Procedure: Speculum examination

Procedure, instructions and discussion

Speculum examination and removal of products

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Instructions

Indications

• Cervical Shock
• Heavy vaginal bleeding
• Foreign body

Contraindications (ABSOLUTE/relative)

• Minors (age <18 years)

Alternatives

• No alternatives

Consent

VERBAL – IF HAS CAPACITY

• Simple procedure with a low risk of complications

NOT REQUIRED – IF LACKS CAPACITY

• Emergency procedure to prevent serious injury or death
• Brief verbal explanation of the procedure is still recommended

Potential complications

• Pain
• Failure (to identify cervical os, remove products or control bleeding)

Infection control

• Standard precautions
• PPE: apron, surgical mask, protective eyewear, non-sterile gloves

Area

• Private bed space

Staff

• Procedural clinician
• Chaperone

Equipment

• Cusco’s speculum
• Good light source (preferably attached to speculum)
• Lubricating jelly
• Rampley’s forceps
• Gauze
• Towel or sheet
• Absorbent pads

Positioning

• Bed facing away from the door
• Empty bladder prior to procedure
• Supine with head elevated on a pillow
• Removal of all clothing from the waist down
• Place absorbent pads underneath patient
• Towel or sheet to cover patient
• Draw her heels up towards her bottom and put her ankles together
• Relaxing the legs outwards (hips and knees flexed, hips abducted, knees dropped to sides)
• A pillow under buttocks can improve view

Medication

• None

Sequence (Removal of products)

• Part labia majora
• Insert the speculum horizontally without rotation (avoiding trauma)
• Maintain pressure on posterior vagina without rotation until you meet resistance
• Open the speculum
• Visualise clots, pooled blood and cervix if visible
• Remove all visible clots with the forceps
• Tissue can be sent for histopathology
• Use gauze on sponge forceps to wipe away clots from the fornices and to clean the cervix
• Remove any products seen within the cervical os with the forceps
• Once the products have been removed, observe cervix briefly for further bleeding

Sequence (Unable to identify cervix)

• Withdraw the speculum and reinsert (rather than manipulating it)
• Place a pillow underneath her buttocks
• Palpate the cervix with a gloved hand to identify position prior to reinsertion
• Ask the patient to push or bear down (exert downwards pressure as in labour)
• If vaginal wall laxity impairing view place a condom over the speculum, cutting the end off

Post-procedure care

FURTHER CARE

• Send products of conception for histopathology
• Document the procedure and findings
• Offer to contact support (partner, family, friends, social work)

MONITORING FOR FURTHER BLEEDING

• Continuous cardiorespiratory monitoring
• Pad checks every 30-60 minutes
• Refer for urgent dilatation and curettage if ongoing heavy bleeding

Tips

• Hypotension and bradycardia indicate cervical shock
• Take care to avoid clamping the cervix while using forceps

Discussion

We focus our discussion on the indications for emergency department speculum.

• CERVICAL SHOCK
• HEAVY PV BLEEDING
• SUSPECTED VAGINAL FOREIGN BODIES

Cervical shock is vaginal bleeding with hypotension and bradycardia caused by products of conception stretching the cervix and producing a vagal response. Removing the products of conception from the cervical os will reverse the hypotension and bradycardia.

Heavy unresolved bleeding may cause hypovolaemic shock. Removing all clot and products of conception from the cervical os in this situation may allow the uterus to contract and slow/stop bleeding, surgery may be required.

The usual vaginal foreign body is a stuck tampon or condom, these are important to remove in the emergency department to prevent the development of infection with risk of toxic shock syndrome.

Emergency department speculum examination is generally not useful in cases of:

• LIGHT BLEEDING IN EARLY PREGNANCY
• SUSPECTED OVARIAN TORSION OR PID

Speculum or bimanual examination cannot be used to rule out ectopic pregnancy and although information may be gained on whether the presentation is a threatened miscarriage (os closed) or an inevitable miscarriage (os open) the test does not influence further investigation or treatment. For these presentations the focus should be on confirming intrauterine pregnancy via ultrasound with close follow up until this occurs. 

In non-pregnant patients, neither ovarian torsion or PID can be excluded based on examination. Suspicion of either will require further testing (swabs, ultrasound) or empirical treatment. Patient-collected vaginal swabs or urine specimens are accurate for sexually transmitted infection testing with amplification assays (NAAT) and have greater sensitivity than cultures.

Experience clinician’s and gynaecologist may have a different skill set to the emergency provider and may wish to perform a pelvic exam in the ED in a wider range of presentations.

References

• Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.
• Dunn RJ, Borland M, O’Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.
• Carusi DA. The gynecologic history and pelvic examination. In: UpToDate. Waltham (MA): UpToDate. 2019 December 16. Available from: https://www.uptodate.com/contents/the-gynecologic-history-and-pelvic-examination
• Breeze C. Early pregnancy bleeding. Aust Fam Physician. 2016 May;45(5):283-6.
• McLean ME, Santiago-Rosado L. Plight of the pelvic exam. Emerg Med J. 2019 Jun;36(6):383-384. 
• Linden JA, Grimmnitz B, Hagopian L, Breaud AH, Langlois BK, Nelson KP, Hart LL, Feldman JA, Brown J, Reid M, Desormeau E, Mitchell PM. Is the Pelvic Examination Still Crucial in Patients Presenting to the Emergency Department With Vaginal Bleeding or Abdominal Pain When an Intrauterine Pregnancy Is Identified on Ultrasonography? A Randomized Controlled Trial. Ann Emerg Med. 2017 Dec;70(6):825-834
• Christophe K. Speculations on the speculum: is a pelvic exam ever needed in the ED? 2019 Apr. Available at http://www.emdocs.net/speculations-on-the-speculum-is-a-pelvic-exam-ever-needed-in-the-ed/
• M Payne; Vaginal Specula in the ED… Why, When and How – RCEMLearning; Published: 24/05/2022 https://www.rcemlearning.co.uk/foamed/vaginal-speculums-in-the-ed-why-when-and-how

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