Instruments For Examination in Obstetrics and Gynecology: Section 1

Instruments and
Procedures in
Obstetrics and
Gynecolog y
Kiran Agarwal
Instruments For
Examination In Obstetrics SECTION 1
 SECTION 1: Instruments For Examination In
Obstetrics And Gynecology
And Gynecology
 SECTION 2: Instruments For Dilatation,
Curettage And Evacuation
 SECTION 3: Instruments For Tubal Patency
Test
 SECTION 4: Instruments For Operative Vaginal SIMS SPECULUM
Delivery
 SECTION 5: Instruments For Destructive Designed by Marion Sims
Operations
 SECTION 6: Catheters It is a nonself-retaining vaginal speculum used in vaginal examinat ion and
 SECTION 7: General Instruments In Obstetrics
operat ions t o ret ract post erior vaginal wall (somet imes lat eral or ant erior wall)
And Gynecology
 SECTION 8: Special Instruments In Obstetrics
and view vagina and cervix.
And Gynecology
 SECTION 9: Instruments For Cervical Screening
▮ TYPES
 Met allic speculum: It needs ext ernal light source

Plast ic speculum: It may be equipped wit h a light source.
▮ SIZES
Small for nulliparous, virgins and adolescent s

Large for parous woman
Used according t o vaginal lengt h and cavit y.
▮ PARTS
BLADES
At an angle t o shaft and point t owards same side. Different sizes are used for
different sizes of vagina. Each valve (blade) is rounded at t he end so t he
inst rument is at raumat ic (Fig. 1.1).
Lubricant : Wat er-based jelly is preferred.

GROOVE
For drainage of secret ions by slight ly t ilt ing t he inst rument and collect ion of
specimen from vagina. 2
T OC Index 
Instruments and
Procedures in
Obstetrics and
Gynecolog y
Kiran Agarwal

Curettage And Evacuation Figure 1.1: Sims bivalved vaginal speculum
Test
 SECTION 4: Instruments For Operative Vaginal ▮ TECHNIQUE
Delivery
 SECTION 5: Instruments For Destructive
Operations
 SECTION 6: Catheters
 SECTION 7: General Instruments In Obstetrics POSITION
And Gynecology
And Gynecology
Lit hot omy by edge of t able /Sims posit ion.

METHOD

Wear gloves. Appropriat e size of t he speculum is t aken. Lubricat e speculum
(except in Pap smear). Labia minora are gent ly separat ed and uret hra is
ident ified prior t o insert ion. Speculum is insert ed well below t he meat us
because of uret hral sensit ivit y. To improve comfort wit h speculum examinat ion
t he woman is asked t o relax post erior wall muscles. Sims speculum should not
be insert ed wit h blades in line wit h cleft of t he vulva and t hen rot at ed in vagina
because it is designed for “direct ” applicat ion. In any case vagina is wider from
side t o side t han from front t o back, so Sims speculum is int roduced direct ly
post eriorly t o it s full lengt h for inspect ion of cervix.

▮ USES
To ret ract vaginal wall and speculat e vagina and cervix.

USES IN GYNECOLOGY
1. P/S (per speculum examinat ion) in gynecology
Inspect cervix for growt h, erosion, discharge

Inspect vagina for vaginit is, cyst ocele, rect ocele, ent erocele, VVF.
2. Perform minor procedures on t he cervix 3
Cervical biopsy, conizat ion of cervix

Cervical t ear st it ching
Polypect omy
Dilat at ion of cervix.
3. Perform procedures on t he ut erus
Dilat at ion and curet t age (D and C)

Endomet rial biopsy (EB)
Int raut erine cont racept ive device (IUCD) insert ion.
4. Major gynecological operat ions

T OC Index 
Vaginal hyst erect omy
Fot hergill's repair
Ant erior colporrhaphy and post erior colpoperineorrhaphy
Instruments and
Procedures in VVF (vesicovaginal fist ula) repair.
Obstetrics and 5. Diagnost ic procedures
Gynecolog y
Kiran Agarwal Hyst eroscopy
Hyst erosalpingography, sonosalpingography
Tubal insufflat ion
 SECTION 1: Instruments For Examination In 6. Collect ion from vagina

 SECTION 2: Instruments For Dilatation, Cyt ology, st aining, cult ure
Three swab t est .
Test
 SECTION 4: Instruments For Operative Vaginal
Delivery
USES IN OBSTETRICS
Operations
 SECTION 6: Catheters 1. P/S (per speculum examinat ion) in obst et rics
And Gynecology Discharge
 SECTION 8: Special Instruments In Obstetrics Leaking
And Gynecology
 SECTION 9: Instruments For Cervical Screening Bleeding in APH (ant epart um hemorrhage), abort ions,
PPH (post part um hemorrhage) t o diagnose t raumat ic PPH and repair t ears.
2. Performing procedures

Medical t erminat ion of pregnancy (MTP)
Dilat at ion and evacuat ion (D and E).
3. McDonald st it ch, Shirodkar st it ch.

