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Procedure: Speculum examination

The Procedure

Hello again from the Emergency Procedures team,

Today we teach you how to find the cervix and discuss just who does need a speculum examination in the emergency department.

Detailed written instructions and explanation are available in our Free App (iOS and Android). This video is hot off the press and we want your help improving it. Drop us a line with any suggestions

So, without further ado…here is the video


The rationale…

Who needs a speculum in the emergency department?

Patients presenting with:

  • 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 PV 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, if this fails 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.

Why do we not recommend a speculum exam for light bleeding in early pregnancy?

It is uncomfortable and invasive for the patient and rarely adds any useful information.

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. 

Why do you not recommend a speculum exam for suspected PID or ovarian torsion?

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 gynaecologists 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.

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    The App


    Emergency Procedures

    Dr John Mackenzie 002

    Dr John Mackenzie MBChB FACEM Dip MSM. Staff Specialist Emergency Prince of Wales Hospital; Consultant Hyperbaric Therapy POW HBU. Lead author of Emergency Procedures App | Twitter | | YouTube |

    Dr Amanda Beech LITFL Author

    Dr Amanda Beech FRACP MBBS (Hons) BSc PHED (Hons). Obstetric medicine physician and endocrinologist. Staff Specialist Royal Hospital for Women, Sydney. Director of Simulation training

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