OB/GYN consult (from a FM resident)

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Leukocyte

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Yes, I am a new Family Medicine resident who needs advice from OB/GYNs,

I suck at PAP smears. Since I started residency (2 weeks ago) I have been dreading the 20 year old female who is coming in for her PAP. I just do not seem to be able to find that damn cervix. It is so embaressing. I hate those speculum exams more than the patient. And yes, it does not help being a virgin male who has never "dealt with" a vigaina outside the clinical setting. I am just too scared to use too much force or cause pain.

Any tips on finding the cervix is greatly appeciated.

Thank you.

A VERY embaressed FM resident:oops:
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first of all, don't worry about it. i remember the first few days of internship, having a tough time finding a cervix or two myself. but, as my attending said "keep on looking, there is nothing else in there!"

what i do is go as slow as you need to when you insert the speculum. there is no rush. keep a steady pressure posteriorly (pretty much everything that hurts, ie urethra and clitoris, are anterior, so this avoids that pitfall). when the blade is well into the vault, dive the tip of it into the pelvis, toward the sacrum. the cervix is almost always further posterior than you think. open the blades WIDE, and the cervix should pop into view.

if it does not, if you have gone as posterior as possible, there is really only one direction to look...more anterior. simply close the blades and move anterior a cm or two, then open the blades wide. repeat until cervix located.

in some cases, it will still be tough to find. but, with expereince, you will typically at least see part of the cervix, and then you can zoom in on the target.

best of luck!
 
I feel your pain. Bear in mind that I am still new at this myself, but sometimes that can be a good person to learn from since they are familiar with all the things they did wrong. One piece of advice that I got from a genital teaching assistant was to insert the speculum, then back up a bit, and then aim downward (posteriorly) and try to "scoop" behind the cervix like you are shoveling snow. I wouldn't recommend you put the same amount of force into it as you would on your sidewalk, but for me this visualization was helpful. I've also found that as a novice, one of the mistakes I tend to make is not opening the speculum enough. I've asked a resident/attending for help visualizing the cervix and they come over, open the speculum a little more and the cervix just "pops" into view. Good luck, and never let them see you sweat.
 
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Leukocyte said:
Yes, I am a new Family Medicine resident who needs advice from OB/GYNs,

I suck at PAP smears. Since I started residency (2 weeks ago) I have been dreading the 20 year old female who is coming in for her PAP. I just do not seem to be able to find that damn cervix. It is so embaressing. I hate those speculum exams more than the patient. And yes, it does not help being a virgin male who has never "dealt with" a vigaina outside the clinical setting. I am just too scared to use too much force or cause pain.

Any tips on finding the cervix is greatly appeciated.

Thank you.

A VERY embaressed FM resident:oops:
Click to expand...

Well I'm just a 3rd year...but I was pretty good at the Pap Smears. Well I was taught to go in at a angle and WATCH OUT FOR THE URETHRA!! (that was screamed at me LOL) So make sure you keep the speculum Inferior...meaning more pressure on teh bottom of the vagina to avoid the URETHRA (sorry...it was screamed to many times). Once you've entered then turn the speculum flat and slowly open while pushing in. To find the cervix...I can't help you because different people have them different places...you just have to look around once you get in there. It's not always right in front in you...have to look to the sides sometimes...but it's always in there...unless they had a hysterectomy...and even with that some people decide to keep the cervix so don't assume that when you see total hysterectomy in the history the cervix is gone.
 
If you're using plastic speculums, try looking through the blades. The cervix looks shinier than the rest of the vaginal wall and sometimes you can either see it through the blades (looks a little different than everything else) or peeking at the tip of the blades. If you see something shiney you can then manuver to figure out if you've got the anterior or posterior lip and go from there. The most important part is not to panic. You'll find it!
 
Wednesday said:
If you're using plastic speculums, try looking through the blades. The cervix looks shinier than the rest of the vaginal wall and sometimes you can either see it through the blades (looks a little different than everything else) or peeking at the tip of the blades. If you see something shiney you can then manuver to figure out if you've got the anterior or posterior lip and go from there. The most important part is not to panic. You'll find it!
Click to expand...

If it's shiny but it's not a cervix feel free to panic though :D
 
The advice above are all great... Here are a couple of PEARLS from me:

1. After several unsuccessful efforts, take the speculum out and perform a digital exam to see where the cervix is. Often, with the difficult exams, the cervix is rather anterior and the speculum is sliding right by it.