▮ ADVANTAGE
Good view.

▮ DISADVANTAGES
Assist ant is required t o hold t he speculum

Cannot visualize t he cervix wit hout ant erior vaginal wall ret ract ion. 4
CUSCO'S SPECULUM
Devised by Cusco Edward Gabrial.
It is a self-retaining vaginal speculum.

▮ TYPES
Met allic
Plast ic.

▮ SIZES
Small
Large.
T OC Index 
▮ PARTS
Instruments and
Procedures in
Obstetrics and BLADES
Gynecolog y
Kiran Agarwal Two blades are shaped like t he beak of a duck
Blades can be opened up and fixed at t he required angle by an adjust able
arrangement (Fig. 1.2).
Curettage And Evacuation HANDLE
Test It is at right angle t o t he blades. When handle is closed blades will open
Delivery Screw mechanism on handle makes it self-ret aining.
Operations
And Gynecology
And Gynecology
Figure 1.2: Cusco's bivalved self-retaining speculum 5

▮ TECHNIQUE
POSITION
Dorsal / Lit hot omy.

METHOD
It is same as in Sims speculum. Wear gloves. Appropriat e size of speculum is

t aken. Lubricat e speculum (except in Pap smear). Prior t o insert ion, labia minora
are gent ly separat ed and uret hra is ident ified and it is inserted with closed
blades in vagina. When speculum is insert ed complet ely it is angled
approximat ely 30° downward t o reach t he cervix. Ut erus lies in ant evert ed
posit ion commonly and ect ocervix lies apposed against post erior vaginal wall.
As speculum is opened ect ocervix is visualized. The fixat ion screw is t ight ened
depending on t he amount of exposure needed, t hen it is unscrewed and blades
closed when speculum is t aken out (if t he cervix is point ing forwards, t he ut erus
is ret rovert ed and if it point ed backwards it is ant evert ed).

▮ USES IN GYNECOLOGY AND OBSTETRICS
1. P/S examinat ion: An import ant examinat ion in obst et rics and gynecology
To visualize t he cervix for erosion, discharge and growt h

To visualize vaginal fornices.
T OC Index  2. Perform minor operat ions on t he cervix

Biopsy
Caut ery
Polypect omy.
Instruments and
Procedures in 3. Collect vaginal pool mat erial and scraping for cyt ological st udy
Obstetrics and 4. IUCD follow-up and removal
Gynecolog y
Kiran Agarwal 5. Colposcopy.

▮ ADVANTAGES
Ideal for visualizat ion and operat ions on cervix
Curettage And Evacuation Self-ret aining, so no assist ant is required
Test It can be used in pat ient s who cannot be put in lit hot omy posit ion.

Delivery
Operations ▮ DISADVANTAGE
 SECTION 7: General Instruments In Obstetrics Limit ed view of vagina as ant erior and post erior walls cannot be visualized. 6
And Gynecology
And Gynecology
 SECTION 9: Instruments For Cervical Screening AUVARD SPECULUM
It is self-retaining vaginal speculum.

It is a heavy inst rument wit h a heavy met al ball.

▮ PARTS
Blade
Groove: A channel is provided on t he handle t o collect t he blood and drain
(Fig. 1.3).
Heavy met al ball: Which makes it self-ret aining.
Figure 1.3: Auvard vaginal speculum

T OC Index 
▮ TECHNIQUE
Posit ion: Lit hot omy
Met hod: Same as in Sims speculum.

Instruments and
Procedures in
Obstetrics and ▮ USES
Gynecolog y
Kiran Agarwal It is used t o ret ract post erior vaginal wall in
1. Operat ions on vagina, cervix and ut erus, e.g. vaginal hyst erect omy.
2. Ant erior colporrhaphy, VVF repair. 7

Curettage And Evacuation ▮ ADVANTAGES
Test
Advant ages of Sims and Cusco's speculum combined.
Delivery Good view of vagina
Operations Self-ret aining.
And Gynecology
▮ DISADVANTAGES
And Gynecology
 SECTION 9: Instruments For Cervical Screening Prolonged use causes post operat ive perineal pain.
Used when operat ion is done under anest hesia.

