Trick of the Trade: No pelvic bed? No problem

Often finding a pelvic examination bed for a female patient needing a speculum exam can be challenging. Without the elevated foot stirrups, the bed under the patient’s buttocks obstructs the pelvic speculum handle so that it can’t rotate completely into a 6 o’clock position.

Trick of the Trade

Rotate the pelvic speculum handle towards ceiling instead of floor

1. Place the patient in a “frog leg” position.
2. Insert the speculum with the handle facing to the right (patient’s left thigh).
3. Rotate the speculum so that the handle points toward the ceiling.

Caution: Do not lift the speculum anteriorly like you would a largynoscope blade. When widening the speculum view, err on the side of applying posterior pressure against the rectovaginal wall. This is much less painful than compressing the anterior structures.

ADDITIONAL TIPS

From Comment Section by Dr. Penny Wilson on 3/31/13:
Nomadicgp.wordpress.com

I’m a GP obstetrician in Australia and do speculum exams pretty much all day every day on a normal (non gynae) bed. I do every exam with the spec handle up as (a) it prevents the no-room-for-the-handle problem you’ve described and (b) it also allows you to more easily hold the spec in place with the left hand while the right hand takes the swabs or whatever. This is essential to avoid the awkward situation of the speculum flying out of the patient with good pelvic floor tone. This is MUCH easier with our standard bi-valve specula which have both sides the same length. It really annoys me to have to use speculum where one leaf is longer!

My other tips:

• Have the examination table high enough so that you don’t have to bend over too far
• When approaching from the patient’s right hand side of the bed, have the light source angled so that it is coming slightly from the left hand side. This avoids your head blocking the light. A head torch can also be helpful!
• The frog-leg position is the best for access – I ask my patients to keep their feet together and their knees flopping and as relaxed apart as much as possible. The feet should be as close to the buttocks as possible for maximum abduction and external rotation of the hips.
• If you can’t see the cervix, get the patient to put their fists under their bum to tilt the pelvis.
• And most importantly, you should NEVER insert a speculum sideways and then rotate it. It is much kinder and less uncomfortable for the patient to part the labial with your left hand and then insert the speculum directly (either handle up or handle down) into the vaginal opening which is now exposed.

Author information

Michelle Lin, MD

ALiEM Founder and CEO
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco

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