Cervical Screening Programme
Department of Health
The Government of the Hong Kong Special Administrative Region

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v.

Insertion of Speculum

  • Cervical cancer screening should be done before doing bimanual examination.
  • Put on gloves before handling instruments.
  • Lubricate speculum with warm water. Avoid using cream or jelly as they may interfere with cytological examination.
  • Hold the speculum with blades closed with your right hand. Inspect the vulva for any abnormality or atrophic changes before gently separating the labium minora to expose the vaginal orifice with your left hand.
  • Align the speculum with the handle pointing towards the right side of the client. Slowly insert the speculum into the vagina with the tip pointing 45° downward to avoid touching the clitoris. Most of the discomfort is caused by pressure on the urethra and trigone.
  • Ask the client to see if she feels any discomfort. Look for non-verbal cues of discomfort such as facial grimacing, clenching of fist and tense leg muscle. Encourage deep breathing and muscle relaxation.
  • On full insertion, turn the handle downwards (for anteverted uterus, which is more common) or upwards (for retroverted uterus) and open the speculum gently to slip the blades into the anterior and posterior fornices, thus exposing the cervix adequately.
  • If the handle hit the examination couch, the client's hip could be raised with a plastic wedge, pillow or phone book.
  • The bivalve speculum could also be used in the lateral position, which may be more comfortable for some women.
Reasons for failure to visualize the cervix

Reason

Solution

The commonest reason of failure to expose the cervix is the tip of speculum slipped into anterior vaginal fornix, especially in nulliparous women.
The speculum is not pointing downward on insertion.
- Elevate your hand, thus pivoting the speculum across the perineal body and depressing the speculum tips into the same axis as the cervix (arrow), or
- Retrieve the speculum a little bit, then reinsert in downward direction.
The uterus is retroverted with the cervix pointing upward and forward.
- Depress your wrist, thus pivoting the anterior blade into the anterior fornix, or
- Retrieve the speculum a little bit, then turn it in upward direction. Insert slightly deeper and open again.
The speculum is inserted not deep enough.
- Close the blades and try to insert deeper, or
- Use a longer speculum.

Lateral vaginal walls bulge inwards on opening the speculum in:
- Vaginal prolapse
- Obese women

- Use a larger size speculum, or
- Apply a condom onto the speculum (make a small scissor cut in the tip of the condom before re-insertion).

 

   
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