Click the picture to watch a video of a
nurse practitioner doing a pelvic exam
The client should not douche before the examination. On the
examination table the client should be lying in the lithotomy position (lying
flat on back), her thighs flexed and abducted (knees up), her feet resting in
stirrups for support, and her buttocks extending slightly beyond the edge of the
examining table. A pillow should support her head.
Relaxation is essential for an adequate examination. To achieve it:
1. The client should be given an opportunity to empty her bladder. An ideal
solution would be to obtain the client's urine test before beginning the exam.
This way her bladder has been emptied and you have her urine sample for testing.
2. Drape her appropriately with a clean sheet or paper drape. Some clients are
more comfortable when a drape is extended well over the thighs and knees. Others
prefer to watch both the practitioner and the examination itself and object to
drapes that obscure their view. Ask the client which method she prefers.
3. The client's arms should be at her sides or folded across her chest.
4. Explain in advance each step in the examination, avoiding any sudden or
5. Have warm hands and a warm speculum.
6. Monitor your examination when possible by watching your client's face.
SET UP ALL SUPPLIES NEEDED.
Equipment should be within reach and should include a good light source, a
vaginal speculum of appropriate size, and materials for bacteriologic cultures
and Papanicolaou smears (Pap smears), if these are to be done. Wear gloves. Male
examiners should be attended by female assistants. Female examiners may or may
not prefer to work alone but should be similarly attended if the client is
emotionally disturbed or upset.
The examiner should be sitting comfortably between the clients legs, low enough
to obtain a good visiual of the genitalia, but high enough to maintain visual
eye contact with the client's face for communication.
INSPECTING THE CLIENT'S EXTERNAL GENITALIA
The examiner should sit comfortably and inspect the mons pubis, the labia and
perineum. With a gloved hand, separate the labia and inspect:
1. The labia minora.
2. The clitorus.
3. The urethral orifice.
4. The vaginal opening or introitus.
Itchy, small, red maculopapules suggest pediculosis pubis (pubic lice). Look for
nits and lice at the bases of the pubic hair.
Enlarged clitoris in masculinizing conditions.
Lesions of the vulva.
Note any inflammation, ulceration of Skene's glands (e.g., from gonorrhea) is
suspected, insert your index finger into the vagina and milk the urethra gently
from the inside outward. Note any discharge from or about the urethral orifice.
If present, a culture should be taken.
If there is a history or appearance of labial swelling, check Bartholin's
glands. Insert your index finger into the vagina near the posterior end of the
introitus. Place your thumb outside the posterior part of the labia majora. On
each side in turn palpate between your finger and thumb for swelling or
tenderness. Note any discharge exuding from the duct opening of the gland. If
present, culture it. Note any surgical scars (episiotomy or other scars) and
Assess the support of the vaginal outlet. With the labia separated by your
middle and index finger; ask the client to strain down. Note any bulging of the
INTERNAL EXAM INSTRUCTIONS
Inspect the vagina and cervix next using a speculum. A speculum is placed inside
the vagina and opened. The speculum is an instrument that holds the vaginal
walls apart and allows the examiner to see the cervix and vagina and check for
inflammation, infection, scars or growths. There may be some feeling of pressure
on the bladder or rectum with the speculum in place. Select a speculum of
appropriate size, lubicate it and warm it with warm water. (Other lubricants,
such as K-Y Jelly, may interfere with cytological or other studies but they may
be used if no such tests are planned.) By having your speculum ready during
assessment of the vaginal outlet, you can ease speculum insertion and increase
your efficiency by proceeding to the next maneuver while the client is still
Place two fingers just inside or at the introitus and gently press down on the
perineal body. With your other hand introduce the closed speculum past your
fingers at a 45-degree angle downward. The blades should be held obliquely and
the pressure exerted toward the posterior vaginal wall in order to avoid the
more sensitive anterior wall and urethra. Be careful not to pull on the pubic
hair or to pinch the labia with the speculum.
After the speculum has entered the vagina, remove your fingers from the
introitus. Rotate the blades of the speculum into a horizontal position
maintaining the pressure posteriorly.
Open the blades after full insertion and maneuver the speculum so that the
cervix comes into full view.
When the introitus is retroverted, the cervix points more anteriorly than
diagrammed. Position the speculum more anteriorly, i.e., more horizontally, in
order to bring the cervix into view.
