Although the “lost condom” is a routine MRCEM OSCE station, we are hesitant to do Disposable Vaginal Speculum examinations in the ED. Our hesitation is understandable at times, but here are a few reasons why ED practitioners should all be comfortable performing speculum examinations and bimanual examinations. It could save your life.
Shock to the Cervical Spine
No one, including doctors, enjoys a Disposable Vaginal Speculum or bimanual examination, but sometimes you just have to face the unavoidable. As a general rule, as with anything else, it will be worthwhile if it will modify immediate management, entirely solve the problem, or aid to stabilise the patient.
Cervical stimulation or stretching can cause a vasovagal reaction, which includes bradycardia and hypotension. If the stimulus is not eliminated, it can lead to circulation problems. Because it requires something to be in the os of the cervix rather than in the canal, the most likely situation would be during a miscarriage with conception materials becoming stuck.
Severe PV Haemorrhage with hemodynamic instability during pregnancy
Patients taking anticoagulation, as well as late-term miscarriages, are more likely to bleed severely (unsurprisingly). If a patient is bleeding heavily and decompensating, you may be able to stop/slow the bleeding if you can remove clots and any visible products of conception that will cause continued bleeding until removed.
A trapped tampon or condom would be the conventional PV FB, but like with rectal FBs, you never know… The first thing to remember is that there’s a good possibility it’s not there, and the patient will usually have a good feeling, with ED being their very last resort. If they haven’t tried to remove it themselves for whatever reason, you could ask them to go to the patient toilet and try it themselves, with reassurance that it’s safe.
When to Avoid Disposable Vaginal Speculum
- If you are unsure or uncomfortable doing a disposable vaginal speculum examination,
- If the patient refuses to consent,
- If there is any suspicion of sexual assault, forensic proof may be required (unless the patient is unstable and it is clinically indicated)
What Do You Need
- Lube, lube, lube!
- PPE (particularly gloves) (especially gloves)
- The specula in the ED are usually single-use plastic double-bladed ones – make sure you know how to open the speculum and screw it open before approaching the patient (it’s not very reassuring for the patient if you have to stop halfway through to mess around and figure out how to use the equipment).
- They are often available in three sizes (but only medium may be available) – the medium size should be adequate for the majority of women.
Preparing The Patient:
- Any personal inspection should ideally take place in a private room (preferably with a lock!) But, we all know that in ED, it is a difficult prospect.
- If you have to use a cubicle, turn the cart around so that the patient’s head is facing the entrance; that way if you are interrupted, at least some of their dignity is protected.
- Before you go anywhere near the patient, make sure you carefully explain what you’re going to do, including a digital inspection if you choose to do so.
- Be certain you know whether or not they are pregnant.
- Don’t assume they’ve had a disposable vaginal speculum inspection before, and keep in mind that there are many stigma/horror stories surrounding vaginal examination, so much comfort may be required.
- Once the patient has agreed to the examination, ask them to remove their bottoms and underwear and lie down on the bed (covered with the second sheet), and then leave the room to give them some privacy.
- Check to see if they’ve used the restroom.
- Make sure the second sheet covers them as much as possible, especially while you’re still prepping your equipment.
- If you anticipate any bleeding/discharge/object removal, place an inch pad under the patient and have additional on hand.