When teaching the pelvic examination, the instructor should be sure that the learners have a firm knowledge foundation of pelvic anatomy. This can be provided through written materials, plastic or cadaveric dissection models, web-based or other computer assisted models and/or didactic presentations. The skills required for the performance of a patient-centered pelvic examination may be broken down into communication or interpersonal skills and technical skills. Important components are listed below and references are provided for more detailed information.
General Approach/Interpersonal Skills
Photographs of different speculum types and sizes, as well as diagrams of proper technique, may be used in the didactic preparation or as a written handout. Some examples are provided below.
Metal speculae (front view): A) small Pedersen, B) medium Graves, C) large Graves
Metal speculae (side view): A) small Pedersen, B) medium Graves, C) large Graves
Plastic speculae (front view): A) small Pedersen, B) medium Pedersen, C) large Pedersen
Plastic speculae (side view): A) small Pedersen, B) medium Pedersen, C) large Pedersen
A) Angle of insertion at entry and B) Angle at full insertion
Angle at full insertion
Open speculum cupping cervix
NOTE: This entire module is also available in PDF Format.
The pelvic examination* is an important component of women’s health care, and the American College of Obstetricians and Gynecologists (ACOG) recommends yearly pelvic examinations for women 21 years or older. The purpose of teaching medical students how to perform the pelvic examination is to complement the history, provide additional information, determine diagnosis and guide management. It also provides the opportunity to educate and reassure the patient.
The intended learning outcomes for teaching the pelvic examination are for the student to demonstrate ability to:
*APGO Medical Student Educational Objectives, 10th Edition
Instruction in pelvic examination skills in undergraduate medical education may be provided in the preclinical years (typically during a physical examination skills course or program) and the clinical years (typically during the ob-gyn clerkship). Currently, 65 percent of medical schools utilize Gynecological Teaching Associates (GTA) to teach pelvic examination skills.
In general, instruction begins with some form of introductory preparation, which may include any of the following, alone or in combination: reading materials, video or PowerPoint presentation, and/or class discussion (suggested videos are listed in resources). This introduction is followed by an examination demonstration by the instructor and then supervised practice by the learner. Methods for these latter components of instruction include the following:
Performing a comprehensive patient-centered pelvic examination requires an integrated series of effective cognitive, psychomotor and interpersonal skills. Training of medical students in this set of skills can be challenging to the instructors and anxiety-provoking to the students. As listed above, a variety of methods have been utilized for training purposes and each has its advantages and disadvantages (see Table 1 in the practical tips section of this manual). Checklists may be used with any of these methods of instruction. An example checklist is provided in the next section.
The opportunity for supervised practice of skills with feedback appears to be essential, regardless of the method of instruction used for training in pelvic examination skills. Beckmann and colleagues reported methods of initial instruction in pelvic exam skills for learners. 72% of schools reported initial instruction occurring in the preclinical years, while 15% started in the clinical years.1 Traditional didactic sessions with lecture and film alone are not adequate. Depending on resources and institutional or departmental commitment, the method of choice will likely depend on the available resources, and may include any of the following: GTAs, high- and low-fidelity pelvic models and live models. Training in the actual patient care setting is also an effective method of instruction. However, as noted in Table 1, this method may not be appropriate for the initial instruction in the pelvic examination. Learners should be provided an opportunity to practice the mechanics of the pelvic examination on either high- or low-fidelity plastic pelvic model prior to the first patient encounter.
A 19-year-old G0 who is presets for her annual gynecological examination. You will not perform a Pap smear, as the patient is under 21 years old and has been sexually active for less than 3 years. You will have 15 minutes to complete this focused patient encounter. You should only address the tasks listed below:
You may not re-enter the room after leaving.
Checklists may be used for teaching and/or for assessment. The checklist should be completed by a trained observer with knowledge of the proper technique of the clinical skill. Due to the nature of the techniques required, an in-room observer is essential to evaluate the technical skills. This observer may be a health care professional or GTA. If the session is taped, the history and communication portion of the checklist may be completed by a trained remote observer.
|General Approach and Communication Skills|
|Properly introduces himself or herself to the patient|
|Asks patient how she would like to be addressed|
|Clarifies purpose of visit|
|Washes hands or uses an antiseptic wash|
|Uses appropriate draping techniques for patient privacy|
|Maintains sterile technique|
|Performs the exam in a systematic fashion|
|Prefaces exam maneuvers with simple explanations|
|Establishes and maintains rapport with the patient|
|Makes the patient feel comfortable|
|Closes the exam in an appropriate manner|
|Gives explanations in clear language; avoids jargon|
|Invites questions/checks for understanding|
|Age at first menses|
|Duration of flow|
|Days between periods|
|History of abnormal pap test|
|History of sexually transmitted infections|
|Sexual activity, men/women/both|
|Number of partners|
|Age at first intercourse|
|Type of contraception|
|Checks all equipment/supplies|
|Adjusts exam light prior to gloving and washing hands|
|Positions patient on back, hips to end of table and heels on foot rests|
|Examines external genitalia|
|Inspects mons pubis|
|Inspects labia majora|
|Inspects labia minora|
|Inspects clitoris without touching clitoris|
|Inspects urethral meatus|
|Inspects Bartholin’s gland|
|Holds speculum at 45-degree angle|
|Inserts speculum properly|
|Rotates speculum at full insertion|
|Opens speculum slowly|
|Secures speculum in open position|
|Handles speculum appropriately|
|Removes speculum appropriately|
|Bimanual Pelvic Examination|
|Introduces correct two fingers into vagina with thumbs tucked|
|Palpates cervix and cervical os|
|Palpates uterine body, apex of fundus|
|Notes uterine size|
|Describes position of uterus|
|Palpates right adnexa/ovary|
|Palpates left adnexa/ovary|
|Instructs patient to return to sitting position at conclusion of exam|
|Re-gloves for RV exam|
|Asks patient to bear down as finger is inserted|
|Inserts middle finger into rectum|
|Inserts index finger into vagina|
|Palpates right adnexa/ovary|
|Palpates left adnexa-ovary|
*Often not performed on GTA—student only asked about technique.
Once adequate practice has been obtained, either with plastic pelvic models, live models, GTAs or actual patient encounters, a formal assessment of knowledge and skills can be conducted. There is currently a lack of evidence to suggest which assessment approach is optimal for pelvic exam skills. Therefore, we suggest that assessment of this skill may be conducted through direct observation using a standardized patient encounter or with a pelvic model simulator (non-computerized or computerized plastic pelvic model). The following resources may be used to conduct the assessment:
Developing a standard protocol for training students in pelvic examination techniques allows for consistent instruction and feedback. In addition to the instructional materials and program for the students, investing some time in training the faculty, residents or other instructors (“train the trainer”) is valuable. Do not assume that all your teachers will use the techniques you prefer or have prepared the students to use—make your expectations for instruction, feedback and assessment clear.
See table below, for advantages and disadvantages of different training methods.
Advantages, Disadvantages and Cost Considerations for Available Methods of Training in the Pelvic Examination
Training Method 1
Actual patient care setting/ faculty or resident supervision
Training Method 2
Plastic pelvic models
Training Method 3
Live model or SP (not specifically trained to provide feedback)
Training Method 4
Gynecology Teaching Associate (GTA) or professional patient (specifically trained to instruct and provide feedback)