This document provides instructions for performing a pelvic exam, including external genitalia examination, speculum examination, and bimanual examination. It describes in detail the equipment, techniques, and procedures involved in each part of the exam. Key aspects covered include using appropriate language, communicating with the patient, obtaining consent, examining with a plastic or metal speculum, performing a Pap smear, and assessing the uterus and ovaries through bimanual palpation. The goal is to thoroughly examine the patient while maintaining comfort, communication, and informed consent.

1. I. Introduction
II. External Genitalia Examination
III. Speculum Examination
IV. Bimanual Examination(Rectovaginal if suspicious or
retroverted)
V. Conclusion
**USE NEUTRAL language: ‘Insert’ ‘remove’ ‘table’ and
‘footrests’
I. Introduction
Formerly, most medical schools performed these exams on
anesthetized patients or even cadavers. Obviously, the
communication was not present and so was never learned
appropriately. We emphasize this throughout the exam
components, along with the manual skills, so you as future
physicians will be able to incorporate this into practice.
Today we will do several things(NAME the above steps).
Let’s start with the plastic speculum. Many places use the
gooseneck lamp, but most of these now have the attachment for
the fiberoptic light. Plastics have other advantages-they aid in
visualization while inserted so the clinician can note any
pathology along the vaginal walls. Their room temperature is
an obvious plus. And, they are easily disposed of.
However, notice something. The aperture, or introitus
opening, is larger than you would normally need for the well
woman exam. It cannot be altered for a woman’s size or the
procedure.
Plastic speculums also have a coarse control mechanism for
opening and closing the bills. This ratchet device can be
disconcerting to the woman, and even cause a clamping down
on the cervix—very unpleasant. We stress you must get

2. comfortable with opening and closing these particularly, since
you will have these in your OB/GYN rotation. You’ll see most
of these in Public Health clinics and inner city hospitals; each
one is about 40 cents. They are ordered in lots; and also come
in small, medium, and large. So we recommend ordering M
first.
Moving to the metal speculums-there are two types: the
Pedersen, which comes in 5 sizes( Pediatric=abuse, kids poke
things up there); slender=young sexually inactive teens, half-
width of small; small; medium; and large).
The Grave’s has 3 sizes: small, medium, and large. If you are
not sure, start with the medium, then move up or down(you’ll
know this from her chart and after locating the cervix in the
first part).
When checking her chart, notice if she’s given birth vaginally.
IF so, then the Grave’s is used; it removes extra sagging tissue
out of the way so the cervix can be fully viewed. It is also a
good speculum for obese patients(other trick—glove or
condom, cut at ends, placed over speculum).
Notice the flaring, or spooning, at the ends of the Graves. In
contrast, the Pedersen has straight (linear) bills or blades. It is
most ideal for nulliparous women or those who had
Caesareans.
Metals can be noisy, and of course cold; many women don’t
like that. You can warm them on a heating pad or in a water
tub after autoclaving. Don’t keep it too warm, since it can
burn tissue. So check the temperature on your gloved wrist
and her inner thigh.
things to check:
1. Are the blades aligned? This avoids any tissue from being
pinched. Adjust using the bolt, screwed to the right tightly;
this also controls the aperture. It is a method of fine control.
2. Thumb lever ‘stopper’—prevents screw from flying off
across the room; kept unscrewed out all the way.

3. 3. How will you hold it? This is based upon personal style; but
make sure thumb is BEHIND levers to keep the bills closed as
you insert!!
4. Check for complete blade closure upon removal.
Remember they may stick, so as you remove speculum help
blades close with your fingers.
5. Think of the introitus as ‘almond-shaped’: you will always
insert at 45 degrees, gradually becoming horizontal when fully
inserted.
Kegel ADVANTAGES:
--prevention of stress incontinence
--prevention of prolapse/-celes
--enhances sexual enjoyment
--easier childbirth
Begin the actual patient interaction:
Knock on door after checking chart:
“Hello, Mrs. C? “ shake hands and SIT DOWN (intimidating
to remain st.)—
“I’m Laura, the MD here to examine you today. Is Mrs. C ok,
do you go by…”
“Tell me what brings you here today.”
“ I see. And when was your last exam? (PAUSE ) Was there
anything that kept you from coming in sooner?”
“Well, first, I want to welcome you here. We’re glad you came.
It’s recommended that a woman gets her Pap and pelvic every
year, so that we can follow her using a baseline of what is
normal and healthy for her. Glad you are here.”

