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Pap smears can be easily and painlessly obtained, in most cases,
following this procedure:
Position
the Patient
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:
- Skin lesions
- Masses
- Drainage
- 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.
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 completely inserted.
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 promptly
- 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.
Transition zone in reproductive years
Transition zone during pregnancy
Transition zone in menopause
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 read.
Spray Immediately
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 immediately.
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 vagina.
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 media
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 container securely.
Others provide for a snap-off broom and recommend that you
send the sealed container with the broom head still inside.
The broom can also be used for conventional glass-slide Pap
smears.
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