SIMS ANTERIOR VAGINAL WALL RETRACTOR
This inst rument is used along wit h Sims speculum t o ret ract t he ant erior vaginal
wall.

▮ PARTS
A long inst rument wit h shaft and oval fenest rat ed ends.
Two loops are set at an angle of 15° wit h t he shaft which face in opposit e
direct ions (Fig. 1.4).
Figure 1.4: Sims anterior vaginal wall retractor 8
Transverse serrat ions on loop prevent slipping of inst rument and fit s int o
rugosit ies of vagina.
It is different iat ed from ut erine curet t e by following point s:
▪ It is larger in size.
▪ Oval loops have t ransverse serrat ions.
▮ TECHNIQUE
Used along wit h Sims speculum.

Inst rument is used t o ret ract ant erior vaginal wall wit h t he angle at oval end
facing upwards.
T OC Index 
Can be used t o ret ract sagging vaginal wall for good exposure of t he cervix.

Instruments and ▮ USES

Procedures in
Obstetrics and
To visualize t he cervix in obst et rical and gynecological operat ions.
Gynecolog y
Kiran Agarwal In post part um hemorrhage just aft er delivery as blunt curet t e t o remove
product s of concept ion and membranes.

Obstetrics And Gynecology VULSELLUM
Curettage And Evacuation Designed by Teals
Test It is a long inst rument which can be applied t o t he ant erior lip or t he post erior lip
 SECTION 4: Instruments For Operative Vaginal of cervix. Usually it is 20 cm in lengt h.
Delivery
Operations
▮ PARTS
And Gynecology
And Gynecology TEETH
Int erlocking sharp t eet h which ensure a firm grip on cervix when it is locked (Fig.
1.5). 9

BLADES
Blades have a curve so t hat field of vision is not blocked during t he procedure.
Dist ance in bet ween blades prevent crushing of t issues held in bet ween t hem.
The inst rument gives a firm grip on t he cervix and pulling cervix straightens
uterocervical canal so t hat chances of perforat ion are reduced.
Figure 1.5: T eals vulsellum

▮ TECHNIQUE
Vaginal exposure is done by ret ract ing vaginal walls using Sims speculum and
Sims ant erior vaginal wall ret ract or.
Ant erior lip of t he cervix is grasped wit h t he t eet h of vulsellum and t he

inst rument is locked. The curve should face upwards.

▮ USES
USES IN GYNECOLOGY
T OC Index 
1. To cat ch t he ant erior lip of cervix for surgical procedures
Operat ions of cervix, e.g. biopsy and caut ery
Instruments and Cryosurgery

Procedures in D and C (dilat at ion and curet t age)
Obstetrics and IUCD insert ion
Gynecolog y
Kiran Agarwal Drainage of hemat omet ra and pyomet ra
Fot hergill's operat ion t o hold t he new cervical st ump aft er amput at ion
Vaginal hyst erect omy

To t est degree of descent of ut erus by giving t ract ion wit h vulsellum in
Obstetrics And Gynecology case of prolapse. 10
Curettage And Evacuation 2. To cat ch t he post erior lip of cervix
Test Aspirat ing pus in pelvic abscess, i.e. post erior colpot omy
 SECTION 4: Instruments For Operative Vaginal Aspirat ing blood in ect opic pregnancy, i.e. culdocent esis
Delivery
Fot hergill's operat ion
Operations Vaginal hyst erect omy
If growt h on t he ant erior lip of t he cervix t hen cat ch t he post erior lip of
And Gynecology cervix.
And Gynecology 3. To hold ut erine fundus during abdominal hyst erect omy.
 SECTION 9: Instruments For Cervical Screening 4. To give gent le t ract ion on fet al head aft er craniot omy or t he collapsed head
in IUD baby.
5. To remove polyps by t wist ing.


USE IN OBSTETRICS
To cat ch t he cervix in pregnant pat ient , e.g. MTP, S and E, D and E.
▮ DISADVANTAGES
Cervical t rauma and bleeding. The cervix is soft in pregnancy so sponge holding
forceps is used t o hold cervix inst ead of vulsellum.
TENACULUM
It is used in t he nulliparous cervix in place of vulsellum.

▮ PARTS
It can be different iat ed from vulsellum by following point s:
St raight inst rument and not curved as vulsellum

Single t oot h is present 11
Grip is more secure t han vulsellum because it s bit e is deeper.

