SKILL LABORATORY PRACTICE MODULE

BLOCK : REPRODUCTIVE SYSTEM

MODULE : # 1
TOPIC : Gynecologic Examination, Pap Smear and IVA Test

General objectives:
After completion of obstetrics and gynecology module, the students shall be
competent in history taking, performing physical examination, providing patient
education, documenting-reporting, and developing a good patient-physician
relationship, specifically in obstetrics and gynecology, in a professional manner as
they will become health care providers in primary health centers.

Sub Module 1.1. Gynecologic examination

I. Sub module objectives:
After completion of gynecologic l sub module practice, the students shall be
competent in history taking, performing physical examination, providing patient
education, documenting-reporting, and developing a good patient-physician
relationship, specifically in gynecology, in a professional manner as they shall be
health care providers in primary health centers.
II. Expected Competency:
a. Students should be able to perform anamnesis in gynecology
b. Students should be able to perform general and gynecologic physical
diagnosis
c. Students should be able to perform Pap Smear and IVA test
d. Students should be able to document and report examination result
e. Students should be able to provide patient education
f. Students should be able to develop patient-physician relationship
III. Topic
a. Gynecologic assessment (inspection, palpation, vaginal examination, Pap Smear and
IVA test)
b. Gynecologic counseling plan
IV. Method
a. Lecture/ reading assignment
b. Case presentation
c. Discussion, case study, demonstration, tutorial
d. Mannequin (anatomy model) practice
V. Laboratory facility
a. Class room
b. Reading materials
c. Audiovisual Aids
d. Anatomy model (pelvic model: normal, cervical polyps and uterine myoma)
e. Student learning guide
f. Tutor
g. Tutor guide

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VI. Venue
a. Gynecology clinic mock-up
b. Training room
VII. Organizer
Department of Obstetrics and Gynecology, Medical School Universitas Islam Bandung.
IX. Evaluation
a. Written examination
b. Case examination
c. Competency assessment in model, based on check list

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Introduction
Patient with gynecological disorders may come with one of these complaints
 Vaginal bleeding
 Leucorrhea
 Pelvic mass
 Pain in lower abdominal

So, the history taking regarding the marital history, menstrual cycles, last menstrual period,
duration of menses, parity, history of abortion, assessing the risk of STI, has to be taken
thoroughly, to find the cause of the complaint.

In the gynecological examination is important to exclude the non-reproductive system cause

of the complaint, so the general condition and vital signs examination must be perform
preceding the local status.

Equipment preparation
─ Grave speculum
─ Spatula Ayre and cervical brush
─ Object glass
─ Standing jar
─ Pap Smear form
─ Acetic acid 3%
─ Lamp
─ Bed for lithotomy position

Patient Preparation (especially for Pap Smear)

 Make sure that the patient is not in her menstrual period. Blood from menstrual
period can interfere with the results of the pap smear, making it less accurate.
 Avoid doing anything that will interfere with the results of the pap smear. In the 24
to 48 hours before the pap smear, it is important to avoid engaging in any activities
or putting anything on or around the vagina that could interfere with the test results.
Avoid the following:
Having intercourse
Using a tampon
Douching (douching should never be done)
Applying vaginal creams or lotions
Remember to empty the bladder. The pap smear will involve having an
instrument inserted into vagina and possibly having the doctor press down

Examiner Preparation
Wear apron
Wear goggle and mask
Hand washing and wear gloves

Assess the patient:

General condition:
Habitus (asthenia, athletic, picnic), Height, Weight measurements

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 Color of conjunctiva, icterus, edema,
Vital sign (blood pressure, pulse, respiratory, temperature)
Cardiopulmonary state
Inspection for abdominal enlargement or mass
Palpation of liver and spleen

Those examinations are to assess the possible cause or the effect of the complaint to
the patients

Gynecologic Examination

Getting Ready
Ask the patient to void & to take off her under wear
Ask the patient to lay down on the examining table & put her in a lithotomy position
Using apron and turn on the lamp and direct it to the examining area
Wash the hands with soap, and dry with clean dry towel

Lithotomy position

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Inspect and palpate suprapubic bulging, find any mass or tenderness
Objective: to find any possible causes of the complain

Specific examination

Inspect the whole vulva and perineum

Separate the labium mayora to open the vulva with the left thumb and index fingers, then
inspect the urethral meatus and vaginal introitus
Possible findings: Bartholin’s cyst, leucorrhea, lesions

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Signs on external inspection during the bimanual examination. A) Uterine prolapse, b) Genital warts, c)
Bartholin’s cyst.

