SIMS SPECULUM
Designed by Marion Sims
It is a nonself-retaining vaginal speculum used in vaginal examination and operations to retract posterior vaginal wall (sometimes lateral or anterior wall) and view vagina and cervix.
▮ Types
- Metallic speculum: It needs external light source
- Plastic speculum: It may be equipped with a light source.
▮ Sizes
- Small for nulliparous, virgins and adolescents
- Large for parous womanUsed according to vaginal length and cavity.
▮ Parts
Blades
At an angle to shaft and point towards same side. Different sizes are used for different sizes of vagina. Each valve (blade) is rounded at the end so the instrument is atraumatic (Fig. 1.1).
Lubricant: Water-based jelly is preferred.
Groove
For drainage of secretions by slightly tilting the instrument and collection of specimen from vagina.2
▮ Technique
Position
Lithotomy by edge of table /Sims position.
Method
Wear gloves. Appropriate size of the speculum is taken. Lubricate speculum (except in Pap smear). Labia minora are gently separated and urethra is identified prior to insertion. Speculum is inserted well below the meatus because of urethral sensitivity. To improve comfort with speculum examination the woman is asked to relax posterior wall muscles. Sims speculum should not be inserted with blades in line with cleft of the vulva and then rotated in vagina because it is designed for “direct” application. In any case vagina is wider from side to side than from front to back, so Sims speculum is introduced directly posteriorly to its full length for inspection of cervix.
▮ Uses
To retract vaginal wall and speculate vagina and cervix.
Uses in gynecology
- P/S (per speculum examination) in gynecology
- Inspect cervix for growth, erosion, discharge
- Inspect vagina for vaginitis, cystocele, rectocele, enterocele, VVF.
-
- Cervical biopsy, conization of cervix
- Cervical tear stitching
- Polypectomy
- Dilatation of cervix.
- Perform procedures on the uterus
- Dilatation and curettage (D and C)
- Endometrial biopsy (EB)
- Intrauterine contraceptive device (IUCD) insertion.
- Major gynecological operations
- Vaginal hysterectomy
- Fothergill's repair
- Anterior colporrhaphy and posterior colpoperineorrhaphy
- VVF (vesicovaginal fistula) repair.
- Diagnostic procedures
- Hysteroscopy
- Hysterosalpingography, sonosalpingography
- Tubal insufflation
- Collection from vagina
- Cytology, staining, culture
- Three swab test.
Uses in obstetrics
- P/S (per speculum examination) in obstetrics
- Discharge
- Leaking
- Bleeding in APH (antepartum hemorrhage), abortions,PPH (postpartum hemorrhage) to diagnose traumatic PPH and repair tears.
- Performing procedures
- Medical termination of pregnancy (MTP)
- Dilatation and evacuation (D and E).
- McDonald stitch, Shirodkar stitch.
▮ Advantage
Good view.
▮ Disadvantages
- Assistant is required to hold the speculum
CUSCO'S SPECULUM
Devised by Cusco Edward Gabrial.
It is a self-retaining vaginal speculum.
▮ Types
- Metallic
- Plastic.
▮ Sizes
- Small
- Large.
▮ Parts
Blades
- Two blades are shaped like the beak of a duck
- Blades can be opened up and fixed at the required angle by an adjustable arrangement (Fig. 1.2).
Handle
- It is at right angle to the blades. When handle is closed blades will open
- Screw mechanism on handle makes it self-retaining.
▮ Technique
Position
Dorsal / Lithotomy.
Method
It is same as in Sims speculum. Wear gloves. Appropriate size of speculum is taken. Lubricate speculum (except in Pap smear). Prior to insertion, labia minora are gently separated and urethra is identified and it is inserted with closed blades in vagina. When speculum is inserted completely it is angled approximately 30° downward to reach the cervix. Uterus lies in anteverted position commonly and ectocervix lies apposed against posterior vaginal wall. As speculum is opened ectocervix is visualized. The fixation screw is tightened depending on the amount of exposure needed, then it is unscrewed and blades closed when speculum is taken out (if the cervix is pointing forwards, the uterus is retroverted and if it pointed backwards it is anteverted).
▮ Uses in gynecology and obstetrics
- P/S examination: An important examination in obstetrics and gynecology
- To visualize the cervix for erosion, discharge and growth
- To visualize vaginal fornices.