Two blades have gap in bet ween t o prevent crushing of st ruct ure.
T OC Index 
Instruments and
Procedures in
Obstetrics and
Gynecolog y
Kiran Agarwal

Figure 1.6: Jarcho's tenaculum
Test ▮ TECHNIQUE
Delivery
Ret ract ant erior and post erior vaginal walls for exposure of t he cervix
Operations Ant erior lip of t he cervix is held wit h a t enaculum (Fig. 1.6).

And Gynecology
 SECTION 8: Special Instruments In Obstetrics ▮ USES
And Gynecology
To hold t he ant erior lip of t he cervix / post erior lip of cervix in place of
vulsellum
 In nulliparous, t o hold t he cervix in sonosalpingography (SSG),
hyst erosalpingography (HSG) and chromopert ubat ion during laparoscopy.
To hold cervix in cryosurgery or caut ery of cervix.
▮ ADVANTAGE
Bet t er for nulliparous cervix because it occupies less space.

▮ DISADVANTAGES
Cervical t ears are great er t han in vulsellum as t he bit e is deeper

Discomfort or pain. 12
UTERINE SOUND
Designed by Simpson.

▮ PARTS
It is 30cm long angulat ed inst rument wit h handle at one end and a rounded
blunt t ip at t he ot her end.
It has graduat ions in inches or cent imet ers (Fig. 1.7).
The angle accommodat es for flexion of ut erus and prevent s perforat ion as it
fit s int o t he ant evert ed or ret rovert ed ut erus.
Angulat ed at 7cm from t he t ip (which is t he normal ut erocervical lengt h).
Blunt t ip does not cause injury when int roduced.
T OC Index 
Instruments and
Procedures in
Obstetrics and
Gynecolog y
Kiran Agarwal
Figure 1.7: Simpson uterine sound

▮ TECHNIQUE
Uterine sounding
Bimanual examinat ion.
Test Ret ract ant erior and post erior vaginal walls for exposure of t he cervix.
Delivery Ant erior lip of t he cervix is grasped wit h vulsellum.
 SECTION 5: Instruments For Destructive Ut erine sound is held as a “Pencil” wit h t humb and t wo fingers.
Operations
Sound is guided slowly t hrough cervical os int o t he ut erine cavit y and t o
 SECTION 7: General Instruments In Obstetrics fundus.
And Gynecology
The dist ance from t he fundus t o ext ernal os is measured by score marks
And Gynecology (graduat ions) along t he lengt h of sound.
▮ USES

It confirms t he direct ion of ut erus, i.e. ant evert ed or ret rovert ed.
It measures ut erine cavit y and cervical lengt h, i.e. ut erocervical lengt h. 13
It is used t o diagnose cervical st enosis and congenit al malformat ions, e.g.

bicornuat e ut erus.
Used as first dilat or prior t o operat ions on ut erus and cervix, i.e. D and C, S and
E.
It is used t o sound a polyp, IUCD, ut erine sept um called sounding of t he
ut erus.
It helps t o break t he adhesions in Asherman's syndrome (t herapeut ic use).
It different iat es bet ween chronic inversion and fibroid polyp.
In a misplaced IUCD, ut erine sound can be insert ed and X-ray of pelvis is
t aken in AP and lat eral view. Posit ion of IUCD in relat ion t o sound shows t hat
IUCD has perforat ed ut erus.
▮ DISADVANTAGE
Perforat ion: If direct ion or size of t he ut erus is misjudged, perforat ion is

suspect ed when inst rument t ravels deeper t han t he measured ut erine lengt h.

▮ CONTRAINDICATIONS
Pregnancy
Infect ion.
BLADDER SOUND
It is a long inst rument similar t o ut erine sound.

T OC Index  ▮ PARTS
It is different iat ed from ut erine sound by following point s:
Short er in lengt h 14
Instruments and No graduat ions are present (Fig. 1.8)

Procedures in The t ip is more blunt and so it is at raumat ic.
Obstetrics and The angle is at a lesser dist ance from t he blunt t ip.
Gynecolog y
Kiran Agarwal It is an obsolet e inst rument used for exploring t he int erior of a bladder t o
det ect st ones by sounding because now noninvasive procedures are available
like radiography and ult rasonography.

Test
Delivery
Figure 1.8: Bladder sound
Operations
 SECTION 7: General Instruments In Obstetrics ▮ USES
And Gynecology
 SECTION 8: Special Instruments In Obstetrics To define t he limit s of bladder in vaginal surgeries
And Gynecology
 SECTION 9: Instruments For Cervical Screening Used as a uret hral dilat or in uret hral st enosis
To diagnose bladder injury in gynecological operat ions.