With your right thumb & index finger palpate & explore both sides of the labium mayora,
especially in the bartholin gland area.

Inspect and record any abnormalities found, example: Bartholin’s cyst

Speculum examination:
INDICATION :
Routine screening
Prolapse
Postcoital bleeding, intermittent menstrual bleeding
Painful intercourse
Presence of infection / discharge

Grave’s Speculum

Select a speculum of appropriate size, lubricate and warm with warm water (Commercially
prepared lubricants interfere with pap smear studies)
Small--not sexually active female
Medium--sexually active
Large--women who have had children
Medium to large speculum may be used if female has had children.

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Insert the speculum :

Take a Grave’s speculum with your right hand, apply speculum using gel lubricant, insert the
left index finger into the introitus to make a slit, and then insert the tip of the specula into
the introitus parallel to the labia. Make sure that there is no tissue trapped between the
blades, and slowly push them in.
When the blades are far enough inside the vagina, turn it 90 ° clockwise so that the handle is
directed downward.

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Arrange the blades by opening the blade lock, so each blade touches the anterior and
posterior vaginal wall.
Push the knob on the speculum to make it open wider and the vaginal lumen and portio is
visible.
Notice the shape and size of portio, fornices, the vaginal wall, any bleeding / discharge from
the ostium.
Pay attention to any abnormalities on portio: erosion, fragile mass on the portio lips or any
mass coming out from external uterine ostium

Cervical appearances in speculum examination:

Normal cervix Ectopy cervix

Inflammatory cervix Polyp cervix

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Cervical cancer

Abundant discharge from the cervix

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Pap Smear examination
Equipment:

Spatula Ayre and cervical brush

Steps:
Take the cervix brush, insert into the introitus avoid touching vaginal wall. Put the longer tip
into the canalis cervicalis ostium and the short tip on the ectocervix.
Turn the cervix brush 3600 clockwise once or more (until 3 times) to get enough sample.

Pull out the cervix brush, avoid touching the vaginal wall.
Smear the sample onto the other side of the object glass.
Put the spatula and the cervix brush into disposal bin
Immediately put the slide into the fixative solution (alcohol 96%) for 15 to 30 minute.

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 Standing jar with fixative solution to put the slide in

Perform Acetowhite Test (in Indonesian: Inspeksi Visual Asam Asetat Tes or IVA Tes)
Many genital human papillomavirus (HPV) infections are clinically invisible epithelial lesions.
They remain so for a considerable time before some develop into clinically apparent lesions.
The inapparent and asymptomatic nature of these lesions poses a problem in the detection
and management of genital HPV infection. Without reliable, and readily available diagnostic
methods, no definite therapeutic approach can be recommended or followed. The
acetowhite test has been recommended to help determine the extent of the affected area.

The steps are:

At cervix inspection, assess whether there is a suspicion of cancer
If yes, the patient must be referred, examination is not carried out
If not, identify squamocolumnar junction (SCJ)
If SCJ appears, do the AVI Test by dipping a clean swab in 3-5% acetic acid solution then
applying it to the entire surface of the cervix
If SCJ is not visible, a naked eye examination without downstaging acetic acid is performed
Clients are advised to have a pap smear for a maximum of 6 months

Wait for the AVI Test results for 1 minute, pay attention to whether there are white spots
(acetowhite) or not

If the spot does not exist, explain to the client when to return for the next AVI test
If there is acetowhite spots, refer the patient for further examination

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 AW: acetowhite area

Bimanual examination
The purpose of the bimanual examination is to determine the size and nature of the uterus
and the presence or absence of adnexal masses.
In 2018, the American College of Obstetricians and Gynecologists (ACOG) issued a
committee opinion that pelvic (bimanual) exams should be performed for
1) symptoms of gynecologic disease,
2) screening for cervical dysplasia, or
3) management of gynecologic disorders or malignancy, using shared decision-making with
the patient.

Bimanual examination

The examining physician shall now stand, apply your right index and middle finger using gel
lubricant, and then separate the labium mayora to open the vulva with the left thumb and
index fingers.
Insert your right index and middle finger into the vagina to perform vaginal examination
(bimanual examination)
Put the tip of your left four fingers upon the suprasymphisis, try to feel the uterine fundus
Define the uterine size, consistency and mobility

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Palpate the adnexa
Adnexal area

In the fornices try to find any cervical motion tenderness :

Cervical motion tenderness is aiming at eliciting visceral pain which usually result from
peritoneal irritation. The visceral peritoneum covering the female genital tract is
ligamentum latum or broad ligament. Refer further to your anatomy book, to precisely see
the connections with uterus, tubes, ovaries and Douglas pouch.

