Question Do you have any suggestions on how to help women become more comfortable during the speculum exam? Also, could you offer some practical hints to help locate the cervix, especially when there is anteflexion? Response From the Expert Barbara Hughes, MS, MBA, CNM Director, Nurse-Midwifery Practice, Exempla, St Joseph Hospital, Denver, Colorado. She has over 2 decades of women's healthcare experience and is well respected on the national level as a nurse-midwifery leader. I approach every new patient as an opportunity to provide excellent customer service and to exceed the woman's expectations. If the patient has had a pelvic exam before, I ask if she has had any problems with discomfort or relaxing during the exam. Many women seem surprised by being asked this question and their affirmative responses express concerns about past pelvic exams. For the young woman anticipating her first pelvic exam, I assume she will have a certain level of anxiety and move on to the following exercise. This exercise can be done quickly while I'm setting up the equipment for the Pap smear or cultures. The exercise goes like this: I pull out a small speculum and show it to the woman, demonstrating how it works and the noises she might hear during the exam, such as the tightening of the screw. I use my left hand to form a firm fist, and try to push the speculum into the end of the fist. The description that I give along with the demonstration is, "Imagine that this opening is your vagina. See how the speculum won't easily go into a vagina that is tense. This is what causes discomfort for many women." Next, I relax the fist and retry the introduction of the speculum. Of course, it slides right into the relaxed opening. The description continues: "See how easily the speculum slides into a more relaxed vagina." For women with a great deal of anxiety I offer a speculum to them to perform the same demonstration on their own hand. It's amazing how this simple and brief exercise helps women relax and I frequently hear women say, "I always wondered what it looked like. Now that I know, I'm not afraid!" After positioning the woman's legs in stirrups, as an option, I offer her a mirror to watch during the exam. Some women eagerly accept the offer and often state, "I always wondered what they were looking for in there." Other women grimace and decline. If the speculum I will be using is not warm from an electric heater drawer, I run it under warm water, then touch the speculum to the woman's inner thigh to be sure it is the right temperature. Some women like the speculum to be very warm; others jump and tense up if they perceive that it is too warm. I tell the woman that I will talk her through the entire exam, explaining what she will feel as well as what I am doing. I give the woman permission to have me stop at any time. Many women later say that they appreciated feeling in control during the exam. I then use my left index finger to begin the BUS exam (Bartholin's, urethra, and Skene's glands) exam and inform the woman when my finger will be entering the vagina. I use gentle downward pressure, and encourage her to relax the pelvic floor muscles while exhaling a deep breath (similar to the cleansing breath referred to in childbirth preparation classes). Then I smoothly insert the speculum, which is angled slightly diagonally, into the vagina over my finger. Once the speculum has passed the hymen, I remove my finger and continue the speculum insertion, directing the speculum in a posterior oblique direction. When the speculum is inserted far enough, I open the blades and remind the woman about the sound of the screw tightening the speculum into the open position. Generally, the cervix slips into the open blades and the rest of the exam proceeds quickly. If the uterus is anteverted, the cervix may be very posterior. In this case, I partially withdraw the speculum and reintroduce it, aiming even deeper and lower in the vaginal vault. On occasion, I'll have the woman put both of her hands into fists and put them under her buttocks, doing a sort of pelvic tilt. A different maneuver is needed for a retroverted uterus, which may result in the cervix being very anterior, sometimes tucked behind the symphysis pubis. If 2 attempts to find the cervix with the speculum fail, I remove the speculum and find the cervix with 1 index finger. I explain to the woman why her cervix was difficult to find. It's a great opportunity to talk about her anatomy and describe the normal variations that occur, and how this variation can influence aspects of her life. For example, women with a retroverted uterus and anterior cervix may find that intercourse in the missionary position creates significant pressure or discomfort, and changing positions may relieve the discomfort and/or increase pleasure. In conclusion, a routine pelvic exam is the healthcare provider's opportunity to reinforce to women that this necessary procedure need not be dreaded, but can be a wonderful time for a woman to learn more about her body and be an active participant in the process. Source
