Frustrated and struggling with speculum exams - advice?

[leaf345]

I was hoping for a bit of advice. I'm a first year resident in FM, and I've become really frustrated with my inability to consistently visualize the cervix on a speculum exam.

I struggled in the first few weeks of residency, but recently was feeling a bit better as I seemed to be visualizing it more consistently. I even did a few IUD insertions with no issues. Fast forward to this week, and I've missed the cervix on 5 out of the 6 exams I've done. I've asked preceptors for advice, and I haven't gotten much more than reassurance that it'll come with experience.

I'm not sure what to do. I insert the speculum fully, and only open when i'm sure I've reached as far as the blades can go. If I don't see the cervix, I pull out a bit and look up and down and progress further in those directions. Still, nothing but vaginal wall.

I feel like I'm the only one at my level of training struggling with this issue. Should I be doing bimanuals before my exam to locate the cevix? Will that mess up the pap smear? If anyone has any advice, I'd greatly appreciate it.

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[deleted87716]

What I've always done is insert the speculum and open it slightly before advancing very far. That way, you can see the cervix as opposed to advancing blindly. If you can't see the os, you can usually tell if the uterus is anteverted or retroverted, and adjust the speculum accordingly. Sometimes a little abdominal pressure is helpful to bring the os into a better position for obtaining a Pap smear. When in doubt, do a quick bimanual exam to orient yourself to the position of the cervix. If the woman is large and/or the vaginal walls are intruding, you may simply need a bigger speculum.

 

[drcrispmd]

Lubricant can alter Pap smear results, so I would not recommend doing a bi manual before.

Are you male? This does make a difference, especially if you are male and learning.

Does you clinic use the metal or plastic ones? The plastic ones you can see the cervix as you are inserting it. Experience is what it takes.

 

[deleted87716]

Lubricant can alter Pap smear results, so I would not recommend doing a bi manual before.

Not true.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3056679/

 

[drcrispmd]

Not true.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3056679/

That is for small amount on the speculum. If you do a bi manual to locate the cervix, you will be using lubricant (or I hope so) and touch the cervix. The small amount of lubricant on a speculum does not get on the cervix (unless you put it on the tip). Interns will start the year using too much lubricant on the speculum or having it on the tip. Those paps usually come back as not an adequate specimen.

 

[deleted87716]

Right. So we should be training residents not to use too much lube.

 

[Lespedeza]

I was hoping for a bit of advice. I'm a first year resident in FM, and I've become really frustrated with my inability to consistently visualize the cervix on a speculum exam.

I struggled in the first few weeks of residency, but recently was feeling a bit better as I seemed to be visualizing it more consistently. I even did a few IUD insertions with no issues. Fast forward to this week, and I've missed the cervix on 5 out of the 6 exams I've done. I've asked preceptors for advice, and I haven't gotten much more than reassurance that it'll come with experience.

I'm not sure what to do. I insert the speculum fully, and only open when i'm sure I've reached as far as the blades can go. If I don't see the cervix, I pull out a bit and look up and down and progress further in those directions. Still, nothing but vaginal wall.

I feel like I'm the only one at my level of training struggling with this issue. Should I be doing bimanuals before my exam to locate the cevix? Will that mess up the pap smear? If anyone has any advice, I'd greatly appreciate it.

Often when I see residents unable to find the cervix, it's because they are not looking posterior enough. When inserting the spec, make sure you're angling the front part of the spec posteriorly (angle towards the floor), then bring it more anteriorly (upwards) as you look for the cervix. Look left and right also!

You can do bimanuals before to locate the cervix, but I would save this for afterwards (if you can't find the cervix).

And I ALWAYS use lube for my paps, and have never had that mess up my results..

 

[deleted87716]

Where lube is concerned, a little dab'l do ya.

 

[VA Hopeful Dr]

I had this problem as well. When in doubt, use the bigger speculum. I think you'll be surpised how often that's all it takes.

I'm pretty liberal with the lube and have never had a specimen come back as inadequate. Its not an RCT, but 400+ paps has some power to it.

 

[cabinbuilder]

Do you have a rotation at planned parenthood? I had trouble too until I had to do 30 exams a day for 8 weeks. It takes practice just like anything else. I like the plastic better and sometime you have to turn the speculum a little sideways for the cervix to pop into view.