Steps:
1. With your 2 inner fingers surround the portio, move the portio gently to the left and right
2. Pay attention to patient’s reaction and expression.
3. While your left hand is still on the suprasymphisis, take out your right fingers from the
vagina.
4. Take your outer fingers off the abdominal wall.
5. Wipe clean the vulva and perineum from secret or liquids.
6. Put the cotton/gauze into the disposal bin

Rectovaginal toucher
If the uterus is retroflexed, try to do the step above by performing rectovaginal toucher

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Indication: Typically, a rectovaginal examination is performed to assess pelvic pain, rectal
symptoms, or a pelvic mass.

Closing
After disposing all the equipment properly, it is important to record all the findings on the
patient’s medical record
Including filling out the Pap Smear form to be sent to the Histopathology Department
Tell the patient about your finding, together, you make the planning for the next
management

Below is the example of Pap Smear form you have to fill

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 LEARNING GUIDE
GYNECOLOGIC ASSESSMENT, PAP SMEAR AND ACETOWHITE TEST
No S T E P PERFORMANCE
. SCALE
1 2 3 4 5
I History taking in gynecologic assessment
A Chief complaint
Greet the patient and introduce yourself , develop a warm and helpful
environment
Politely ask : Patient identity
Find out : is there anyone accompanying the patient, if so, ask one to
accompany her in the examining room
B Anamnesis
1. Ask the reason why the patient needs to come to the clinic
2. Ask the followings
 marital history
 Menstrual cycles, first day of last menstrual period (LMP),
duration
 Parity and number of living children, last delivery/abortion
 History of ectopic pregnancy
 History of menstruation-related pain
 Anemia, general fatigue
 History of urinary tract infection, sexually transmitted disease or
pelvic inflammatory disease
 Promiscuity (multiple sexual partner)
 Other complaints such as bleeding or vaginal discharge,
enlargement of abdomen, feeling abdominal mass that brings
the patient to the clinic.
II INFORMED CONSENT
5. Explain the procedure to the patient
6. Explain the goals or the expected result of the examination
7. Explain that some women may experience certain discomfort during
procedure and sometime worry, but that it shall not harm or put her in
danger
8. Make sure that the patient understand about the procedure and the
aim of the examination
9. Ask for verbal consent, if the patient agrees, soon as she understands
the procedure
III PREPARATION
10. A. Patient
 Examining table
 Cotton and high disinfectant level solution
 Nelaton catheter (voiding is best)
 Grave’s speculum and tray
 Cervical brush and spatula

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  Instrument table
 Lamp
B. Examining physician
 High-level disinfected hand gloves
 Soap and tap water
 Apron
 Clean and dry towel
IV PHYSICAL EXAMINATION
11. General
 General state
 Habitus ( asthenia, athletic, picnic)
 Height
 Weight
 Color of conjunctiva, icterus, edema,
 Vital sign (blood pressure, pulse, respiratory, temperature)
 Cardiopulmonary state
 Inspection for abdominal enlargement or mass
 Palpation of liver and spleen
V GETTING READY
12. Ask the patient to void and to take off her under wear
13. Ask the patient to lay down on the examining table, and put her in a
lithotomy position
14. Using apron and turn on the lamp and direct it to the examining area
15. Wash the hands with soap, and dry with clean dry towel
SPECIFIC
16. Inspect suprapubic bulging and try to palpate uterine fundus. Locate
mass or abdominal tenderness
VI PUTTING ON HANDGLOVES
17. Take the gloves, unfold it and put it on the table.
18. Use your left thumb and index finger to hold the the right gloves on the
tip of the folded part
19. Insert your right hand by gentle traction of the tip of the folded part up
way to your fore arm
20. Take the left glove by slipping your four right fingers under the folded
part of the left glove, and use your thumb to hold the gloves upright.
21. Insert your left hand to the gloves and tighten it up by unfolding and
pulling it upward to your fore arm
SPECIFIC
22. Sitting on a chair the physician faces genital aspect of the patient
23. Take some cotton and high disinfectant level solution and wipe it on the
examining area
24. Inspect the whole vulva and perineum
25. Separate the labium mayora to open the vulva with the left thumb and
index fingers, then inspect the urethral meatus and vaginal introitus
26. With your right thumb and index finger palpate and explore both sides

