Weill

Cornell Medical College in Qatar

Kristina Sole, MD, FACOG


OBGYN Clerkship
OBGYN Simulation Workshop
Training Guide
GYN Simulation Station



GYN Simulation Station Objectives:

After completing the GYN Simulation station, students should be able to:
Perform a breast exam
Perform a pelvic exam
Counsel a patient on health maintenance issues




Workshop Preparation
Required Readings

Beckman CRB, Ling FW, et al. Chapter 1: The womens health examination. Obstetrics &
Gynecology, 6th edition. 2010 Lippincott Williams & Wilkins. pp 1-14.

Beckman CRB, Ling FW, et al. Chapter 2: The obstetrician-gynecologists role in screening
and preventive care. Obstetrics & Gynecology, sixth edition. 2010 Lippincott Williams &
Wilkins. pp 15-22.

Beckman CRB, Ling FW, et al. Chapter 3: Ethics in obstetrics and gynecology. Obstetrics &
Gynecology, 6th edition. 2010 Lippincott Williams & Wilkins. pp 23-28.

Review Health Maintenance guidelines

Students should understand basic screening guidelines for cervical cancer, breast cancer,
colon cancer, osteoporosis, and sexually transmitted diseases. They should also be familiar
with CDC vaccination guidelines.
United States Preventive Services Task Force (USPSTF)
American Congress of Obstetricians and Gynecologists (ACOG)
American Society for Colposcopy and Cervical Pathology (ASCCP)
Center for Disease Control (CDC)
National Cancer Institute (NCI)
National Osteoporosis Foundation (NOF)

Weill Cornell Medical College in Qatar

Kristina Sole, MD, FACOG


Hands-On Practice!

Wash hands prior to and after the patient encounter!

Breast Exam
Draping and positioning
(The SPs will wear the breast models)
Wear gloves to protect the breast model material
Patient wears the gown opened to the front.
Keep patients breasts covered when not being examined.
Sit patient on the exam table for breast inspection and lymph node
palpation, and place in supine position for the breast/nipple exam.
Drape gown over lap while sitting and over body while supine

Inspection
Instruct patient to sit with arms raised over head and fingers clasped behind
head. Inspect the breasts, looking for skin/nipple changes
Instruct patient to sit with hands on hips and shoulders rolled forward.
Inspect the breasts, looking for skin/nipple changes
Student should demonstrate maneuvers to the patient so that she can copy
them.

Lymph nodes
Stand in front of patient
Palpate bilateral supraclavicular nodes while patient is sitting
Palpate bilateral axillary nodes while patient is sitting. Student should
support the ipsilateral arm during palpation by either holding the upper arm
or resting the arm on the students shoulder. Nodes should be palpated in
the axillary space superiorly, anteriorly, and medially
Do not palpate through the gown

Breast/nipple exam
Pull out table foot extension, and place patient in the supine position on
exam table with ipsilateral arm raised over head
Ensure that sheet covers legs/torso
Appropriate draping: uncover only one breast at a time
Palpate breast (all four quadrants or radial exam), using superficial and deep
palpation. Breast tissue extends to axilla.
Palpate nipple and express nipple to check for discharge
Repeat breast/nipple exam on other side, remember to place ipsilateral arm
over head
Cover breasts with gown when finished

Weill Cornell Medical College in Qatar

Kristina Sole, MD, FACOG

Pelvic Exam
Position and drape the patient
Wash hands/wear gloves
(The SPs will lie in dorsal lithotomy position with the pelvic model positioned
on the exam tables foot extension and between the SPs legs)
Patient/model should be kept draped as much as possible during the exam
Patient/model should be covered up immediately after the exam
Adjust table height
Adjust and turn on light source, and focus light on vulva
Ensure that all equipment is readily available
Ask patient if she is comfortable

Examination of external genitalia
Sit on stool in front of patient.
Inspect and palpate labia minora, labia majora
Inspect clitoris, urethral meatus, Skenes glands
Palpate for Bartholins gland cysts
Inspect and palpate posterior fourchette/introitus
Inspect perineum
Inspect anus and perianal area

