Pre‐procedure

ActionRationale

1. 1.Show
   Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed. Discuss the benefits and limitations of screening and the significance of smear results. Explain the purpose of the procedure and what will occur at each step.
   To ensure that the patient feels at ease, understands the procedure and gives her valid consent. To ensure that she understands that the procedure involves removing underwear and that the speculum will be inserted into her vagina (NHSCSP [161], C; NMC [165], C). To allow the patient time to ask any questions. E
2. 2.Show
   Document the woman's clinical and screening history, specifically:

   • date of last menstruation
   • any abnormal bleeding
   • any unusual vaginal discharge
   • contraception
   • date of last cervical smear
   • any abnormal smear results
   • any treatment to the cervix.
   To ensure a relevant history is recorded (NHSCSP [161], C).
3. 3.Show
   Place all the equipment required for the procedure on the trolley.
   To facilitate the efficient taking of the sample. E
4. 4.Show
   Close the room door and/or curtains and ask the woman to remove her underwear.
   To provide privacy and comfort for the woman. E

Procedure

1. 5.Show
   Turn the light source on and position it at the end of the examination table.
   To provide illumination of the cervix and increase the accuracy of the smear taking (NHSCSP [161], C; RCN [201], C).
2. 6.Show
   Assist the patient into a supine position on the couch, with knees drawn up and legs parted. Keep her as covered as possible.
   To facilitate easy access of the vaginal speculum and the taking of the cervical smear (NHSCSP [161]; WHO [259], C).
3. 7.Show
   Wash hands with antibacterial detergent and running hand‐hot water. Ensure hands are dried with disposable paper hand towels.
   To reduce the risk of contamination and cross‐infection (NHS England and NHSI [155], C, E; RCN [200], C).
4. 8.Show
   Apply gloves and apron.
   To reduce the risk of contamination and cross‐infection (NHS England and NHSI [155], C; RCN [200], C).
5. 9.Show
   Select the appropriate size of speculum, from small, medium and large, or a long‐bladed narrow speculum if the vagina is long or the cervix is lying posterior. The sterilized speculum can be warmed or cooled using clean tap water.
   To promote patient comfort and reduce anxiety (NHSCSP [161], C). If removed from a sterilizer, the speculum may need to be cooled down; if cold, it may need to be warmed up to reduce patient discomfort. It must be explained to the patient that the speculum has been sterilized but that the water will not contaminate it. E
6. 10.Show
   Apply lubricant to the speculum. Part the labia and, holding the speculum blades together sideways, slip the speculum into the vagina.
   To insert the speculum and reduce patient discomfort (Fraise and Bradley [62], E; RCN [201], C; WHO [259], C).
7. 11.Show
   When the speculum is half way into the vagina, turn it so that the handle is facing down.
   To promote patient comfort and reduce contamination of the cervix with lubricants (NHSCSP [161], C).
8. 12.Show
   Gently open the blades of the speculum and look for the cervix. It may be necessary to move the speculum up or down until the entire cervix is visible.
   To reduce patient discomfort and visualize the cervix (WHO [259], C).
9. 13.Show
   Using the cervix brush, insert the central bristles into the endocervical canal so that the shorter, outer bristles fully contact the ectocervix.
   To ensure accuracy of the site sampled (NHSCSP [161], C; Singh et al. [230], R).
10. 14.Show
    Using pencil pressure, rotate the brush in a clockwise direction five times. Note: the plastic fronds of the brush are bevelled for rotation in a clockwise direction only.
    To ensure good contact with the ectocervix and gather a high cellular yield (NHSCSP [161], C).

    Firm pressure is required to ensure the cells cling to the brush (NHSCSP [161], C).
    Either:

    If using ThinPrep, using a swirling motion, rinse the brush into the fixative vial; then push the brush into the base of the vial at least 10 times, forcing the bristles apart.
    To ensure a usable amount of cellular material is collected (NHSCSP [161], C).
    Inspect the brush for any residual material and remove any remaining material by passing the brush over the edge of the fixative vial.
    To ensure the cellular material reaches the preservative solution (NHSCSP [161], C).
    Ensure that the material reaches the liquid. Then tighten the cap so that the material passes the torque line on the vial and give the vial a shake.
    To ensure that the cells do not cling to the device (NHSCSP [161], C).
    Or:

    If using SurePath, remove the head of the brush from the stem and place into the vial of fixative. Then screw the lid on tightly and shake the vial. Note: it is essential that the sample is placed into the vial immediately in order to achieve fixation.
    To ensure accurate preservation of cervical material (NHSCSP [161], C).
11. 15.Show
    Gently pull the speculum out until the blades are clear of the cervix, then close the blades and remove the speculum, placing it in a clinical waste bin if disposable or into a CSS container if reusable.
    To prevent pinching the cervix or vaginal walls and to ensure safe disposal of contaminated equipment (NHSCSP [161], C).
12. 16.Show
    Cover the patient and offer tissue paper to wipe away any excess vaginal discharge.
    To ensure dignity and privacy while promoting hygiene and comfort. E

Post‐procedure

1. 17.Show
   Remove gloves and dispose of waste in clinical waste receiver.
   To safely dispose of clinical waste (DH [48], C).
2. 18.Show
   Assist the patient off the examination table and allow her to dress.
   To ensure safety and promote dignity and privacy. E
3. 19.Show
   Using a black ballpoint pen, label the vial with the patient's name, clinic number and date of birth.
   To ensure the patient's details are documented correctly. E
4. 20.Show
   Place the vial into a plastic specimen bag with the correctly labelled specimen form and send it to the laboratory.
   To ensure safe handling and transportation of a biohazard (DH [48], C; HSE [94], C; WHO [260], C).
5. 21.Show
   Document the procedure in the patient's records.
   To ensure timely and accurate record keeping (NMC [165], C).