells
       Sweep brush 360˚ around the cervix
       Need to do this 5 times.
       Place the brush into the medium provided.

       Label specimen and send to laboratory
       On request form – write ‘visualised entire os and swept 360° x5’
       Remove speculum slowly – with blades partially open to examine vaginal epithelium

12.   Endocervical Swab
       Uses an APTIMA swab
       Insert the swab into the endo-cervical canal
       Rotate the swab in the canal for approximately 20 seconds
       Remove the swab
       Be careful not to make contact with the vaginal walls

       Label specimen and send to laboratory

13.   High Vaginal Swab
       Uses a standard wound culture swab
       Insert the swab into the fornices
       Remove the swab – be careful not to make contact with the vaginal walls.
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       Label specimen and send to laboratory

14.   Remove the speculum
       Pull the speculum out a few centimetres – this avoids closing the speculum on the
         cervix
       Undo the rachett and close the speculum blades
       Slowly remove the speculum from the vagina

15.   Vaginal Examination - Palpation of Vulva
       Separate labia majora with fingers of 1 hand
       Systematically palpate the:
                o Labia majora
                o Labia minora
                o Introitus
                o Urethra
                o Clitoris

       Bartholin’s glands
                o With your index finger, feel just inside the introitus (entrance to vagina),
                    with your thumb on the outer aspect of labia majora
                o Bartholin’s glands should not be palpable

       Ask patient to bear down/ cough
                o If the pelvic floor muscles are intact and stable – you should see no bulges
                    or swellings through the vaginal walls or urinary incontinence

       Note any
                o    Vaginal discharge
                o    Signs of trauma
                o    Changes in colour
                o    Masses/ ulceration
                o    Excoriation (scratching)
                o    Abnormalities of anatomy

16.   Vaginal Examination – Palpation of Vagina and Cervix
       Separate labia with thumb and first finger of left hand
       Gently introduce right hands middle and index finger into vagina (gloved and
         lubricated)

      With internal fingers, assess:
       Vaginal wall
       Cervix
                 o Consistency             should be firm, rounded and smooth
                 o Tears
                 o Ulcerations
                 o Tenderness
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                  o Cervical excitation     mobility of the cervix should not cause pain
                  o Os                      should be closed

17.   Bimanual Examination of the Uterus

         Place Left hand on lower abdomen
         ‘Capture’ uterus between fingers
         Palpate the uterus – using a bimanual technique
         Assess
                   Uterus size
                   Consistency of uterus
                   Direction
                   Mobility
                   Tenderness
                   Whether any masses are palpable

18.   Bimanual Examination of the Adnexae
       Palpate each adnexae in turn
       Difficult to feel in obese women
       Place fingers in each lateral fornix and palpating hand over each iliac fossa in turn
       Should be relatively painless – but discomfort may occur – offer reassurance

       Ovaries are firm, oval and often impalpable
       Fallopian tubes are impalpable

19.   Bimanual Examination of the Pouch of Douglas
       Palpate the posterior fornix
       Assess
                o Swellings
                o Tenderness
                o Tethering

20.   Withdraw fingers slowly
       Inspect gloves for any blood or discharge

21.   Re-drape patient
22.   Reassurance examination over
23.   Allow patient to re-dress in privacy
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 FINDINGS ON GYNAECOLOGICAL EXAMINATION
                                             VULVA

            Findings                                         Significance
                                     Infections
Rashes                               Dermatological conditions
(Redness/ swelling/ leucopakia)      Chemical irritants
                                     Allergies

Injury or scars                      Trauma

Enlarged clitoris (clitoromegaly)    Congenital adrenal hyperplasia


Red painful cystic lump beneath
                                     Bartholin’s cyst or abscess
the posterior part of labia majora

                                     Menstruation
                                     Miscarriage
Bloody vaginal discharge             Cancer
                                     Cervical polyp
                                     Cervical erosion

Purulent vaginal discharge           Infection

Frothy, watery, pale, yellow-
                                     Infection e.g. Trichomonas vaginalis
white discharge and pruritus

Thick, white discharge and
inflammation of skin and             Infection e.g. candida albicans
mucous membranes

                                 SPECULUM EXAMINATION

          Findings                                       Significance

                                Chadwick’s sign – due to increased blood flow that occurs
Bluish colour to cervix
                                during pregnancy, resulting in venous congestion

                                Ectropian – cells from cervical canal come out into cervix.
Redness of cervix               More prominent in women taking the combined oral
                                contraceptive pill
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         Findings                                     Significance


Small, round, white or      Nabothain cysts – due to obstruction of the endocervical glands
yellow lesions on cervix    Only important if they become infected

                            Suspect infection if pungent odour – therefore take endocervical
Cervical discharge
                            swabs

Inflamed cervix with
                            Acute or chronic cervicitis
mucopurulent discharge

                            May grow from cervix
Cherry-red friable polyps
                            May be a source of post-coital bleeding

Ulceration to cervix        Cervical carcinoma

Growth to cervix            Cervical carcinoma

White vaginal mucosa
which is quite thin, with   Atrophy of the vagina – a postmenopausal change
pale red spots

Dry vaginal mucosa          Post menopausal change due to loss of vulval adipose tissue



              BIMANUAL EXAMIANTION OF UTERUS AND ADENXAE

         Findings                                     Significance
Difficult to insert a
                            Vaginismus
lubricated finger

Impalpable uterus           Retroverted uterus

Palpable mass laterally     Mass in ovary or fallopian tube

Enlarged nodular uterus     Fibroids

                            Cervical excitation due to acute irritation or fixity of the
Discomfort when cervix      cervical ligaments (sign of peritonism) – present in women with
moved                       ectopic pregnancy, acute or chronic pelvic inflammatory disease
                            or endometriosis
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          Findings                                       Significance

Uterus just palpable above
                             Described as ~12 weeks size (even if not pregnant)
symphysis pubis

Uterus reaching level of
                             Described as ~20 weeks size (even if not pregnant)
umbilicus

Position of uterus           Anteverted/ retroverted/ axial



                             ABDOMINAL EXAMINATION

                                    Inspection

                       Transverse suprapubic incision (plannelstiel scar)
 Scars                 Laparoscopic scars
                       What surgery? Why? When?

                       Abdomen moving with breathing/ or whether guarding is present
 Movements
                       Foetal movements seen in advanced pregnancy
                       5F’s – fat/ faeces/ foetus/ fluid/ flatus
 Distension
                       Fibroids/ ovarian disease/ pregnancy

                       Pregnancy/ weight gain
 Striae                Recent onset - purple colour
                       Old striae - silvery appearance

                       Pigmentation from umbilicus to pubic symphysis
 Linea nigra
                       Occurs in pregnancy


                                           Palpation
 Tenderness           Lower abdo pain – PID/ ectopic pregnancy

 Peritonism           Ectopic pregnancy/ appendicitis

 Masses               If impalpable lower border – pelvic in origin

 Herniae              Femoral more common than inguinal in women

 Inguinal Lymph
                      Localised infection/ metastatic disease
 nodes

								
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