Obs and Gynae - Removal of products

Indications

Heavy vaginal bleeding in first trimester pregnancy

Contraindications (absolute in bold)

Minors (age <18 years)

Alternatives

No alternatives

Informed consent

Medical emergency

Consent is not required if the patient lacks capacity or is unable to consent

Brief verbal discussion is recommended if the situation allows

or

Verbal consent

Less complex non-emergency procedure with low risk of complications

Potential complications

Pain

Failure (to identify cervical os, remove products of conception or control bleeding)

Procedural hygiene

Standard precautions

PPE: apron, surgical mask, protective eyewear, non-sterile gloves

Area

Private bed space

Staff

Procedural clinician

Chaperone

Equipment

Cusco’s speculum (small, medium, large sizes according to patient habitus)

Good light source (preferably attached to speculum)

Lubricating jelly

Ring forceps or Kelly clamp

Gauze

Towel or sheet

Absorbent pads

Positioning

Empty bladder prior to procedure

Bed facing away from the door

Supine with head elevated on a pillow

Removal of all clothing from the waist down

Place absorbent pads underneath patient

Towel or sheet to cover patient

Draw her heels up towards her bottom and put her ankles together

Relaxing the legs outwards (hips and knees flexed, hips abducted, knees dropped to sides)

Medication

None

Sequence (removal of products)

Insert the speculum (see vaginal speculum insertion guideline)

Empty vaginal vault by removing clots with forceps

Use gauze on sponge forceps to wipe away clots from the fornices and to clean the cervix

Remove any products seen within the cervical os with the forceps

Once the products have been removed, observe cervix briefly for further bleeding

Sequence (unable to identify cervix)

Withdraw the speculum and reinsert (rather than manipulating it)

Ask the patient to form her hands into fists and place them underneath her buttocks

Palpate the cervix with a gloved hand to identify position prior to reinsertion

Ask the patient to push or bear down (exert downwards pressure as in labour)

If vaginal wall laxity impairing view place a condom over the speculum, cutting the end off

Post-procedure care

Further care:

Send products of conception for histopathology

Document the procedure and findings

Offer social work support

Monitoring for further bleeding:

Continuous cardiorespiratory monitoring

Pad checks every 30-60 minutes

Refer for urgent dilatation and curettage if ongoing heavy bleeding

Tips

Hypotension and bradycardia indicate cervical shock

Take care to avoid clamping the cervix while using forceps

Discussion

The pelvic exam consists of a speculum examination during which the cervix and vaginal walls are visualised, with a bimanual examination for cervical motion tenderness, adnexal tenderness and pelvic mass.

While it is important to perform a speculum exam when it has diagnostic or therapeutic benefit, we should avoid unpleasant tests if they do not influence further investigation and treatment. The available evidence indicates that abnormal findings on pelvic exam are difficult to discern and subjective and often do not influence further management. We do not recommend performing a routine speculum exam for every female pelvic issue.

In early pregnancy, the pelvic exam cannot be used to rule out ectopic pregnancy for a patient presenting with vaginal bleeding or abdominal pain. For stable patients with minimal bleeding who have an ultrasound performed, the pelvic exam is unlikely to change disposition.

In non-pregnant patients, the pelvic exam is not generally required to assess for ovarian torsion or sexually transmitted infection. Neither condition can be excluded based on examination and suspicion of either will require further testing or empirical treatment.

Patient-collected vaginal swabs or urine specimens are accurate for sexually transmitted infection testing with amplification assays (NAAT) and have greater sensitivity than cultures.

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O’Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

Carusi DA. The gynecologic history and pelvic examination. In: UpToDate. Waltham (MA): UpToDate. 2019 December 16. Available from: https://www.uptodate.com/contents/the-gynecologic-history-and-pelvic-examination

Corton MM. Williams gynecology. 2nd ed. New York: Mc-Graw Hill Medical; 2012.

Breeze C. Early pregnancy bleeding. Aust Fam Physician. 2016;45(5):283-286.

McLean ME, Santiago-Rosado L. Plight of the pelvic exam. Emerg Med J. 2019;36(6):383-384. doi:10.1136/emermed-2019-208474

Linden JA, Grimmnitz B, Hagopian L, et al. Is the pelvic examination still crucial in patients presenting to the emergency department with vaginal bleeding or abdominal pain when an intrauterine pregnancy is identified on ultrasonography? A randomized controlled trial. Ann Emerg Med. 2017;70(6):825-834. doi:10.1016/j.annemergmed.2017.07.487

Christophe K. Speculations on the speculum: is a pelvic exam ever needed in the ED? 2019 Apr. Available at http://www.emdocs.net/speculations-on-the-speculum-is-a-pelvic-exam-ever-needed-in-the-ed/

© Agency for Clinical Innovation 2021

Feedback