"Very clean" pap smears

I originally wrote this post in March of 2013 - found it while reviewing posts for my book. Updated to include improved gender inclusive language and a link to the scripts for empowering gynecologic care without stirrups / foot pedals. Enjoy!

Look at this picture, and tell me how clean, really clean, is everything on this tray? If you were receiving a pap smear using these tools, would you be confident in their cleanliness? If an exam is not sterile, at least make sure anything that goes into the vagina is "clean," and at my clinics I can assure you, I practice "very clean."

Every provider has their own way of setting up for a pap smear. Sometimes the Medical Assistant or Nurse will have already laid out the speculum, lubricant, and brushes. Sometimes the provider themselves prefers to grab the instruments when needed. I learned many ways in which to set-up and stay "clean" during the pap exam, but none left me feeling satisfied with how clean the speculum, gloves, or brushes are by the time they enter the person's body. A speculum exam is not a sterile exam, but by all means, it should be as clean as possible: what I would like to term "very clean."

Primarily, I work very hard to consider the care I provider to each person as being equal to the care I would provide for my best friend. Some of my best friends are sticklers about cleanliness, which I respect (nod to you, my friend who Cloroxes her Dansko's after every hospital shift!). Secondly, the number of times in the past week alone that I have discussed the sensitivity of the vaginal environment, the tenacity of yeast and bacteria to win a battle of vaginal dominance, and the propensity for some vaginas to react to the slightest change, reinforces a "very clean" approach to a pap smear that does not set off any level of vaginitis if I can help it. Besides this, all womxn deserve the cleanest speculum exams and pap testing that is possible. Period.

I know I state the obvious, but really, really think about the cleanliness of all the components of your exams. How many people touched the swabs before you touched them with gloved hands? What about the lubricant packets? How many things do you touch before touching the necessary light and chair, and then what do you touch after? What other hands have been in the drawers stocking the tools?

Note: in my clinics we use individually wrapped plastic speculums.

Here is my struggle:

- The person setting up the tools may or may not wear gloves while touching the lube tube, packets, brushes, or speculum pack.
- All of the tools are stocked in drawers, in the rooms, in which multiple people have their hands in and out throughout the day (including kids toddling about while the client's history is being taken...).
- I always wash my hands before grabbing gloves from the box, but should not assume that of all providers (or mothers grabbing gloves to blow up and entertain their kids while they wait...).
- If it is an annual exam, after the breast/chest exam I will need to touch the exam table or footholders, the light, the chair, and then reach to put on my gloves to prepare for the speculum exam.
- Even if all efforts are made to ensure the tools going into the vagina stay as clean as possible, if a pelvic exam is needed (which I don't often do anymore), then the gloves that touched tools that touched bare hands that touched other things may then go inside the vagina.

So here is how I have made my speculum exam "very clean":

Support staff washes hands beforehand and/or wears gloves when stocking drawers and setting up the pap exam. Then they set out a drape or paper towel, on which is set the pap specimen container, brush(es), speculum in opened package, and lube, so things do not directly touch the counter. Then the patient has their vitals taken and brought into the room, asked to remain clothed.

After completing the history, giving the opportunity for questions and answers other than my own, offering the patient the chance to use the bathroom, and then providing the gown and drapes, I leave for a few minutes and then come back.

Pull drape. Place chair at foot of table.

• Wash hands.
• Grab gloves. Set gloves on the draped table.
• Prep the speculum: open the plastic pack by pulling on the perforated area and keeping the speculum inside, open the lubricant, squirt into the plastic pack and rub the speculum blades on the lube, within the plastic bag.
• Open the pap specimen container.

Now to stay clean between touching the patient and touching tools in the room:

• Breast/chest exam.
• Hand sanitizer.
• Assist patient into position for speculum exam, arrange table or foot pedals (here is guidance on not using the stirrups / foot pedals), organize light and chair.
• Hand sanitizer.
• Glove.

Now the trick to stay clean throughout:

• Have all items placed on the one side. (In these steps I have the tools placed on my right as I'm right-handed.)
• Hold speculum in right hand, which will be the 'clean hand' throughout the exam.
• Completed the external exam with left hand.
• Separate labia with left hand, insert speculum with right hand.
• Hold spec in place with left hand (for those sometimes surprisingly wiggly cervices), grab brush(es) with right hand and obtain sample, place brushes in specimen container. Speculum has now been touched by left hand.
• Remove speculum with the left hand (and smell it, or show it to the patient to display yeast-like discharge or normalcy or whatever your midwife-y thing it is you do).
• Remove left glove with right glove.
• Hold specimen container with left hand while right gloved hand swirls/stamps the brushes.
• (If doing a pelvic exam, push rest of lube packet with left hand onto right hand fingers, still clean to do pelvic).
• Remove right glove.
• Help patient sit up with either hand.
• Wrap paper towel on which all items rest around the speculum and gloves and throw in biohazard container.
• Hand sanitizer.
• Replace light and foot pedals, move chair, shake hands/hug.

Done. Clean. Hopefully, very clean!

What do you think? What do you do differently? Would love to know any feedback you have, or how you ensure your spec exams stay clean!