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 of the labium mayora, especially in the bartholin gland area. Inspect and
record any abnormalities found.
27. Take a Grave’s speculum with your right hand, apply speculum using gel
lubricant, insert the left index finger into the introitus to make a slit, and
then insert the tip of the specula into the introitus parallel to the labia.
Make sure that there is no tissue trapped between the blades, and
slowly push them in.
28. When the blades are far enough inside the vagina, turn it 90 ° clockwise
so that the handle is directed downward.
29. Arrange the blades by opening the blade lock, so each blade touches the
anterior and posterior vaginal wall.
30. Push the knob on the speculum to make it open wider and the vaginal
lumen and portio is visible.
 Notice the shape and size of portio, fornices, the vaginal wall, also
any bleeding or discharge from the ostium.
 Pay attention to any abnormalities on portio like erosion,
leukoplakia fragile mass on the portio lips or any mass coming out
from external uterine ostium
Perform Pap Smear Test
Take the cervix brush, insert into the introitus avoid touching vaginal
wall. Put the longer tip into the canalis cervicalis ostium and the short
tip on the ectocervix.
Turn the cervix brush 3600 clockwise once or more (until 3 times) to get
enough sample.
Pull out the cervix brush, avoid touching the vaginal wall.
Smear the sample onto the other side of the object glass.
31. Put the spatula and the cervix brush into disposal bin
32. Immediately put the slide into the fixative solution for 15 to 30 minutes.
Perform Perform Acetowhite Test

At cervix inspection, assess whether there is a suspicion of cancer

If yes, the patient must be referred, examination is not carried
out
If not, identify squamocolumnar junction (SCJ)

If SCJ appears, do the acetowhite test by dipping a clean swab in 3-5%

acetic acid solution then applying it to the entire surface of the cervix

If SCJ is not visible, a naked eye examination without acetic acid is

performed (downstaging)
Clients are advised to have a pap smear for a maximum of 6 months

Wait for the acetowhite test results for 1 minute, pay attention to
whether there are white spots (acetowhite) or not

If the spot does not exist, explain to the client when to return for the
next acetowhite test,

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 If there is acetowhite spots, refer the patient for further examination

Dispose all the equipment properly

Bimanual Examination
33. The examining physician shall now stand, apply your right index and
middle finger using gel lubricant, and then separate the labium mayora
to open the vulva with the left thumb and index fingers.
34. Insert your right index and middle finger into the vagina to perform
vaginal examination (bimanual examination)
35. Put the tip of your left four fingers upon the suprasymphisis, try to feel
the uterine fundus
(if the size may be palpable).
36. Define the uterine size, consistency and mobility
Note :

37. Try to palpate the adnexal area, find any mass or tenderness, also the
mobility of the mass.
38. In the fornices try to find any cervical motion tenderness
Performing cervical motion tenderness:
 With your 2 inner fingers surround the portio, move the portio
gently to the left and right
 Pay attention to patient’s reaction and expression.
Caution: It may be very painful if peritoneal irritation exists !!
39. While your left hand is still on the suprasymphisis, take out your right
fingers from the vagina.
40. Take your outer fingers off the abdominal wall.
41. Wipe clean the vulva and perineum from secret or liquids.
42. Put the cotton/gauze into the disposal bin
43. Tell the patient that the examination is completed
44. Let her get dressed and be seated for consultation
45. Put the instrument soaked in the decontamination solutions.
46. Put your hands (still wearing the glove) in the decontamination solution
and then slowly take it off.
Pay attention that you do not spill any liquids or secret to your
surroundings.
Note : The gloves and the instruments should be processed further.
See equipment treatment in the other chapter of infection prevention
of this learning guide.
VII DATA RECORDING
47. Record your findings in the medical record
Fill the Pap smear Form completely
48. Handling the slide
49. Take out the slide from the fixative solution and let it dry.
50. Write the identity of the patient on the label of the object glass
Put the slide into the container.

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 Note:
Pay attention when you place the slide, the surface should not get any
scratch or touch. Make sure the container strong enough so the slide
will not brake until received by the pathology laboratory
Put the Pap smear form and the container into an envelope and
addressed it to pathology laboratory
VII MANAGEMENT PLAN
51. Suggest additional examination if necessary, such as routine laboratory,
ultrasonography scanning and others
Note:
Final diagnosis sometimes includes the findings from routine
laboratory and other additional examination.
52. Describe the condition to the patient
53. Arrange for follow up visit
54. Explain that if special examination or interdisciplinary consultation is
needed . informed consent would be requested.
Note:
The patient has the right to ask for expert assistant and referral to
higher rank medical facility
55. Tell important signs of symptoms the patient should be aware of and to
immediately come back for consultation
56. Tell the patient where the higher rank health facility is located and the
referral system
57. Make sure that the patient understands about all the information, the
result of examination and diagnosis and the management plan
58. Give the medical record visiting card , show the patient the way out and
greet her.

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