Advice for finding the cervix?

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PreMedAdAG

PreMedAdAG

I am so smart. S-M-R-T :)
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I know this is lame - but I have my ob/gyn rotation practical coming up and well... I'm a little embarassed, but I have never been able to find the cervix while doing a speculum exam - I always ending up aborting and getting help from a resident. It really sucks b/c I've tried probably like 4-5 times in the past year or so - and every time I screw it up. Today was the last straw - I really hurt the patient - she went flying up and my speculum came out and I felt awful :(

Any advice on how to find the cervix? Everyone keeps saying - oh it just takes practice - well I only have 2 weeks to figure it out and about 3-4 more tries max before that test :(
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lol, are you a guy or a girl? It would be hilarious if a girl was like "where's the cervix?" Sounds like your problem is you're trying too hard. It's not like the vagina is that long, so you are probably slamming the speculum in deep and overshooting and then smacking the cervix when you attempt to open it. Go in a few inches and then open the speculum and the cervix should fall into view. Also, hold your breath because it's stinky down there.
 
Sometimes I can't find it with the speculum, but easily palpate with Bimanual.
Although it may be out of order, I have been told that it is not wrong to do the bimanual first, to determine by feel where you need to look for the cervix. I still have troubles sometimes. Try what snoop said too.
 
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well yes I am female - and just b/c I have one doesn't mean that I know where mine is - doing a self spec exam would be pretty amazing :laugh:


Anyway - I guess what they tell me is to
1. Put the spec as far back as it goes using posterior pressure (downward)
2. Then open it - popping the cervix into your view

this is what I do.... and yet no cervix - just vaginal wall :(

I like the idea of feeling for the cervix before - I'll give it one more try and if it doesn't happen for me - I'm going to try the second method - god this sucks :(
 
PreMedAdAG said:
I know this is lame - but I have my ob/gyn rotation practical coming up and well... I'm a little embarassed, but I have never been able to find the cervix while doing a speculum exam - I always ending up aborting and getting help from a resident. It really sucks b/c I've tried probably like 4-5 times in the past year or so - and every time I screw it up. Today was the last straw - I really hurt the patient - she went flying up and my speculum came out and I felt awful :(

Any advice on how to find the cervix? Everyone keeps saying - oh it just takes practice - well I only have 2 weeks to figure it out and about 3-4 more tries max before that test :(
Click to expand...

Lol. Sorry to hear that! Your post is sad and quite funny at the same time. That's the one thing I was pretty much always able to do in OB. Good thing I had that going for me! Anyways, I'm thinking you are probably putting the speculum in too fast. If you put it in slowly, the cervix should pop up without any struggle. I don't know what method you've been taught, but use your fingers to open up the vag. canal first and then insert the speculum sloowwwwllllyyy and it should work. Good luck!
 
Medstudentquest said:
Lol. Sorry to hear that! Your post is sad and quite funny at the same time. That's the one thing I was pretty much always able to do in OB. Good thing I had that going for me! Anyways, I'm thinking you are probably putting the speculum in too fast. If you put it in slowly, the cervix should pop up without any struggle. I don't know what method you've been taught, but use your fingers to open up the vag. canal first and then insert the speculum sloowwwwllllyyy and it should work. Good luck!
Click to expand...

forget cervix, i'll bet you can't find your own penis without asking for directions.
 
arthrodisiac said:
forget cervix, i'll bet you can't find your own penis without asking for directions.
Click to expand...

Huh? I don't have a penis fyi and I have no idea what you are referring to. Why all the hostility?
 
I agree with putting the speculum in slowly and opening it, but also point the speculum down. The cervix runs in almost an anterior to posterior direction and when the patient is lying on their back it can be buried in the posterior wall of the vagina. If you have the speculum pointed down as you go into the vagina it will pop right into view.
 
Man - everything you all say is exactly what i THINK i'm doing - yet it's never successful

I've actually only done the spec exam 4 times - here are the outcomes

1. first year - the 4th year student had to help me :( but it wasn't so bad - i was just a little off
2. third year - the first one I did - I almost found by myself - again same as above
3. The 3rd time I did it it was on an obese patient - it was like I was being buried alive - my speculum that is - the vaginal wall caved in
4. The last time - same deal - morbidly obese patient - then when i used the bigger speculum on her is when I apparently scraped the crap out of something on her - the funny thing is - i think i had the cervix, but that one edge of the spec was jabbing the posterior fornix

It just seems like i'm "following all the rules" yet - I still can't find it - ARGH!

is there a You tube video on this :) :laugh:
 
There's your problem. You're trying on a fat lady. You're right, they have a lot of, uh, tissue. Why don't you find a nice skinny lady and then point her my way and then find another one and do a speculum exam on her? Remember, gotta do the easy ones first (ho ho ho).
 
