The Perfect Pelvic ExamNPO conference 2018 Jacquelyn Quetal, FNP-C

“Jacqui, do you have any disclosures?”

Nope

Objectives

Discuss challenges as a group

Understand how to gain consent and how/when to transfer power to the patient

Rethink patient positioning techniques

Avoid triggering touch, words and language

Contextualize with some case studies

Tell me your feelings about pelvic exams…

Discuss pros and cons

Why do we do them?

Data collection--PAP, wet mount, STD testing

IUD insertion or removal

Annuals

We were trained to be thorough

We think it improves patient satisfaction

What are the guidelines?

PAP start age 21, q 3 years

Cotest at 30 and older, q 5 years

If presenting with problems, examine

Pelvic pain, abnormal bleeding, infection concerns.

Bimanual for IUD insertion

Do any orgs recommend specific yearly pelvic exam?

The how

State the purpose of the exam and what can be gained

Ask/interview when clothes are on if possible

Get consent Walk them through the process

Let them know they can stop

Get them into position

Narrate along the way

Check in when done

Debrief if needed

What is power transfer?

When we ask open ended questions and truly care what comes out of the patient’s mouth.

1When we say it’s OK not to have a pelvic exam.

2When we let a patient do a self swab/place their own speculum.

3When you let her make a decision about how to make the exam more comfortable.

4

To self swab or not?

Chlamydia and gonorrhea testing

Wet mount

Rectal swabs

HPV screening

Discussing anatomy

Use language the patient uses

Ask before you start

Teach as you go

Give compliments and reassurances

Trigger words

Relax

Lie back

Spread

Bed

Triggering actions

Squirting gel/lube onto the skin

Lingering touches

Mind your thumb/touching the clitoris

Other challenges?

Hx of abuse/trauma

First pelvic

Large bodies

People who have less flexible bodies

Trans folks

People who have had vaginal intercourse but don’t anymore (or often)

Scared/ashamed/embarrassed patients

Speculums…

The exam

Time to practice

Check out your handouts

One more thought…

If you do find something unusual…

Case study #1

17 year old female

Vaginal discharge and odor

No current sexual partner, but hx of 2 male partners in the last 12 months

LMP 2 weeks ago, normal bleeding, not painful

What tests do we need?

Do we need a pelvic exam?

Case study #2

30 y/o female

Mutually monogamous relationship with male partner

Last pap was 2 years ago, normal result cytology and no reflex to HPV

Asymptomatic

Using IUD successfully

Does she need any testing?

Pelvic exam?

Case study #3

24 year old trans male

Never had a pap or pelvic exam

Asymptomatic

What else do we need to know?

Do we need to do a pelvic exam?

Thank you for being here!

jquetal@kingcounty.gov

References

ACOG. (2017) Practice Advisory; Screening Pelvic Examination. https://www.acog.org/Clinical-Guidance-and-Publications/Practice-Advisories/Practice-Advisory-Screening-Pelvic-Examination.

Brooks Barr, W. (2006). Vaginal speculum examinations without stirrups. BMJ. 333(7560): 158–159. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1513505/

Guirguis-Blake JM, Henderson JT, Perdue LA. Periodic screening pelvic examination: evidence report and systematic review for the U.S. Preventive Services Task Force. JAMA. 2017;317(9):954-966.

Petersen, H.N. et al. (2018). Implementation considerations using HPV self-collection to reach women under-screened for cervicalcancer in high-income settings. Curr Onc. 25 (1). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5832289/

Ravi, A., Little, V. (2017). Providing Trauma-Informed Care. Am Fam Physician. 95(10):655-657. https://www.aafp.org/afp/2017/0515/p655.html

Reproductive Health Access Project. (2015). Contraceptive Pearl: Trauma Informed Pelvic Exams. https://www.reproductiveaccess.org/resource/trauma-informed-pelvic-exams/

Tillman, S. (2016). Empowering Gynecologic Exams: Speculum Care Without Stirrups. http://www.feministmidwife.com/2016/11/02/empowering-gynecologic-exams-speculum-care-without-stirrups/#.WyM9qS_Myu4

US Preventive Services Task Force Recommendation Statement. Screening for Gynecologic Conditions With Pelvic Examination. JAMA. 2017;317(9):947-953. https://jamanetwork.com/journals/jama/fullarticle/2608228

https://www.acog.org/Clinical-Guidance-and-Publications/Practice-Advisories/Practice-Advisory-Screening-Pelvic-Examinationhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC1513505/

The Perfect Pelvic Exam“Jacqui, do you have any disclosures?”ObjectivesTell me your feelings about pelvic exams…Why do we do them?What are the guidelines? The howWhat is power transfer?To self swab or not?Slide Number 10Discussing anatomyTrigger wordsTriggering actionsOther challenges?Speculums…Slide Number 16The examSlide Number 18Slide Number 19Time to practiceOne more thought…Slide Number 22Case study #1Case study #2Case study #3Thank you for being here!References