Use of a vaginal speculum and taking a vaginal swab
The vaginal speculum has been in use for over 2000 years. It is used for both obstetric and gynaecological examinations. Midwives will carry out examinations using a speculum in certain circumstances during pregnancy and need to be competent in this skill.
The insertion of the speculum can be uncomfortable and may cause anxiety or embarrassment for some women. The level of anxiety may also be related to the reason for the examination so this should be taken into consideration. It is essential the midwife gives a full explanation of the indications for the speculum examination and procedure so as to obtain informed consent. Any queries or anxieties the woman has must be addressed at this time. It is probable that the woman has at some point had a cervical smear, which is obtained using a speculum, so it can be useful to use this as part of the explanation of the procedure so the woman knows what to expect.
A Cusco vaginal speculum is used for examination in pregnancy. Figure 53.1 shows the speculum with blades open; Figure 53.2 shows the blades closed. In pregnancy the midwife should use an aseptic technique if the membranes have ruptured; sterile gloves should be used. The speculum blades will require lubrication prior to use and the woman needs to be positioned correctly as described below.
- Wash hands.
- Prepare the woman; the midwife must ensure the indications for examination and procedure have been explained and informed consent gained.
- Position the woman; heels/ankles together, draw up towards the buttocks then relax the knees outwards so legs are open. Ensure privacy and dignity whilst woman is in the appropriate position with a cover over her. She can move this up when you are ready to begin.
- Open pack and gloves. Open all necessary equipment onto pack (gel, speculum, swab, cleaning fluid). Put on your apron, wash hands and put on gloves.
- Lubricate the outer aspect of the blades; ensure blades are closed to avoid gel going inside the speculum.
- Identify your clean/ dirty hand and clean perineum and vulva using aseptic technique, swabbing downwards with the ‘dirty’ hand.
- Part labia with ‘dirty’ hand and insert speculum (blades closed) in the AP diameter in a slightly downward direction (Figure 53.3).
- During insertion rotate the speculum until the handle is upwards towards the clitoris (Figure 53.4).
- Open the blades using the mechanism present (often a screw but may vary between models) and hold the speculum in place.
- Using the light source you should be able to inspect the vagina and cervix. You may need to insert the speculum further or ask the woman to tilt her pelvis upward (put her fist under her bottom) if the cervix cannot be visualised. Take high vaginal swab (HVS) if indicated.
- If spontaneous rupture of membranes is suspected and no liquor is seen, ask the woman to cough. This raises the intra-abdominal pressure and can push liquor out. It can also help to ask the woman to lie on the bed for up to 30 minutes before examination to allow time for the liquor to pool in the vagina.
- When the examination is complete close blades slightly and remove. Ensure blades are gradually closed as speculum is rotated back to AP diameter as you remove it. It can be very painful if the vaginal wall is trapped whilst doing this.
- Assist the woman in removing the disposable sheet and replacing her sanitary towel and underwear.
- Ensure all equipment is disposed of in the correct clinical waste bin.
- Wash hands.
- Ensure you communicate all findings to the woman and her partner, including plan of care, then document all accurately. If any deviations from the norm, then escalate to the senior midwife and senior obstetrician.
A vaginal swab can either be a high vaginal swab (HVS) or low vaginal/vaginal swab (LVS). A speculum must be used to enable an HVS to be taken (Evans and Morgan, 2012). This is then sent to the laboratory for microscopy and then culture and sensitivity if indicated by microscopy examination. It can be used for diagnosis of vaginal infections such as bacteria vaginosis, Group B streptococcus and candidiasis. Some texts do not specify HVS, only vaginal swab and also advocate the woman being able to take the swab herself. Care must be taken to ensure the swab is not contaminated before placing it into the vagina to ensure that organisms detected are vaginal rather than from the perineum or anus.
The swab should be taken and then placed in the transport medium within the receiver provided, adhering to local policy and procedure. The transport medium is normally Amies transport medium with charcoal. The purpose of the charcoal is to protect the bacteria from the light and the transport medium provides a moist environment to keep the bacteria alive during transport to the laboratory. It is the responsibility of the midwife to ensure that the swab is clearly labelled and documented in the notes so that the result can be followed up and appropriate treatment given if required.