80 people viewing this thread and only 10 responses (4 of which are mine!) - that means there are a lot of people who can't find it either :confused:


Mother - I'm in cervix hell - I can't stop thinking about the frieking os - it's going to haunt me in my sleep
 
No it just means that there are a lot of people who find threads focused on female genitalia to be interesting. Seriously, this thread has great potential. :D
 
My typical pelvic exam:

1. Outside survey for lesions
2. Bimanual
3. Speculum with swabs

When looking for the cervix, I typically spread the labia slightly with outside pressure, insert the speculum straight in and rotated slightly to the right and angled downwards. Once inserted I straighten the speculum so it's flat (i.e. blades are parallel to the floor, handle perpendicular to the ground), and then insert while maintaining downward pressure, with the tip angled slightly downward. Once it's 2/3 to fully inserted (depending on patient size :p), open the blades and the cervix should fall into view. If not, relax your deathgrip so the blade slightly relax (make sure you don't pinch the walls between the blades), withdraw the speculum slightly, and re-open the blades and attempt to visualize the cervix. If it's still a no-go, it may be an anteriorly placed cervix (which you can sometimes tell on the bimanual). Pretty much after this it's trial and error :laugh:

Perform swabs, relax the blades, and withdraw speculum, continuing to maintain downward pressure with the tip pointed toward the floor. Tell the patient she did well, and wander out the door trying to decide what's worse, giving a pelvic exam, testicular exam, or the rectal exam.
 
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:laugh:

I think it's one of those things that come with experience. I have been doing alot recently and have not had any problems. I will try to describe, though I doubt it will help

I go in gently, keeping the pressure posterior, then open partially as soon as I am halfway in/can comfortably do so. Then I go in at a sl downward angle. Usually this gets it. If not, I look for a more anterior uterus by backing up and going in at a slight incline, or a retroverted uterus by diving.

If you think about it, the penis never fails to find the cervix unless it is too short :smuggrin:, and there aren't many places it can hide in a narrow tunnel that is even shorter in an unaroused female, so if you can't see it with your 5 inch speculum, it is very close by! Just be patient and poke around in a circle, it is like looking for a vein or whealing an abscess with lidocaine.

PS. Use large metal speculums on large patients, can lubricate with hot water , and keep two sets of fingers on the speculum at all times when you are starting off/hunting alot to avoid losing control and hurting someone.
 
smq123 said:
Sorry - is it just me or does that icon look like a cervix?
Click to expand...


Totally!! It's a multip!!


However - this is what I see when I try to find the os --> :thumbdown:
 
I remember the first speculum exam I had to do. It was a pretty large lady and she needed one for some sort of form. The attending told me to just go do it and he left the room (the nurse was there of course). I spent what seemed like forever looking for it and eventually had to ask him to help me.

We eventually learned she was s/p vag histerectomy.
 
THP said:
I remember the first speculum exam I had to do. It was a pretty large lady and she needed one for some sort of form. The attending told me to just go do it and he left the room (the nurse was there of course). I spent what seemed like forever looking for it and eventually had to ask him to help me.

We eventually learned she was s/p vag histerectomy.
Click to expand...

lol. I feel your pain. I always check the chart first before I do anything now.
 
PreMedAdAG said:
80 people viewing this thread and only 10 responses (4 of which are mine!) - that means there are a lot of people who can't find it either :confused:
Click to expand...
Or that there are a lot of people who can find it fine and have no more advice to give. ;)
 
PreMedAdAG said:
well yes I am female - and just b/c I have one doesn't mean that I know where mine is - doing a self spec exam would be pretty amazing :laugh:


Anyway - I guess what they tell me is to
1. Put the spec as far back as it goes using posterior pressure (downward)
2. Then open it - popping the cervix into your view

this is what I do.... and yet no cervix - just vaginal wall :(

I like the idea of feeling for the cervix before - I'll give it one more try and if it doesn't happen for me - I'm going to try the second method - god this sucks :(
Click to expand...

