Obtaining a Pap Smear
Position the Patient
Field Expedient Exam Table
A folded blanket can elevate the head and a second blanket can provide for draping.
Stability of the litter is important. An assistant may be positioned at the opposite end of the litter for this purpose, or sandbags may be used.
A packing crate can serve as a stool, but kneeling on the ground usually positions the examiners eyes at perineum level.
Lighting needs to be the best allowed by the the tactical circumstances. Good lighting can be obtained from a generator-supplied surgical lamp, flashlight, or natural sunlight with a mirror to direct the light into the vagina. At times, the tactical situation may only permit the light from a single red-filtered flashlight. Even with this restriction, a reasonably satisfactory examination may be possible.
Privacy should be provided by a tent, rigging of ponchos, or appropriate blankets. When these methods are not available, employing psychological or "virtual privacy" methods should be attempted.
Pad the Stirrups
Inspect the Vulva
Gently spread the labia apart and inspect the vulva, looking for lesions, masses, drainage, or discolorations of the skin. Explain what you are doing to the patient to keep her relaxed.
Warm the Speculum
Insert the Speculum
Field Expedient Vaginal Speculum
Optimally, these retractor and speculum substitutes should be sterilized before use. Ordinarily, this would require an autoclave, packaging, autoclave heat sensitive tape and control tests. In a military environment, these may not be available but placing the spoons in boiling water for 10 to 15 minutes is a reasonable substitute. If the tactical situation does not allow for any sterilization, clean instruments are much better than dirty instruments.
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.
Rotate the Spatula Against the Cervix
Sample the SQJ
Make a Thin Smear
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.
Insert and Rotate the Brush 180 Degrees
Dysplasia
This video shows the development, evaluation, and management of dysplasia on the cervix. Using photographs, graphics and video of live patients, this can be useful to anyone seeking insight into the clinical condition of dysplasia of the cervix.
www.brooksidepress.orgAllow 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. When operational circumstances disallow prompt sending of the slides, they can be held for weeks to months without significant loss of readability.
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.
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