Performing a Papanicolaou Smear (Pap Smear)
Aims and objectives
The aim of this procedure is to enable the student to clearly visualise the
cervix and perform a papanicolou smear with sensitivity to the needs of the
patient.
Gaining permission
A chaperone should always be present. Consider the need for an interpreter
if English is not the patient’s first language. Using clear and simple terms
understandable to the patient, explain the need to perform the Papanicolou smear.
Discuss the procedure with her and obtain her permission to proceed. Invite
her to empty her bladder if appropriate to minimise any discomfort during the
examination. Provide privacy for her to change and provide suitable cover to
ensure modesty.
Preparing the room
Organise the equipment and ensure that the clinical examination area is prepared
before commencing the procedure. Include: glass slides, pencil, slide holder,
cytological fixing solution, Ayre’s spatula, endocervical brush, vaginal swabs
for culture, cusco speculum and KY lubricating gel. Label the slide in pencil
with the patient’s name, identifying chart number and date of birth. Place
the light source in an appropriate position
Performing the examination
Perform a general physical examination as indicated by the patient’s history.
An abdominal examination is essential prior to any pelvic examination. This
allows the patient to relax and is itself necessary to fully evaluate any pelvic
problem. In particular, a fibroid uterus or ovarian mass may only be detected
per abdomen.
Uncover the area to be examined, ensuring adequate exposure while allowing
for patient modesty. Don examination gloves. Inspect the vulva and peri-anal
region Note skin lesions of erythema, ulcers, leukoplakia or condylomata.
Warm the speculum. Lubricate with water or a little KY gel. Part the labia
minora with index and middle fingers of left hand. Indicate to the patient
that you are about to introduce the speculum. Introduce the speculum to the
introitus at an angle, 30-45° from the horizontal level. Gradually insert it
deeper and posteriorly, while rotating to the direct horizontal position. Once
completely inserted, open the valves of the speculum. The vaginal fornix being
more distensible than the lower walls of the vagina permits opening of the speculum
with minimal discomfort. However, it is wise to warn the patient of further
pressure prior to opening the speculum. A clear view of the cervix should be
obtained. Should the cervix not be visualised the speculum may be withdrawn
a little and directed anteriorly to locate the cervix of a retroverted uterus.
Once adequately visualised, tighten the screw to keep the speculum open in
this position. The cervix is examined for the presence of an ectropion, polyps,
ulcers or growths suggestive of neoplasia.
Determine which end of the Ayre’s spatula is more appropriate to use - generally
the long narrow end is suited to the nulliparous or postmenopausal cervix, the
broader end to the parous cervix. Insert one end of the spatula into the endocervix
and rotate through 360 degrees. Remove the spatula and spread the smear thinly
over 2/3 of the glass slide. A thick smear cannot be interpreted by the laboratory.
Place the endocervical brush in the endocervical canal and rotate through 360
degrees. Smear this also thinly on the remaining 1/3 of the glass slide. Spray
the glass slide generously with fixative and allow to air dry, in the slide
holder.
The presence of vaginal discharge should be noted and a swab for culture be
taken if appropriate. Open the speculum screw and gently remove the speculum
taking care not to allow it to trap the walls of the vagina. Inspect the walls
of the vagina as you remove the speculum.
A bi-manual examination of the pelvic organs is performed after
the smear test, to minimise interference with the cervical cytology.
Completing the procedure
Allow the patient to dress in privacy. Explain the findings of the examination
and discuss further management with the patient. Give her an explanatory booklet
if appropriate. Arrange follow up appointment. Dispose of equipment.
Documentation
Clearly fill out the pathology request form. Include details of patient’s
name, identifying chart number, date of birth, date of last menstrual period,
cervical smear history and appearance of the cervix. Sign the form.
Useful Websites:
See “Royal College of Obstetricians and Gynaecologists - Intimate Examinations
- Report of a Working Party” 22/03/01 for information on vaginal speculum examination
and bimanual palpation of the female internal genitalia. This report is available
on the website of The Royal College of Obstetricians and Gynaecologists
http://www.rcog.org.uk/intimate_examin.html
See also Canadian STD Guidelines: 1998 Edition. This publication has a section
on the collection of specimens including Pap Smear. Go to Health Canada Online:
http://www.hc-sc.gc.ca/
Select English Translation. This will bring up “Health Canada Online” website.
In the fast find section click on Sexuality/STDs. This will take you to a site
for sexually transmitted infections. Choose Canadian STD Guidelines: 1998. Then
select the PDF version of the report. Pages 49 – 56 contain a section on the
collection of specimens including Pap Smear which is on page 52.
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