Well, if you're just getting the vaginal wall, then perhaps you need a longer speculum. I also angle the speculum downward and if the cervix doesn't pop into place, then I try to visualize it through the clear speculum blades (won't work if you're using the metal ones) and reposition. If you're using the metal ones and still cant see, then you may just be too far posterior; try angling the speculum more anteriorly.
 
domer621 said:
Or that there are a lot of people who can find it fine and have no more advice to give. ;)
Click to expand...

You had to go off and be a jerk didn't you :laugh:

I'm going to get it this weeked - come hell or high water - the cervix is mine!
 
I like to stick the speculum in on an angle (45 deg) and slowly rotate as you go in. Once it's in, open the speculum and you should see the cervix. move it gently around if you can't find it (down first). when you're done doing your pap or whatever, move the opened speculum slightly back so you don't pinch the cervix. then close it and remove it on an angle- same way it came in.

hope that helps.
 
I thank god every day that my preceptor for fam med I doesn't do female genitalia.


That is all. I am so dreading Ob/Gyn rotation.
 
PreMedAdAG said:
I know this is lame - but I have my ob/gyn rotation practical coming up and well... I'm a little embarassed, but I have never been able to find the cervix while doing a speculum exam - I always ending up aborting and getting help from a resident. It really sucks b/c I've tried probably like 4-5 times in the past year or so - and every time I screw it up. Today was the last straw - I really hurt the patient - she went flying up and my speculum came out and I felt awful :(

Any advice on how to find the cervix? Everyone keeps saying - oh it just takes practice - well I only have 2 weeks to figure it out and about 3-4 more tries max before that test :(
Click to expand...

Are you getting enough light?
 
Are you getting enough cervix?
 
Dive down, like a speculum submarine!
Doing the bimanual first is great advice. Feel for where it's at before you go taking your spec after it.

"It's like a pink bagel..."
Also, see above icon.
 
maybe it's the unlikely possibility that you've been dealing with androgen insensitivity patients all this time...
 
I couldn't help but flinch when I read this...

snoopy brown said:
...Sounds like your problem is you're trying too hard. It's not like the vagina is that long, so you are probably slamming the speculum in deep and overshooting and then smacking the cervix when you attempt to open it...
Click to expand...


:eek:
 
PreMedAdAG said:
80 people viewing this thread and only 10 responses (4 of which are mine!) - that means there are a lot of people who can't find it either :confused:


Mother - I'm in cervix hell - I can't stop thinking about the frieking os - it's going to haunt me in my sleep
Click to expand...


Okay, I'm a lurker, but I just wanted to know why some people can do this well and some can't -though I can't say I've ever had an MD "overshoot" it is obvious that it's a skill. Not that you've got a lot of free time, but isn't there some way you could team up with some other friendly student/resident/md for a couple of pointers in person?

Just try to choose a pt who's had a baby already, don't go adventuring on some poor teen in for her first or second pap smear ever.

:luck:
 
Ask for permission from the patient and tell her what you are going to do
position her in the lithotomy or dorsal position.
swab the vulva from the anterior commissure to the posterior commisure. Pick up your cusco's (bivalve) speculum.

slightly incline your cuscos away from the vertical plane. insert your cuscos, in the middle of passing the spec rotate it into the horizontal plane, open it slightly to view the path ahead. If the cervix is posterior as it is supposed to be ( i am assuming she hasn't got a favourable cervix and is not in active labour) you will visualize the good old cervix - pinpoint external os if she is nuliiparous and of course slit if she is multiparous. Continue your progress into the vagina whiles gradually opening and visualising at the same time

Follow these instructions to the letter, you will be smiling... i promise.
 
Akuffo said:
Ask for permission from the patient and tell her what you are going to do
position her in the lithotomy or dorsal position.
swab the vulva from the anterior commissure to the posterior commisure. Pick up your cusco's (bivalve) speculum.

slightly incline your cuscos away from the vertical plane. insert your cuscos, in the middle of passing the spec rotate it into the horizontal plane, open it slightly to view the path ahead. If the cervix is posterior as it is supposed to be ( i am assuming she hasn't got a favourable cervix and is not in active labour) you will visualize the good old cervix - pinpoint external os if she is nuliiparous and of course slit if she is multiparous. Continue your progress into the vagina whiles gradually opening and visualising at the same time
Click to expand...

* What the he** is a "Cuscos"? In the US, we tend to use Graves or Pedersons only - I've never even seen any other models. Where are you from?

* I think that this is what the OP had been doing, but even that wasn't working. I think that part of it is being so afraid of hurting the patient that it makes it hard to take your time with it. Once you kind of get past the anxiety of causing any discomfort to the patient (face it - you probably will cause some discomfort, because it's an inherently uncomfortable exam), you'll probably be more confident with it.