PINARD'S STETHOSCOPE
(Fet oscope)
Invent ed by Adolphe Pinard.
Inst rument t o hear fet al heart sound.
▮ PARTS
Simple hollow t ube wit h one broad end and anot her narrow end (Fig. 1.9). 15
Figure 1.9: Pinard's stethoscope
Narrow end has a wide rim which is used as an earpiece.

Broad end is placed over t he pat ient 's abdomen.

▮ TECHNIQUE
The inst rument is kept at right angle on pat ient 's abdomen.
T OC Index 
The inst rument should not be t ouched wit h hand while list ening t o FHS.
It is rarely used now since use of st et hoscope and digit al fet al Doppler.
Instruments and
Procedures in STETHOSCOPE And DIGITAL FETAL DOPPLER
Obstetrics and
Gynecolog y These inst rument s are t o hear FHS wit h high acoust ic sensit ivit y.
Kiran Agarwal
St et hoscope has ear t ips wit h ear t ubes set t o accommodat e t he anat omy
of t he ear (Fig. 1.10).

Digit al fet al Doppler has display t o give read out of fet al heart rat e (FHR) in
Obstetrics And Gynecology beat s per minut e (bpm) (Fig. 1.11). 16
Test
Delivery
Operations
And Gynecology
And Gynecology
Figure 1.10: Stethoscope
Figure 1.11: Digital fetal Doppler
Auscult at ion
The fet al heart is auscult at ed for one minute (normal 110–160 bpm)NICE
guidelines. During labor fet al heart rat e should be auscult at ed during and
immediat ely aft er ut erine cont ract ion t o det ect lat e decelerat ion.
▪ Low-risk pregnancy
Auscult at ion in—1st st age labor: 30 minut es int erval
2nd st age labor: 15 minut es int erval.
▪ High-risk pregnancy
Auscult at ion in—1st st age labor: 15 minut es int erval
2nd st age labor: 5 minut es int erval.
T OC Index 

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Instruments and

 Met allic speculum: It needs ext ernal light source

Small for nulliparous, virgins and adolescent s

Lubricant : Wat er-based jelly is preferred.

 SECTION 1: Instruments For Examination In

To ret ract vaginal wall and speculat e vagina and cervix.

1. P/S (per speculum examinat ion) in gynecology

Inspect cervix for growt h, erosion, discharge

2. Perform minor procedures on t he cervix 3

Cervical biopsy, conizat ion of cervix

3. Perform procedures on t he ut erus

Dilat at ion and curet t age (D and C)

4. Major gynecological operat ions

 SECTION 1: Instruments For Examination In 6. Collect ion from vagina

3. McDonald st it ch, Shirodkar st it ch.

Assist ant is required t o hold t he speculum

It is a self-retaining vaginal speculum.

Figure 1.2: Cusco's bivalved self-retaining speculum 5

Dorsal / Lit hot omy.

It is same as in Sims speculum. Wear gloves. Appropriat e size of speculum is

▮ USES IN GYNECOLOGY AND OBSTETRICS

To visualize t he cervix for erosion, discharge and growt h

T OC Index  2. Perform minor operat ions on t he cervix

Figure 1.3: Auvard vaginal speculum

 SECTION 1: Instruments For Examination In

Figure 1.4: Sims anterior vaginal wall retractor 8

Used along wit h Sims speculum.

Instruments and ▮ USES

 SECTION 1: Instruments For Examination In

Figure 1.5: T eals vulsellum

Ant erior lip of t he cervix is grasped wit h t he t eet h of vulsellum and t he

Operat ions of cervix, e.g. biopsy and caut ery

Instruments and Cryosurgery

 SECTION 1: Instruments For Examination In

To cat ch t he cervix in pregnant pat ient , e.g. MTP, S and E, D and E.

It can be different iat ed from vulsellum by following point s:

St raight inst rument and not curved as vulsellum

Grip is more secure t han vulsellum because it s bit e is deeper.

 SECTION 1: Instruments For Examination In

Bet t er for nulliparous cervix because it occupies less space.

Cervical t ears are great er t han in vulsellum as t he bit e is deeper

It is used t o diagnose cervical st enosis and congenit al malformat ions, e.g.

Perforat ion: If direct ion or size of t he ut erus is misjudged, perforat ion is

Instruments and No graduat ions are present (Fig. 1.8)

 SECTION 1: Instruments For Examination In

Figure 1.9: Pinard's stethoscope

Narrow end has a wide rim which is used as an earpiece.

 SECTION 1: Instruments For Examination In

Figure 1.10: Stethoscope

Figure 1.11: Digital fetal Doppler

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