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Pre‐procedural considerations

Equipment

There are several devices that are used in sampling the uterine cervix (Figure 20.4).

Vaginal speculum: this is an instrument used during gynaecological examination to facilitate the visualization of the vagina and cervix. The speculum is introduced via the vagina, and its cylinder with a rounded end shape allows easy passage. Once in situ, the speculum is opened, holding the vagina open and allowing the healthcare professional to have access to the cervix and perform the cervical smear. Most speculums are now made of plastic and are single use, replacing those formerly made of metal and requiring sterilization after use. There are two categories of speculum: virgin and non‐virgin. The latter is available in four sizes: small, medium, large and long. Special attention should be paid when selecting a speculum for use in women previously treated with pelvic radiotherapy or who are postmenopausal (Singh et al. [150]).
Cervical broom: these are plastic broom‐shaped tools with a pyramidal arrangement of flexible flat ‘teeth’. The longer ‘central’ tuft fits into the cervical os and must be rotated clockwise through a full circle five times. When used to take a conventional smear, this brush is an adequate and effective sampling device (NHSCSP [105]). The brush should be inserted into the cervical os with the lower bristles remaining visible, and rotated between a half and a whole turn to reduce trauma (Insinga et al. [73]).

Figure 20.4 Vaginal specula and cervical broom.

LBC is the current standard method of screening in the NHS cervical screening programme (NHSCSP [104]). The National Institute for Health and Clinical Excellence ([107]) recommended that LBC be used as the primary means of processing samples in the cervical screening programme in England and Wales. It achieves ‘cleaner’ preparations, which are generally easier to read. Its advantage is a reduction in inadequate samples and there may be gains in reducing borderline results and increasing sensitivity (NHSCSP [102]).

Whichever device is used, once the sample is taken it is vital that the cells collected are transferred onto a glass slide and preserved immediately or placed into the correct vial containing liquid preservative and fixative. Slides must not be placed in a refrigerator (Higgins [65], NHSCSP [105]).

The environment is also important, with the following equipment required:

height‐adjustable couch
angle‐positioned light source which is ideally free standing for manoeuvrability (RCN [129]).

Specific patient preparation

The examination must be undertaken in a private room which cannot be entered during the examination. Adequate private changing facilities that are warm and comfortable should also be available. Where possible, face the examination couch away from the door to enhance privacy and dignity for the patient (RCN [129]).

The patient should be given the opportunity to empty her bladder prior to the examination. Ask the patient to undress and explain the position required on the couch. The most common position is prone or alternatively left lateral as it is comfortable and aids in the visualization of the cervix. Once the patient is ready, she should inform the practitioner. A modesty towel or covering should be supplied to enable the patient to partially cover herself (RCN [129]).

Education

Explain the procedure to the patient prior to commencing. It is good practice to offer the patient a demonstration of the speculum and to explain what part will be inserted into the vagina. Any possible side‐effects such as spotting post examination should also be discussed prior to commencing the examination (RCN [129]).

Procedure guideline 20.1

Cervical uterine smear using liquid‐based cytology

Table 20.3 Prevention and resolution (Procedure guideline 20.1)

Problem	Cause	Prevention	Action
Inadequate sample.	Cervix has not been scraped firmly enough to obtain adequate epithelial cells (WHO [170]).	Ensure adequate pressure to obtain sample.	Repeat cervical smear.
	Brush not rinsed immediately, allowing the sample to dry and causing the cells to become misshapen (NHSCSP [104]).	Ensure brush is rinsed immediately after scraping the cervix.	Repeat cervical smear.
	Sample contaminated with lubricants, spermicide or blood (Higgins [65]).	Ensure sample is not contaminated by educating the patient not to use lubricants or spermicide 24 hours prior to test.	Repeat cervical smear.
Unable to visualize the cervix.	Position of the patient or anatomical position of the cervix.	Adequate positioning of the patient.	Reposition the patient from the prone to the lateral position. Place a pillow under the buttocks or turn the speculum. Consider assistance from another sample taker or refer to colposcopy clinic if unable to visualize.