[No - I'm not suggesting that injuring the patient is okay. Or that you shouldn't worry about causing pain or anything. But some mild discomfort is to be expected.]
 
smq123 said:
* What the he** is a "Cuscos"? In the US, we tend to use Graves or Pedersons only - I've never even seen any other models. Where are you from?
Click to expand...

where the he** are your stupid brains, that is why i placed the word bivalve in parenthesis. If you were smart enough you would have known what i was talking about. Whatever those models are, they definitely have two blades.
How do you plan on practicing if you cannot pay simple attention to detail. Develop the integrative aspects of your brain. BUMP.
 
OK, since nobody has told you this yet: if you have trouble finding the cx, ask her to slide her hips all the way to the edge of the exam table (my standard line is "I promise, I've never had anybody fall off"). Then ask her to roll her hips forward as this invariably lines things up a little straighter. Also, downward pressure with the speculum and most posterior cervices will just pop right into view. I've literally done a few thousand speculum exams and I still have trouble once in a blue moon. This trick almost always works for me. And if you still need help, asking her to "bear down" while placing the speculum usually brings the cervix into view.
And when that fails, find it with bimanual first so you know which direction to look.
Good luck!
 
PreMedAdAG said:
I know this is lame - but I have my ob/gyn rotation practical coming up and well... I'm a little embarassed, but I have never been able to find the cervix while doing a speculum exam - I always ending up aborting and getting help from a resident. It really sucks b/c I've tried probably like 4-5 times in the past year or so - and every time I screw it up. Today was the last straw - I really hurt the patient - she went flying up and my speculum came out and I felt awful :(

Any advice on how to find the cervix? Everyone keeps saying - oh it just takes practice - well I only have 2 weeks to figure it out and about 3-4 more tries max before that test :(
Click to expand...

Just shove it in and open wide. People who don't find it are too gentle with it. If the patient wants a more gentle exam, they can go to their OBGYN.
 
Ah, well, I guess I should try to be meaner. Might be a tough switch after 8 years of a gentle touch....but yes, "vaginal discharge for 6 months" in the ED at 4am is one of my great pet peeves. UGH. Fair enough.

RockfordWF said:
It prevents patients from coming to the ER for primary care.
Click to expand...
 
RockfordWF said:
It prevents patients from coming to the ER for primary care.
Click to expand...

You have a point. I have had a couple of ER patients tell me they wish I was their ob/gyn - not much discouragement for showing up with their chronic issues.... :rolleyes:

primadonna gives good positioning advice, one of those things people forget to mention. But this one:
And if you still need help, asking her to "bear down" while placing the speculum usually brings the cervix into view.
Click to expand...
is ill advised! :laugh:
 
This response is probably too late and someone may have said this already but I was too lazy to read all of the posts . . . but the best advice I received was to follow the discharge. It actually works. If you see discharge, basically just follow it up (opposite of gravitational pull) or laterally to the side it's coming from. Hope that helps :)
 
On women with an anterior cervix, I would occasionally place the speculum in too far and have the cervix sitting above the speculum and out of view. I found that keeping the blades slightly open and pulling back slowly would allow the cervix to fall into view.

As an aside, I once saw a patient who had a cervix sitting up above her pubis where her G spot would normally be. Obviously, I couldn't see it on a speculum exam and neither could the attending at first. After locating it with palpation, my attending had to raise the electric table and get down on the floor in order to get the proper viewing angle.

BEST... EXAM... EVER!!!
 
Just a point to remember... If the ultimate purpose of finding the cervix is to perform a pap smear, hold the lube. If you perform the bimanual with lube before obtaining your cervical specimen, there's a good chance the pathologist won't be able to read the smear (and he'll bitch about the lube).
 
K3l3v said:
Just a point to remember... If the ultimate purpose of finding the cervix is to perform a pap smear, hold the lube. If you perform the bimanual with lube before obtaining your cervical specimen, there's a good chance the pathologist won't be able to read the smear (and he'll bitch about the lube).
Click to expand...

Good thing we don't do paps in the ER...

Pass the KY!!!
 
Since you are a female, you really should know how to find your own cervix. They sell clear disposable speculae and you can use a mirror and see your own; if you don't feel like going to the trouble just stick a finger deep into your vagina while bearing down and you should feel it- it's like the tip of your nose.
 
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