Why is it done?
· Abnormal bleeding; between menstruation, dyspareunia (pain after sex)
· Pain
· Discharge
Introduction
· Wash hands and introduce yourself
· Confirm patient details: Name, age, DOB and check their hospital ID
· Explain the examination
Make sure to comment about a chaperone!
“I will be performing a vaginal examination; this is going to involve you removing your clothing from the waist downwards and lying on a couch. I will then have a look around the vagina and insert 2 gloved, lubricated fingers, I will also feel your tummy at the same time. This should not cause any pain, however, may be uncomfortable. I will do my best to be as quick as possible. A chaperone who knows about the examination will also be present today and today, that chaperone will be the examiner
· Gain consent – “Do I have your consent to continue”
· Make sure to ask if: There is any chance of being pregnant They have passed urine recently/ suggest that they should pass urine before if they have not done so recently
· Then ask the patient to remove their clothing from the waist down, lie on the couch and cover themselves with a blanket, while you set up your tray
Setting up
· Check the expiry date on an alcohol wipe, then use to clean a blue tray
· Wash hands
· Don gloves and apron
· Put 2 tissues in the tray – 1 for putting lubrication on and 1 for patient to clean themselves afterwards
· Let the patient know you are ready and check that they are
Positioning
· Ask the patient to draw their knees up
· Place feet in front of their buttocks
· Let their knees drop to the side
General inspection
· Does the patient seem comfortable? Ill? Any signs of weight loss? Mobility issues?
Inspection of the vulva
· From anterior to posterior borders
· Warn the patient then part the labia majora with 2 fingers
· Skin abnormalities – scars? Rashes?
· Evidence of trauma?
· Discharge
· Atrophy – secondary to post-menopausal changes
· Abnormal lumps
· Then ask the patient to Strain down – like giving birth/ opening bowel – observe for any prolapse/ bulging
Cough – observes for any leakage of urine
Internal examination
· Apply the lubrication gel to your first and middle finger
· Warn the patient and then gently insert 1 lubricated finger into the vagina
· Allow the patient time to relax
· Introduce the second finger
The vagina
· Pass your fingers downwards and backwards in line with the vagina
· Feel the walls of the vagina – do they feel bumpy? Any lumps?
The cervix
· This will be felt as a hard dome
· Either a dimple or slit will be in the centre Dimple – not had a vaginal delivery Slit – had a vaginal delivery
· Is there any pain Pain when touching the cervix = cervical excitation = sign of ectopic pregnancy
· Feel around and assess the fornices around the cervix
Images: Left: Nulliparous – simple dimple Right: Multiparous - slit
Bimanual examination
The fundus / superior border of the uterus is not palpable in health, but becomes palpable after 12 weeks of pregnancy or if enlarged
If the uterus is palpated, then palpate for: Size / shape/ mobility/ masses or irregularities/ consistency
· Ward the patient you are going to apply pressure over their abdomen
· Place your fingers in posterior fornix and apply an upward pressure to the cervix and uterus
· With your other hand start at the umbilicus, use the lateral edge of your index finger to apply pressure and push downward
· Move your hand down and continue toward the pubic
symphysis - applying this pressure as you palpate
The adnexae
The adnexae is the fallopian tubes and ovaries – these are normally impalpable in health May be palpable if the patient is very slim / ovaries are significantly enlarged If they are palpated then describe: size / shape/ mobility/ consistency/ tenderness
· Place your finger in the medial/ lateral fornix
· Use the pulp of your fingers apply pressure over the same iliac fossa with your other hand to feel for the ovaries
Finally
· Bring your fingers back to the midline before removing your fingers
· Warn the patient and remove your fingers
· Inspect your fingers for signs of blood /discharge/mucus
· Offer patient wipes / to clean them up
· Remove 1 glove before you cover the patient up – this will avoid any contamination of the cover
· Dispose of gloves and apron
· Wash hands
· Invite patient to get dressed and say that you will discuss findings after they are dressed
Lymph nodes:
They can either be felt by examining the inguinal lymph nodes (groin) pelvic lymph nodes
1) Before palpation of the vulvar area –
2) After the internal examination; you would need to remove your gloves and don a new pair before palpating the lymph nodes
Documentation/ summary
· Be systematic; document what you’re positive and negative findings in an order
· In black pen
· Patient’s details: Name, DOB, date examination, signature and name printed, position or role
Examination details: Findings on inspection of vulva Palpation of the cervix – position/ multiparous/ multiparous / any excitation / hard or soft/
Fornices – any narrowing Uterus – not palpable/ enlarged Adnexa – not palpable/ enlarged Any blood/ mucus/ discharge on fingers
Further investigations
· Urinalysis – B-HCG (pregnancy test)
· Speculum examination
· Vaginal swabs/ endocervical swabs
· Further imaging – e.g. USS
· Full abdominal examination
Questions
1) Give 3 reasons for performing a bimanual examination
2) Give 2 causes of a palpable uterus
3) What is the blood supply to the vagina?
4) What are the adnexae?
5) When during the pregnancy is the uterus palpable?
6) What is cervical excitation? What is it indicative of?
7) What is the LH surge responsible for in the menstrual cycle?
8) Give 3 causes of PV bleeding
9) What is a nulliparous cervix? Multiparous?
10) Signs of cervical cancer
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