Pap Smears

[Relentlessrook18]

In our FP residency clinic, we are able to paps on our patients. I'm about 50/50 with finding the cervix. Some of our patients have high BMIs, some are normal. Seems like the lower the BMI the easier it is. Anyone have any tips on adjusting the speculum to find the cervix much easier?

---

Members don't see this ad.

 

[VA Hopeful Dr]

In our FP residency clinic, we are able to paps on our patients. I'm about 50/50 with finding the cervix. Some of our patients have high BMIs, some are normal. Seems like the lower the BMI the easier it is. Anyone have any tips on adjusting the speculum to find the cervix much easier?

Use a bigger speculum, that does the trick probably 95% of the time. If that alone doesn't fix it, its often due to an anterior cervix so you insert the speculum all the way in, angle it up and then slowly withdraw. The cervix will usually just kinda pop into view. If that doesn't work, there's a reason you have attendings - ask for help.

 

[smq123]

In our FP residency clinic, we are able to paps on our patients. I'm about 50/50 with finding the cervix. Some of our patients have high BMIs, some are normal. Seems like the lower the BMI the easier it is. Anyone have any tips on adjusting the speculum to find the cervix much easier?

Oddly, I was taught to use a smaller speculum - many pelvic exams fail because of patient discomfort, so a smaller speculum may make it easier for the patient to tolerate the exam. I agree with this logic based on personal experience.

If you really can’t find the cervix, there’s no real harm in doing the bimanual exam first, which will at least tell you where the cervix is. Just be sure to use a lube that doesn’t interfere with the pap sample.

 

[VA Hopeful Dr]

Oddly, I was taught to use a smaller speculum - many pelvic exams fail because of patient discomfort, so a smaller speculum may make it easier for the patient to tolerate the exam. I agree with this logic based on personal experience.

If you really can’t find the cervix, there’s no real harm in doing the bimanual exam first, which will at least tell you where the cervix is. Just be sure to use a lube that doesn’t interfere with the pap sample.

I agree with that now that I'm fairly good at them, but in residency I can count on 1 finger the number of exams that didn't get better with a bigger speculum.

 

[SLC]

I had this problem as a Med-student till Gyn rotation. I must’ve done 150 of them during that rotation.

I always insert speculum with the tip angled down slightly (toward the posterior fornix). Then advance as far as it can go, open a bit, and then withdraw slowly till the cervix “pops” into view. Sometimes a scopette can also be used to help move the cervix into a better position to obtain the pap.

 

[Keona]

I had this problem as a Med-student till Gyn rotation. I must’ve done 150 of them during that rotation.

I always insert speculum with the tip angled down slightly (toward the posterior fornix). Then advance as far as it can go, open a bit, and then withdraw slowly till the cervix “pops” into view. Sometimes a scopette can also be used to help move the cervix into a better position to obtain the pap.

This is exactly what I do. Sometimes you can put a pillow under the patient’s butt and it’ll move things around that quarter of an inch that you need. If it’s an obese patient typically i need a larger speculum because the vaginal walls collapse in from the lateral sides and I can’t see anything.

 

[Keona]

This is exactly what I do. Sometimes you can put a pillow under the patient’s butt and it’ll move things around that quarter of an inch that you need. If it’s an obese patient typically i need a larger speculum because the vaginal walls collapse in from the lateral sides and I can’t see anything.

I also had an attending tell me if nothing else works sometimes you have to position the patient on all 4s to get everything possible to see. I’ve never had to do this and hope I never do.

 

[Eysteve228]

This is exactly what I do. Sometimes you can put a pillow under the patient’s butt and it’ll move things around that quarter of an inch that you need. If it’s an obese patient typically i need a larger speculum because the vaginal walls collapse in from the lateral sides and I can’t see anything.

Agree with all this. Make sure they've scooted all the way to the edge so their bottom is just slightly off the table, legs relaxed in stirrups to the sides (basic positioning but I see med students and interns/residents forget this often). Aim downward as mentioned works 95% of the time time and open slowly but fully and pull back slowly if not in view already. I often see people try to open it as little as possible but you're causing more harm than good if it means you're spending another few minutes down there because you can't find the cervix. I work in a very poor/underserved area and we only have small to medium sized speculums available for use, regardless of body habitus and gravidity I have at most minimal difficulty with the aforementioned method for finding the cervix so while large speculums are nice for multigravid/obese women, they should rarely be a necessity. If this doesn't work then I'd go with what one of the others mentioned for a possibly anterior cervix; aim upward/anteriorly.

 

[DrMeowMeow]

The most common mistake I see most med students do is that they don't advance the speculum far enough. They usually put it in halfway then start opening, and that can cause the patient more pain. If it's not in all the way you'll most likely just see the collapsed vaginal walls. Especially with a small speculum, I will put it in posterior and as far as it can go

 

[nwciowa]

My $.02:

As above, some fundamentals: advance the speculum as far as it will go. KEEP CONSTANT POSTERIOR PRESSURE (towards the ground) - this helps your exam and is most comfortable for the patient. Posterior cervices are easier to see when antero-flexed (patient's fists under their sacrum). Move slow, be diligent, speak through everything you are doing. A relaxed patient makes for an easier exam.

Tips level 2.0: Know your patient's history - there is a big difference between a nulligravid cervix and a G4 cervix; they just look different. Adjust the size of the speculum accordingly, as well as according to body habitus. If lateral pressure collapses the vaginal walls into your line of sight, the most useful thing an OB ever taught me was to cut the tip of the thumb off of a sterile glove, slide it over the speculum spoons, and advance it that way. When you open, it will require more squeezing pressure, but it also will hold the vaginal tissue to the side as you do your exam. And it really works! Hope that helps.

 

[AMEHigh]

I agree with most of the tips above, so ditto.

Another thing is to try your best to get the patient to relax their pelvic muscles. This is best accomplished is they really relax their knees out to the side. If someone is tensing up then I take as much time as they need to help them relax. I let them know it’ll be more comfortable if they’re able to let their knees relax to the side and I’ll more easily be able to see what I need to see. Practicing trauma informed care is helpful too.