<aside> 💡 Ask: “Any areas of concern?”

</aside>

1. 1. “First I am going to inspect the external genitalia (check on the outside), “Please put soles of feet together and relax knees apart”

   1. Touch inner thigh before touching genitals
   2. Open labia majora
   3. Inspect labia minora, clitoral hood, urethral orifice; ask patient to bear down and inspect for cysto/rectocele, urethral/uterine prolapse; inspect Bartholin’s glands, fourchette, perineum, anus. Also inspect skin, mons pubis, intertrigenous areas and hair distribution.

2. “I will now insert the speculum so I can see your cervix and obtain a sample from the cervix (and cultures)”

   1. Pick up speculum with L hand. Apply lubricant to back 2/3 of speculum with R index finger. Switch speculum to R hand.
   2. Touch inner thigh before touching genitalia
   3. Place bottom bill of speculum against the fourchette and introduce speculum into vagina with downward pressure until it is fully inserted.
   4. Open speculum by pressing on lever, open and adjust until cervix comes into view, tighten screw on lever to hold speculum in open position while accessing testing/culture supplies. Keep hand on speculum.
   5. Obtain cervical samples /cultures.
   6. Note position of cervix (prolapsed, normal)
   7. Note whether cervix is parous or nulliparous
   8. Note any discharge from cervix (mucoid, clear, yellow, bloody) or in vaginal vault.
   9. Note if cervix is friable or has any lesions
   10. Note whether vagina has ruggae or is atrophic
   11. Release screw while keeping pressure on lever (to avoid bills closing on cervix) remove speculum approximately 1 cm, then release lever so speculum is closed as it is removed from the vagina.
   12. “Everything appears healthy and normal” OR... discuss abnormal findings after exam is completed and patient is dressed.

3. “I am now going to do the bimanual exam.” “This consists of inserting 2 gloved fingers into the vagina and palpating the uterus and ovaries”

   1. Touch inner thigh before touching genitals
   2. Insert gloved index and middle finger of R hand into vagina with downward pressure on fourchette, may say “try to relax this muscle”
   3. Determine location of cervix, move fingers behind cervix and move cervix upward to test for cervical motion tenderness, observe patient’s face for reaction.
   4. Place fingers on cervix while placing L hand on patient’s abdomen and assess size, contour and mobility of uterus.
   5. Remove fingers a few cm and place along L side of cervix in fornix. Fingers point upward as L hand palpates along L side of uterus to assess adnexa. Remove fingers a few cm and repeat on R side.
   6. Remove fingers and then gloves and say to patient “everything appears healthy and normal” “ I’ll leave so you may get dressed” “I will be back to answer any questions you may have”
   7. Hand patient box of tissues
   8. Rectal exam as indicated