Pap smears can be easily and
painlessly obtained, in most cases, following this procedure:
Position the patient with her buttocks just
at the edge or just over the edge of the exam table. If she is not down far
enough, inserting the speculum can be more difficult for you and
uncomfortable for her.
Appropriate draping should be used
to help make the patient more comfortable but not to the point that it
obstructs your view. Good lighting is important and is often accomplished
with a goose-neck lamp.
Pad the Stirrups
Pad the stirrups so that they don't dig into the patient's foot.
Oven mitts or socks can be used to
cushion the stirrup. Allowing the patient to keep her socks on will provide
additional padding and help keep the patient's feet warm during the exam.
Inspect the Vulva
Gently spread the labia apart and inspect the vulva, looking for:
Discolorations of the skin
Signs of trauma
Pubic hair distribution
(triangular = normal)
Insect movement (pubic lice)
within the pubic hair
Explain what you are doing to the
patient to keep her relaxed.
You will need to move the labia and
skin folds. Otherwise, you won't be able to see everything.
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Warm the Speculum
Warm the vaginal speculum.
Running water works well for this
as it also lubricates the speculum. Some health care providers use a heated
drawer or heating pad to keep the speculums warm. Do not overheat as a
speculum that is too hot is just as uncomfortable as one that is too cold.
Never use K-Y Jelly(r), Surgilube(r),
petroleum jelly or other lubricant to moisten the speculum as it may render
your Pap smears unreadable under the microscope.
Insert the Speculum
After warming the speculum,
separate the labia and keep them apart.
Insert the speculum into the
vagina, letting the speculum follow the path of least resistance. Some
vaginas go straight back, parallel to the floor. Other vaginas tilt slightly
downward toward the floor as the speculum advances. Others angle upward,
away from the floor. Keep the speculum blades closed until the speculum is
Open the speculum and usually the
cervix is immediately visible. If not, the cervix is usually just below the
lower blade or just above the upper blade. Rocking the speculum downward and
upward usually causes the hidden cervix to drop into view.
Lock the blades in the open
position, wide enough apart to allow complete visualization of the cervix
but not to far open as to be uncomfortable for the patient.
With practice, insertion of the
speculum should be painless.
Start with the Spatula
The Ayer spatula is specially designed for obtaining Pap smears. The concave
end (curving inward) fits against the cervix, while the convex end (curving
outward) is used for scraping vaginal lesions or sampling the "vaginal
pool," the collection of vaginal secretions just below the cervix.
The spatula is made of either wood
or plastic. Both give very satisfactory results.
The concave end of the spatula is
placed against the cervix and rotated in circular fashion so that the entire
area around the cervical opening (os) is sampled.
Usually this can be done without
causing any discomfort, although some women are sensitive to the sensation
and may experience minor cramping. Sometimes, obtaining this sample causes
some bleeding. In this case, reassure the patient that:
although she may have some minor
bleeding or spotting for a few hours, it is not dangerous,
it will stop spontaneously and
it is caused by the Pap smear.
Sample the SQJ
In obtaining the Pap smear, it is important to sample the "Squamo-columnar
Junction." This is the circular area right at the opening of the cervix
where the pink, smooth skin of the cervix meets the fiery-red, fragile,
mucous-producing lining of the cervical canal.
If there is a problem with cancer
or precancerous changes, it is this area that is most likely to be effected.
This area of unstable skin is also known as the transition zone.
The transition zone location varies
with age and estrogen status.
Make a Thin Smear
Spread the sample taken from the cervix on a glass slide. Try to make the
smear as thin as possible since this makes it easier for the pathologist to
read. Make sure the slide is labeled (using pencil on the frosted end).
In your zeal to make a thin slide,
don't spend too much time or else the slide will dry, making it harder to
Immediately spray the glass slide with cytological fixative.
If the slide is not immediately
sprayed (within about 10-15 seconds), the smear will dry out, making
interpretation more difficult or impossible.
If cytological spray is
unavailable, any material that has a significant amount of acetone in it can
be a reasonably good substitute. Hair spray works well.
Next Use a Brush
Next, use a "Cytobrush" to sample the endocervical canal, the inside of the
opening leading into the uterine cavity.
These soft brushes are designed to
be inserted into the canal without causing damage.
Push the cytobrush into the canal,
no deeper than the length of the brush (1.5 cm - 2.0 cm). Rotate the brush
180 degrees (half a circle) and pull the cytobrush straight out. Don't keep
spinning the brush round and round or you will cause bleeding. Even the 180
degree rotation may cause a little bleeding but usually it doesn't.
Smear the sample on another slide,
spreading the material evenly over the slide. Spray with fixative
Allow the slides to dry completely
before placing them in the Pap smear container. Once dry and packaged, it is
best to send them out promptly for interpretation.
Make sure the slides are properly
labeled and that important clinical information is included with the
requisition. Telling the cytologist that the patient has had a hysterectomy
will save considerable amounts of time in evaluating the smear.
For women who have had a
hysterectomy, Pap smears are obtained by using the convex end of the Ayer
spatula, scraping it horizontally across the top of the vagina. Then the
cytobrush is used to reach into the the right and left top corners of the
This outline of Pap smears
describes a "two-slide" technique. Often, only a single glass slide is used
(a "one-slide" technique). Using only a single slide, the Ayer spatula is
smeared over one end of the slide and the cytobrush is smeared over the
other end. It is fine if there is overlap between the two areas and it
doesn't matter which smear is placed on which end of the slide.
Use a broom for liquid-based
Liquid-based media offer some advantages over traditional glass slide media
for Pap smears. They tend to be somewhat easier to read, somewhat more
forgiving of contamination with red cells and white cells, and accuracy that
is at least as good and probably better than traditional glass slide
preparations. An additional advantage is the ease with which reflex HPV
testing can be done in the event of an abnormal result.
The primary drawback to
liquid-based media is the increased cost. Some gynecologists feel that it is
superior technology and the added cost leads to better results. Others feel
that the glass slide technique is good enough and added cost of liquid
medium does not provide enough additional benefits to be justified.
Either approach works well.
After visualizing the cervix,
insert the broom's long, central fibers into the endocervical canal. The
rotate the broom in a complete circle, five times. Don't rotate backwards in
the opposite direction as you may lose cells.
Follow the directions from the
manufacturer of the liquid media collecting jar. For example, some ask that
you immediately squish the broom against the bottom of the jar fifteen
times, followed by several spins. Then remove the broom and seal the
Others provide for a snap-off broom
and recommend that you send the sealed container with the broom head still
The broom can also be used for
conventional glass-slide Pap smears.