- Perform minor operations on the cervix
- Biopsy
- Cautery
- Polypectomy.
- Collect vaginal pool material and scraping for cytological study
- IUCD follow-up and removal
- Colposcopy.
▮ Advantages
- Ideal for visualization and operations on cervix
- Self-retaining, so no assistant is required
- It can be used in patients who cannot be put in lithotomy position.
▮ Disadvantage
AUVARD SPECULUM
It is self-retaining vaginal speculum.
It is a heavy instrument with a heavy metal ball.
▮ Parts
- Blade
- Groove: A channel is provided on the handle to collect the blood and drain (Fig. 1.3).
- Heavy metal ball: Which makes it self-retaining.
▮ Technique
- Position: Lithotomy
- Method: Same as in Sims speculum.
▮ Uses
It is used to retract posterior vaginal wall in
- Operations on vagina, cervix and uterus, e.g. vaginal hysterectomy.
▮ Advantages
Advantages of Sims and Cusco's speculum combined.
- Good view of vagina
- Self-retaining.
▮ Disadvantages
- Prolonged use causes postoperative perineal pain.
- Used when operation is done under anesthesia.
SIMS ANTERIOR VAGINAL WALL RETRACTOR
This instrument is used along with Sims speculum to retract the anterior vaginal wall.
▮ Parts
- A long instrument with shaft and oval fenestrated ends.
- Two loops are set at an angle of 15° with the shaft which face in opposite directions (Fig. 1.4).
- Transverse serrations on loop prevent slipping of instrument and fits into rugosities of vagina.It is differentiated from uterine curette by following points:
- ▪ It is larger in size.
- ▪ Oval loops have transverse serrations.
▮ Technique
- Used along with Sims speculum.
- Instrument is used to retract anterior vaginal wall with the angle at oval end facing upwards.
- Can be used to retract sagging vaginal wall for good exposure of the cervix.
▮ Uses
- To visualize the cervix in obstetrical and gynecological operations.
- In postpartum hemorrhage just after delivery as blunt curette to remove products of conception and membranes.
VULSELLUM
Designed by Teals
It is a long instrument which can be applied to the anterior lip or the posterior lip of cervix. Usually it is 20 cm in length.
▮ Parts
Teeth
Blades
Blades have a curve so that field of vision is not blocked during the procedure. Distance in between blades prevent crushing of tissues held in between them. The instrument gives a firm grip on the cervix and pulling cervix straightens uterocervical canal so that chances of perforation are reduced.
▮ Technique
Vaginal exposure is done by retracting vaginal walls using Sims speculum and Sims anterior vaginal wall retractor.
Anterior lip of the cervix is grasped with the teeth of vulsellum and the instrument is locked. The curve should face upwards.
▮ Uses
Uses in gynecology
- To catch the anterior lip of cervix for surgical procedures
- Operations of cervix, e.g. biopsy and cautery
- Cryosurgery
- D and C (dilatation and curettage)
- IUCD insertion
- Drainage of hematometra and pyometra
- Fothergill's operation to hold the new cervical stump after amputation
- Vaginal hysterectomy
- To catch the posterior lip of cervix
- Aspirating pus in pelvic abscess, i.e. posterior colpotomy
- Aspirating blood in ectopic pregnancy, i.e. culdocentesis
- Fothergill's operation
- Vaginal hysterectomy
- If growth on the anterior lip of the cervix then catch the posterior lip of cervix.
- To hold uterine fundus during abdominal hysterectomy.
- To give gentle traction on fetal head after craniotomy or the collapsed head in IUD baby.
- To remove polyps by twisting.
Use in obstetrics
- To catch the cervix in pregnant patient, e.g. MTP, S and E, D and E.
▮ Disadvantages
Cervical trauma and bleeding. The cervix is soft in pregnancy so sponge holding forceps is used to hold cervix instead of vulsellum.
TENACULUM
It is used in the nulliparous cervix in place of vulsellum.
▮ Parts
It can be differentiated from vulsellum by following points:
- Straight instrument and not curved as vulsellum
- Grip is more secure than vulsellum because its bite is deeper.Two blades have gap in between to prevent crushing of structure.
