Before starting this procedure, be sure to set up your tray with all the necessary equipment.

Maintain the patient's privacy and ensure that she feels comfortable and relaxed.

Maintain a professional conduct at all times and engage sensitivity.

Ask the patient to empty her bladder if necessary.

Ask the patient to remove her lower clothing, including her underwear, and to lie in the supine position.

Give her a cover sheet to drape over her lower abdomen and legs.

Ask the patient to move her legs into the examination position (ie, knees and hips flexed, feet placed together, and knees parted sideways).

Expose the perineum only.

Take universal precautions.

Inspect the following external anatomy features:

• Pubic hair pattern
• Clitoris and prepuce
• Labia majora
• Labia minora
• Perineal body
• Hymenal carunculi
• Urethral opening
• Vaginal opening
• Bartholin's gland openings
• Skene's gland openings

Identify any lesions or discharge.

Palpate the groin for lymphadenopathy.

Palpate the labia majora and labia minora if surface abnormalities are visible (eg, swellings, discharge) or the patient expresses discomfort/pain.

In multiparous women, also test the perineal tone by asking the patient to bear down or cough. Observe for any involuntary loss of urine or descent of the vaginal wall or the cervix into the vaginal opening.

Apply water-based lubricant sparingly onto the speculum blades; some lubricants can interfere with the cervical sample result.

Part the patient's labia with your free hand.

With the blades closed, turn the speculum sideways and insert it into the vaginal introitus.
 
Advance the speculum into the vagina in an oblique posterior direction. When the speculum is halfway into the vagina, turn the speculum so that the handle is up. (Note that it is usually better to view a retroverted cervix with the handle up and an anteverted cervix with the handle down.)
 
Being gentle, partially open the speculum blades and look for the cervix. If the vaginal walls prolapse and obstruct your view, use either a Sims or a larger speculum.
 
If you cannot visualize the cervix, gently adjust the speculum position. If necessary, remove the speculum, palpate the cervix, and then try again.

Once the cervix is located, position the speculum blades in the anterior and posterior fornices and lock or fasten them.

Inspect the cervix and note the following:

• Size, color, shape, discharge, lesions, and the mobility (a normal cervix is 2-3 cm in size, with pink, smooth epithelium).
• Identify the external cervical os for ectropion, eversion, odor, color, and consistency.

Remove any large mucus plugs obscuring the external os with a dry swab before taking the smear.

Select a spatula (plastic or wooden) to use prior to using a Cervex or Cytobrush.

Ensure the sample is transferred to the appropriate medium as soon as possible after sampling to prevent the cells from drying.

Through the open speculum firmly insert the spatula into the cervix. Rotate the spatula 360 degrees in one direction several times. If cervical ectropion is present, also sample the ectropion border by using the flat end of the spatula.

Cells from the spatula can be used to make both microslides and liquid-based cytology samples.

Transfer cells from both sides of the spatula onto a microslide with an even spreading motion, immediately after the sample has been taken. Discard the spatula.

If combined spatulas/samplers are used, transfer cells from one sampler onto one end of the slide, and then transfer cells from the other sampler onto the opposite end of the slide.

Fix the sample immediately with fixative spray. Spray 2 sprays from approximately 15 cm (6 inches) away onto the slide. Closer spraying can wash away cells or cause freezing artifacts. Spray within 30 seconds, as drying of cells without fixative spray or alcohol makes accurate interpretation impossible.

Allow the slide to stand for 4 to 7 minutes before storage in a laboratory container.

Rinse the spatula in a liquid-based cytology bottle/vial by swirling it vigorously at least 10 times. Discard the spatula.

Securely tighten the cap on the bottle/vial.

Ensure the sample is transferred to the appropriate medium as soon as possible after sampling to prevent the cells from drying.

If you are using a Cytobrush, insert it into the endocervical canal until only its lowest fibers are protruding. Rotate the Cytobrush 90 to 180 degrees in one direction. This may result in bleeding. The Cytobrush should not be used in pregnant women due to the risk of introducing infection or rupturing the membranes.

If you are using a Cervex brush, insert it into the endocervical canal until its shorter bristles are in full contact with the ectocervix. Rotate the Cervex brush 5 times through 360 degrees in one direction whilst applying light pressure.

Cells taken with the Cytobrush can be used to make both microslides and liquid-based cytology samples.

Cells taken with the Cervex brush can only be used to make liquid-based cytology samples.

Transfer cells from the Cytobrush onto a microslide with an even spreading motion, immediately after the sample has been taken. Discard the sampler.

If combined Cytobrush and spatula are used, transfer the cells from one sampler onto one end of the slide, and then transfer cells from the other sampler onto the opposite end of the slide.

Fix the sample immediately with fixative spray. Spray 2 sprays from approximately 15 cm (6 inches) away onto the slide. Closer spraying can wash away cells or cause freezing artifacts. Spray within 30 seconds, as drying of cells without fixative spray or alcohol makes accurate interpretation impossible.

Allow the slide to stand for 4 to 7 minutes before storage in a laboratory container.

Push the Cervex brush into a liquid-based cytology bottle/vial forcing the bristles apart at least 10 times. Then rinse it in the bottle/vial by swirling it vigorously. Discard the Cervex brush.

Rinse the Cytobrush in the same bottle/vial by rotating it at least 10 times whilst also pushing it against the walls of the bottle/vial. Then rinse it in the bottle/vial by swirling it vigorously. Discard the Cytobrush.

Securely tighten the cap on the bottle/vial.

Unfasten or unlock the blades of the speculum and gently remove it from the fornices.

Close the blades and gently remove the speculum from the vagina. Examine the vaginal walls as the speculum is being pulled out.

Postprocedure considerations