4. There are 3 parts to this exam. Before them I will also perform
the breast exam.
For the rest, the first part is when I will examine your external
genitalia, or female parts, and look for normal healthy tissue.
Then I’ll insert (be nondemonstrative here) 1 finger to locate
your cervix, which will aid me with the second part, the
speculum exam. Have you seen a speculum (NEVER
ASSUME—SHOW DEMO)?”
“ I won’t be using this actual one;--but it is inserted at this part
only, about 1 finger long and 2 fingers wide, while opening it
about this wide (about an inch) to view your cervix. Any noises
you hear are just me adjusting it. I will then offer you a
mirror if you like.
“ The last part is the Bimanual exam, where I’ll be inserting
two fingers into your vagina while my other hand is placed on
your abdomen. I’ll be palpating your uterus, cervix, and
ovaries, again for normal healthy tissue.”
Do you have any questions?
“ Ok-I’ll wash my hands. Have you emptied your bladder?”
(PULL OUT FOOTRESTS, TABLE AT 45 DEGREES, THEN
WASH).
Table at 45 d. to improve eye-to-eye communication and to
bring the normally retroperitoneal ovaries into the abdomen
for improved palpation. This is a clean, not aseptic, exam; after
gloving, only touch the drape and female.
• Also discuss privacy and warmth of drape (check) at all
times.

5. P Sign: nondominant hand-low on perineum, lower half of
introitus. Purpose is to remove hair and tissue that could hurt
her unnecessarily.
Sit down.
1. Bend gloved hand down, wrist up. Ask patient to move
down until her back of thigh touches your hand.
2. Adjust drape to view patient’s face.
3. State “PT, it is normal to want your knees in like this-if you
would, please let them fall into my hands’
4. Then stand up(unless you are really tall)
5. “PT, no part of this exam should be painful. If it is, tell me
and I’ll adjust my technique.(LOOK HER IN EYE).
(3 reasons for pain: psychogenic, actual pathology, your
technique)
6. Roll up drape to expose genitals. Establish touch by
palpating abdomen, inguinal and perineal nodes, then move
from lateral to medial using the ‘pinch’ method on labia,
crevices. Check for lice, ulcers, etc. Use index fingers very
lateral to prepuce, push away over mons pubic bone to reveal
clitoris(check for adhesions; spcl. Cream can remove).
NEVER TOUCH THIGHS OR LEAN ON KNEES
7. “I am now going to insert one finger into your vagina to
locate your cervix.”
SIT for this, palm up, thumb away. You may need to stand if
it is located deeply.
Note amt. of lubrication, position and cervix angle. At your
first knuckle, upon removal, check for Bartholin’s glands(5
oclock and 7 oclock)
REDRAPE.
If lubrication is needed, just use warm water on speculum NO
others since they interfere with Pap.

6. Use P sign: Leverage speculum to place pressure on posterior
wall of perineum, angle at 45 degrees. Gradually turn to
horizontal and flush with perineum. (will need to remove
nondominant hand and check for hair, tissue pull-ins). Also
remove some fingers from behind the handle. AVOID tendency
to remove spec. slightly as you open the bills.
Look for pinker, shiny smooth cervical tissue and os(use
micromovements). Scoop ; offer mirror.
PAP SMEAR:
First is the the cytobrush (pipe cleaner like) in the endocervical
canal-twist 360 degrees; same on slide. Then, with plastic
‘spatula’, use longer angle to swivel and scrape along the
squamo-columnar junction , circumferentially (360); same on
slide. Spray the fixative (warn patient).
For GC and Chlamydia—leave test in endocervix 1 min.
SPECULUM REMOVAL:
Be sure thumb is on lever, holding open angle!!
Gradually clear the cervical area(need light). Once clear,
Then grad. Release the lever and let blades close. Be sure
pressure and handle is DOWNWARD. Gradually remove at 45
degrees(note dark vaginal rugaed walls closing in. May need to
assist with bill closure using thumb).
REDRAPE, rinse speculum (if reuse).
SIT.
“I’ll now insert two fingers into your vagina for the bimanual
exam.” Add lubricant to both fingers, front and back(never
KY jelly-bacteriostatic, leading to yeast infections)
Again, P-sign and palm up with watching fingers!(insert index
over middle to ease discomfort)

7. SIT, then stand.
Have fingers under cervix, look for motion at hairline—use
other hand to deeply palpate uterus (easier if anteverted).
Check for CMT with two fingers at sides of cervix; wiggle
gently. Go into either fornix(pocket); need lubricant on
abdomen-starting point is between anterior iliac crest and
umbilicus. MAY feel pulse at uterine artery inside.
(USE THE MODEL TO DEMO WITH HANDS)
Deep, sweeping smooth motion with abdominal hand to bring
adnexa DOWN onto hooked interior fingers.
The ovary-if felt- will be a brief, almond or grape-shaped item;
sometimes patient can feel it so be gentle!
Assess size and shape; compare with the other side.
Before removal of fingers, ask female to do a KEGEL(explain
as ‘bearing down by squeezing as if you want to stop urine
flow)
REDRAPE.
Deglove below the seat, out of her sight. Let her know she can
scoot back and sit up.
“Everything was normal and healthy(if not, see her DRESSED
in office). You should get your Pap results in 12 to 14 days; if
not, feel free to call the office. You may have some spotting
and slight cramping over the next day-which is normal(from
procedure)-we have pantiliners available, as well as tissues to
wipe away the excess lubricant. Do you have any questions for
me?”