▮ Technique
- Retract anterior and posterior vaginal walls for exposure of the cervix
- Anterior lip of the cervix is held with a tenaculum (Fig. 1.6).
▮ Uses
- To hold the anterior lip of the cervix / posterior lip of cervix in place of vulsellum
- In nulliparous, to hold the cervix in sonosalpingography (SSG), hysterosalpingography (HSG) and chromopertubation during laparoscopy.
- To hold cervix in cryosurgery or cautery of cervix.
▮ Advantage
Better for nulliparous cervix because it occupies less space.
▮ Disadvantages
- Cervical tears are greater than in vulsellum as the bite is deeper
UTERINE SOUND
Designed by Simpson.
▮ Parts
- It is 30cm long angulated instrument with handle at one end and a rounded blunt tip at the other end.
- It has graduations in inches or centimeters (Fig. 1.7).
- The angle accommodates for flexion of uterus and prevents perforation as it fits into the anteverted or retroverted uterus.
- Angulated at 7cm from the tip (which is the normal uterocervical length).
- Blunt tip does not cause injury when introduced.
▮ Technique
Uterine sounding
- Bimanual examination.
- Retract anterior and posterior vaginal walls for exposure of the cervix.
- Anterior lip of the cervix is grasped with vulsellum.
- Uterine sound is held as a “Pencil” with thumb and two fingers.
- Sound is guided slowly through cervical os into the uterine cavity and to fundus.
- The distance from the fundus to external os is measured by score marks (graduations) along the length of sound.
▮ Uses
- It confirms the direction of uterus, i.e. anteverted or retroverted.
- It is used to diagnose cervical stenosis and congenital malformations, e.g. bicornuate uterus.
- Used as first dilator prior to operations on uterus and cervix, i.e. D and C, S and E.
- It is used to sound a polyp, IUCD, uterine septum called sounding of the uterus.
- It helps to break the adhesions in Asherman's syndrome (therapeutic use).
- It differentiates between chronic inversion and fibroid polyp.
- In a misplaced IUCD, uterine sound can be inserted and X-ray of pelvis is taken in AP and lateral view. Position of IUCD in relation to sound shows that IUCD has perforated uterus.
▮ Disadvantage
Perforation: If direction or size of the uterus is misjudged, perforation is suspected when instrument travels deeper than the measured uterine length.
▮ Contraindications
- Pregnancy
- Infection.
BLADDER SOUND
It is a long instrument similar to uterine sound.
▮ Parts
It is differentiated from uterine sound by following points:
- No graduations are present (Fig. 1.8)
- The tip is more blunt and so it is atraumatic.
- The angle is at a lesser distance from the blunt tip.
It is an obsolete instrument used for exploring the interior of a bladder to detect stones by sounding because now noninvasive procedures are available like radiography and ultrasonography.
▮ Uses
- To define the limits of bladder in vaginal surgeries
- Used as a urethral dilator in urethral stenosis
- To diagnose bladder injury in gynecological operations.
PINARD'S STETHOSCOPE
(Fetoscope)
- Invented by Adolphe Pinard.
- Instrument to hear fetal heart sound.
▮ Parts
- Narrow end has a wide rim which is used as an earpiece.
- Broad end is placed over the patient's abdomen.
▮ Technique
- The instrument is kept at right angle on patient's abdomen.
- The instrument should not be touched with hand while listening to FHS.It is rarely used now since use of stethoscope and digital fetal Doppler.
STETHOSCOPE And DIGITAL FETAL DOPPLER
These instruments are to hear FHS with high acoustic sensitivity.
Stethoscope has ear tips with ear tubes set to accommodate the anatomy of the ear (Fig. 1.10).
Digital fetal Doppler has display to give read out of fetal heart rate (FHR) in beats per minute (bpm) (Fig. 1.11).16
Auscultation
The fetal heart is auscultated for one minute (normal 110–160 bpm)NICE guidelines. During labor fetal heart rate should be auscultated during and immediately after uterine contraction to detect late deceleration.
- ▪ Low-risk pregnancyAuscultation in—1st stage labor: 30 minutes interval2nd stage labor: 15 minutes interval.
- ▪ High-risk pregnancyAuscultation in—1st stage labor: 15 minutes interval2nd stage labor: 5 minutes interval.