Vaginal Swabs – OSCE Guide

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This guide to performing vaginal swabs provides a step-by-step approach to performing vaginal swabs in an OSCE setting.


Introduction 

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Explain what the procedure will involve using patient-friendly language: “Today I need to take some vaginal swabs. The procedure will involve me inserting a small plastic device called a speculum into the vagina and then taking several swabs from the vagina and neck of the womb. It shouldn’t be painful, but it will feel a little uncomfortable. You can ask me to stop at any point. You may experience some light vaginal bleeding after the procedure.”

Explain the need for a chaperone: “One of the female ward staff members will be present throughout the examination, acting as a chaperone, would that be ok?”

Gain consent to proceed with the examination: “Do you understand everything I’ve said? Do you have any questions? Are you happy for me to carry out the examination?”

Ask the patient if they have any pain or if they think they may be pregnant before proceeding with the clinical examination.

Explain to the patient that they’ll need to remove their underwear and lie on the clinical examination couch, covering themselves with the sheet provided. Provide the patient with privacy to undress and check it is ok to re-enter the room before doing so.

  • Wash hands
    Wash your hands

Gather equipment

Collect the relevant equipment, remove the outer packaging and place in a clean tray:

  • Gloves
  • Lubricant
  • Speculum
  • A light source for the speculum
  • Paper towels
  • High-vaginal charcoal media swab
  • Endocervical charcoal media swab
  • Endocervical nucleic acid amplification test (NAAT)

Vulval inspection

Position

1. Don a pair of non-sterile gloves.

2. Position the patient in the modified lithotomy position: “Bring your heels towards your bottom and then let your knees fall to the sides.”

  • Vaginal examination
    Position the patient supine

Inspect the vulva

Inspect the vulva for abnormalities:

  • Ulcers: typically associated with genital herpes.
  • Abnormal vaginal discharge: causes include candidiasis, bacterial vaginosis, chlamydia and gonorrhoea.
  • Scarring: may relate to previous surgery (e.g. episiotomy) or lichen sclerosus (destructive scarring with associated adhesions).
  • Vaginal atrophy: most commonly occurs in postmenopausal women.
  • White lesions: may be patchy or in a figure of eight distribution around the vulva and anus, associated with lichen sclerosus.
  • Masses: causes include Bartholin’s cyst and vulval malignancy.
  • Varicosities: varicose veins secondary to chronic venous disease or obstruction in the pelvis (e.g. pelvic malignancy).
  • Don gloves
    Don gloves

Inserting the speculum

Warn the patient you are going to insert the speculum and ask if they’re still ok for you to do so.

If the patient consents to the continuation of the procedure:

1. Use your left hand (index finger and thumb) to separate the labia.

2. Gently insert the speculum sideways (blades closed, angled downwards).

3. Once inserted, rotate the speculum back 90° so that the handle is facing upwards.

4. Open the speculum blades until an optimal view of the cervix is achieved.

5. Tighten the locking nut to fix the position of the blades.

  • Insert Speculum
    Gently insert the speculum sideways with the blades closed

Visualising the cervix

Inspect the cervix:

  • Identify the cervical os: if open, this may indicate an inevitable or incomplete miscarriage.
  • Inspect for erosions around the os: most commonly associated with ectropion, however, early cervical cancer can have a similar appearance.
  • Cervical masses: typically associated with cervical malignancy.
  • Ulceration: most commonly associated with genital herpes.
  • Abnormal discharge: several possible causes including bacterial vaginosis, vaginal candidiasis, trichomonas, chlamydia and gonorrhoea.
  • Inspect cervix
    Inspect the cervix

Taking the vaginal swabs

Swab technique

1. Pick up the swab’s sample tube using your dominant hand and pass it to your non-dominant hand.

2. Remove the lid of the sample tube using your dominant hand and place in the tray.

3. Pick up the swab itself with your dominant hand and take the relevant samples (details about how to perform specific swabs are included below).

4. Place the used swab back into its tube, which should still be in your non-dominant hand and tighten the lid.

5. Place the completed swab into the tray.

Double vs triple swabs

Depending on your local guidelines you may be expected to take “double swabs” or “triple swabs”:

  • Double swabs: an endocervical NAAT swab and a high vaginal charcoal media swab.
  • Triple swabs: an endocervical NAAT swab, a high-vaginal charcoal media swab and an endocervical charcoal media swab.

Swab details

The swabs are listed below in the order which you should take them.

Endocervical nucleic acid amplification test (NAAT)

The  endocervical NAAT swab should be performed first:

1. The endocervical NAAT kit usually comes with an additional cleaning swab. The large tipped white cleaning swab should be used to remove excess mucus from the cervical area to allow visualisation of the external os and then discarded.

2. Remove the testing swab from the tube and gently insert it into the endocervix by approximately 5mm.

3. Rotate the swab for 10-15 seconds in the endocervix.

4. Remove the swab and break off into the transport tube at the score line on the shaft.

5. Screw the lid onto the sample tightly.

The endocervical NAAT is used to detect:

  • Chlamydia
  • Gonorrhoea

Endocervical charcoal media swab 

The endocervical charcoal media swab should be performed second:

1. Remove the testing swab from the tube and gently insert it into the endocervix by approximately 5mm.

2. Rotate the swab for 10-15 seconds in the endocervix.

3. Remove the swab and break off into the transport tube at the score line on the shaft.

4. Screw the lid onto the sample tightly.

The endocervical charcoal media swab is used to detect:

  • Gonorrhoea

High-vaginal charcoal media swab

The high-vaginal charcoal media swab should be performed last:

1. Insert the charcoal media swab into the posterior fornix, where discharge frequently pools.

2. Rotate the swab for 10 seconds, or for the length of time recommended in the manufacturer’s instructions.

3. Place the swab into the sample tube and screw the lid on tightly.

The high-vaginal charcoal media swab is used to detect:

  • Bacterial vaginosis
  • Trichomonas vaginalis
  • Candida
  • Group B streptococcus

Removing the speculum

1. Loosen the locking nut on the speculum and partially close the blades.

2. Rotate the speculum 90°, back to its original insertion orientation.

3. Gently remove the speculum, inspecting the walls of the vagina as you do so.

4. Cover the patient with the sheet, explain that the procedure is now complete and provide the patient with privacy so they can get dressed. Provide paper towels for the patient to clean themselves.

5. Dispose of the used equipment into a clinical waste bin.

6. Wash your hands.

  • Loosen the locking nut
    Loosen the locking nut

To complete the procedure…

Label the samples with the relevant details

Thank the patient for their time.

Advise the patient that they’ll be contacted with results via their preferred method (e.g. face to face or text message).

Document the procedure in the medical notes including the details of the chaperone.

Send the vaginal swabs to the lab for processing.

Further assessments and investigations


 

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