2. In general urethral and clitoral pain is what people tell you to be weary of, however also keep in mind that the majoroty of the pain is from pressure receptors. Therefore the slower you go, the better it will be for the patient. Slowly enter the blades at an oblique angle and once 1/4 way in, slowly rotate to the horizontal position. Then, as stated above, turn the blades posteriorly. Once you are completely at the posterior position, start straightening your wrist and work your way anterior.

Best of luck!
 
Thank you very much. Great pointers. I just feel a lot of pressure to finish the exam quickly once I put the speculum in, and forget to take a deep breath and relax. I just do not want the agonizing patient to think I do not know what I am doing when I go fishing out for the cervix. I guess I will eventually learn to find the cervix quickly, I just need more practice.

Thanks you very much for showing me the way to my goal.
 
At the same time, there is a balance between doing a speculum exam slowly and gently and going S-L-O-W. Many people when starting doing speculum exams the first time go in a centimeter, stop, go a centimeter more, stop and all this hesitation-stop-start-stop is not comfortable to the patient. It should be one fluid movement. Also, something that most people who are learning do that makes it more difficult is either not put the speculum in all the way, or once they put it in all the way, when they open it, they pull back slightly, which allows the vagina to collapse in front of the cervix.

It just takes practice.
 
fuzzyerin said:
Also, something that most people who are learning do that makes it more difficult is either not put the speculum in all the way, or once they put it in all the way, when they open it, they pull back slightly, which allows the vagina to collapse in front of the cervix.
Click to expand...

Yes, exactly. The collapsing vagina. The collapsing vagina. Whenever I open the speculum, the vagia collapses in front of me. I hate that. Also once I am in, there is realy not much room to maneuver.

The vagina is realy a hostile place! I am scared of vaginas.

Anyway, today a lady came in for vaginal discharge. I noticed that her last pap was > 1 year ago, and I started sweating bullets. So I kept my cool (although I was freaking out inside). So:

-I put the plastic speculum in, pressing FIRMLY posteriorly (as far as I can).

-I then shoved that speculum ALL THE WAY IN (as far as I can)

-Then I opened the speculum WIDE (hoping to see the glorious cervix), but DAMN IT, it is the "collapsing" vaginal wall again.:mad:

-So I said to myself, there is no way that Son Of a Bi*ch is further posterior. So I started to pull back slowly, and BAM, that sucker's single eye started to appear. I could not see the whole cervix, just part of it and part of the os.

-fearing I might loose it, I did not pull back more to see the whole cervix, but I was at least able to see the os.

I was very happy. Finally I found it.:cool:

But this feeling of success may be short lived. I was lucky this time because the vagina was HUGE. If I see a small vagina tommorow, I will be screwed .:scared:
 
Leukocyte said:
Yes, exactly. The collapsing vagina. The collapsing vagina. Whenever I open the speculum, the vagia collapses in front of me. I hate that. Also once I am in, there is realy not much room to maneuver.
Click to expand...

Just out of curiosity - are you sure that you're always using the correct speculum size for each particular patient?
 
smq123 said:
Just out of curiosity - are you sure that you're always using the correct speculum size for each particular patient?
Click to expand...

The thing is, at our clinic, we use a "one size fits all" plastic speculum We just have one drawer full of them, and the nurse just picks one up and gives it to the doctor.
 
Leukocyte said:
The thing is, at our clinic, we use a "one size fits all" plastic speculum We just have one drawer full of them, and the nurse just picks one up and gives it to the doctor.
Click to expand...

Sounds painful for some of your patients!
 
nykka3 said:
Sounds painful for some of your patients!
Click to expand...

...it hurts me even more, I assure you.

If we really really have to, we can tell the nurse to give us a specific size speculum (the traditional metal speculum). Otherwise, the nurse automatically gives us one of the plastic speculums in the clinics's drawer. So we do carry different sized speculums (only metal ones), but they are rarely used.
 
i just want to add something very important the speculum should be perpendicularat first with fourchette when its inside alittle bit rotate it to be horizontal and lift it up alittle if the uterus is retroverted ,down if its anteverted .imagine the uterus its position will help u alot.Try to examine Pv first will help
 
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