Speculum exam
Warm up speculum using warm water
Apply small amount of lubricant to speculum
Inform patient that you will start exam
Lay gloved hand/speculum on inner thigh to prepare patient
Insert speculum at 45% angle and rotate after insertion
Push speculum into vagina gently and at a downward angle, aiming toward
the sacrum
Once fully inserted, open speculum and identify the cervix.
Lock speculum in place and keep one hand on the speculum at all times so
that it doesnt fall out of the patient.
Inspect cervix, fornices, and vaginal walls
Identify the presence and appearance of mucus discharge

Pap smear
Inform patient that pap smear will be collected
Wipe off cervix with cotton-tipped swab
Use plastic spatula to make a circumferential sweep around ectocervix,.
Remove and place spatula in container for liquid-based cytology
Insert cytobrush into endocervical canal and rotation 1-2 times. Remove
and place cytobrush in container for liquid-based cytology
May use specialized pap combi-brush instead of spatula/cytobrush.
Unlock speculum and allow it to close while gently removing it from the
vagina. Inspect vaginal sidewalls during speculum removal.
(Spatula/cytobrush can be smeared on a slide and fixed with
hairspray/cytofixative, if liquid-based cytology is not available)

Weill Cornell Medical College in Qatar

Kristina Sole, MD, FACOG

Bimanual exam
Stand up
Inform patient that bimanual exam (internal exam) will be performed
Insert two fingers (index and middle fingers) of the dominant hand into the
vagina to the cervix
Gently grasp cervix between fingers and move the cervix horizontally to
elicit cervical motion tenderness
Place fingers in the posterior fornix and lift cervix/uterus, while using the
non-dominant hand to palpate the uterus abdominally. Palpate from
umbilicus to pubic symphysis
Place fingers in bilateral fornices and push antero-superiorly, while using the
non-dominant hand to palpate the adnexa abdominally. Palpate from
bilateral ASIC to pubic symphysis
Watch patient to assess for pain/discomfort
Remove fingers from vagina

Rectovaginal Exam
Continue standing
Inform patient that a rectovaginal exam will be performed
While instructing the patient to valsalva, insert the middle finger of the
dominant hand into the rectum, and the index finger of the dominant hand
into the vagina
Palpate the rectovaginal septum
Palpate the posterior cul-de-sac with the vaginal/rectal fingers while
palpating the uterus/adnexa abdominally with the other hand
Palpate the cardinal ligaments lateral to the cervix
Assess rectal tone
Remove fingers from rectum/vagina
Cover up patient with abdominal hand
Remove gloves and wash hands
Leave the room to allow the patient to get out of dorsal lithotomy position.
(A retroverted uterus is more easily palpated on RVE than on BME)
(Adnexal masses can often be palpated on RVE and not on BME)

Weill Cornell Medical College in Qatar

Kristina Sole, MD, FACOG

Additional Resources
Lu MC, Williams III J, Hobel, CJ. Chapter 1: A life-course perspective for womens health
care. Hackers and Moores Essentials of Obstetrics & Gynecology. 2010 Saunders. pp 3-11.

Lu MC, Williams III J, Hobel, CJ. Chapter 2: Clinical approach to the patient. Hackers and
Moores Essentials of Obstetrics & Gynecology. 2010 Saunders. pp 12-21.


Suggested Websites
New England Journal of Medicine has online videos in clinical medicine. This is the link for
the pelvic examination video:
http://www.nejm.org/doi/full/10.1056/NEJMvcm061320

Cleveland Clinic Womens Health Maintenance Guidelines:
http://my.clevelandclinic.org/Documents/Family_Health_Centers/womens-health-
guidelines.pdf

The following websites have womens health maintenance recommendations:
United States Preventive Services Task Force (USPSTF):
http://www.uspreventiveservicestaskforce.org/

American Congress of Obstetricians and Gynecologists (ACOG): http://www.acog.org/

American Society for Colposcopy and Cervical Pathology (ASCCP): http://www.asccp.org/

Center for Disease Control (CDC): http://www.cdc.gov/

National Cancer Institute (NCI): http://cancer.gov/

National Osteoporosis Foundation (NOF): http://www.nof.org/