Inspect the cervix and its os. Note the color of the cervix, its position, any
ulcerations, nodules, masses, bleeding or discharge. A normal cervix will appear
pinkish in color. The cervix will appear as purplish in color if a woman is
pregnant. Secure the speculum with the blades open by tightening the thumb
OBTAINING SPECIMEN SAMPLES
If you are going to obtain specimens for cervical cytology (Papanicolaou smears,
also known as a pap smear). Take these steps in order:
1. The Endocervical Swab: Moisten the end of a cotton applicator stick with
saline and insert it into the os of the cervix. Roll it between your thumb and
index finger, clockwise and counter clockwise. Remove it.
Smear a glass slide with the cotton swab, gently in a painting motion. (Rubbing
hard on the slide will destroy the cells.) Place the slide into the
ether-alcohol fixative at once.
2. Cervical Scrape: Place the longer end of the scraper on the os of the cervix.
Press, turn and scrape. Smear on a second slide as before.
3. Vaginal Pool: Roll a cotton applicator stick on the floor of the vagina below
the cervix. Prepare a third slide as before. If the client has an infection or a
discharge from the cervix or the vagina, this would be a good time to take a
sample with a cotton swab for analysis.
If the cervix has been removed, do a vaginal pool and scrape from the cuff of
Do a vaginal examination. Withdraw the speculum slowly while observing the
vagina. As the speculum clears the cervix, release the thumb screw and maintain
the speculum in its open position with your thumb. Close the blades as the
speculum emerges from the introitus, avoiding both excessive stretching and
pinching of the mucosa. During the withdrawal, inspect the vaginal mucosa,
noting its color, inflammation, discharge, ulcers or masses.
Perform a bimanual examination. From a standing position, introduce the index
and middle finger of your gloved and lubricated hand into the vagina, again
exerting pressure primarily posteriorly. Your thumb should be abducted, your
ring and little fingers flexed into your palm. Note any nodularity or tenderness
in the vaginal wall, including the region of the urethra and bladder anteriorly.
Identify the cervix, noting its position, shape, size, consistency, regularity,
mobility and tenderness. Palpate the fornix around the cervix. Note that during
pregnancy, the cervix will be softer in consistency (like palpating your lips)
as compared to nonpregnancy (like the end of your nose).
Place your abdominal hand about midway between the umbilicus and symphysis pubis
and press downward toward the pelvic hand. Your pelvic hand should be kept in a
straight line with your forarm, and inward pressure exerted on the perineum by
your flexed fingers. Support and stabilize your arm by resting your elbow either
on your hip or on your knee which is elevated by placing your foot on a stool.
Identify the uterus between your hands and not its size, shape, consistency,
mobility, tenderness and masses. This procedure may cause some discomfort for
the client. Uterine enlargement suggests pregnancy, benign or malignant tumors.
Place your abdominal hand on the right lower quadrant, your pelvic hand in the
right lateral fornix. Maneuver your abdominal hand downward, and using your
pelvic hand for palpation, identify the right ovary and nay masses in the
adnexa. Three to five years after menopause, the ovaries have usually atrophied
and are no longer palpable. If you can feel an ovary in a post-menopausal woman,
suspect an ovarian tumor. Note the size, shape, consistency, mobility and
tenderness of any palpable organs or masses. The normal ovary is somewhat
tender. Repeat the procedure on the left side.
Vaginal-Rectal Exam: Withdraw your fingers, removing your gloves and throwing
them away. Reglove using fresh, clean gloves. Place lubricant (K-Y Jelly) on
internal exam glove. Then slowly reintroduce your index finger into the vagina,
your middle finger into the rectum. Ask the client to strain down as you do this
so that her anal sphincter will relax. Tell her that this examination may make
her feel as if she has to move her bowels - but, she won't. Repeat the maneuvers
of the bimanual examination, giving special attention to the region behind the
cervix which may be accessible only to the rectal finger. In addition, try to
push the uterus backward with your abdominal hand so that your rectal finger can
explore as much of the posterior uterine surface as possible. Check the rectum
itself and other nearby structures for any abnormalities.
After the examination, wipe off the external genitalia and anus or offer the
client some tissue with which to do it herself.