[Pelvic exam in gynecology and obstetrics: Guidelines for clinical practice]

OBJECTIVE

To provide guidelines for the pelvic clinical exam in gynecology and obstetrics.

MATERIAL AND METHODS

A multidisciplinary experts consensus committee of 45 experts was formed, including representatives of patients' associations and users of the health system. The entire guidelines process was conducted independently of any funding. The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized.

METHODS

The committee studied 40 questions within 4 fields for symptomatic or asymptomatic women (emergency conditions, gynecological consultation, gynecological diseases, obstetrics, and pregnancy). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology.

RESULTS

The experts' synthesis work and the application of the GRADE method resulted in 27 recommendations. Among the formalized recommendations, 17 present a strong agreement, 7 a weak agreement and 3 an expert consensus agreement. Thirteen questions resulted in an absence of recommendation due to lack of evidence in the literature.

CONCLUSIONS

The need to perform clinical examination in gynecological and obstetrics patients was specified in 27 pre-defined situations based on scientific evidence. More research is required to investigate the benefit in other cases.

Speculum examinations: Clinicians' attitudes and approaches to obtaining consent in a sexual assault context

BACKGROUND

In many countries, a forensic medical examination by a trained professional is offered to people who have experienced recent sexual assault. The consultation may include a vaginal speculum examination to visualise injuries and collect forensic evidence, but not all patients will consent to the examination. Clinicians' attitudes to a speculum examination in a sexual assault context and the consequent wording when obtaining consent may influence uptake rates and ultimately health outcomes for sexual assault survivors.

OBJECTIVES

This survey study identifies (i) factors affecting clinician attitudes towards the use of speculum examinations in sexual assault forensic medical examinations; (ii) situations in which they would offer a speculum examination; and (iii) approaches to seeking consent.

METHODS

An online survey was sent to all eligible forensic examiners working in sexual assault services across New South Wales (NSW), Australia (n = 100), between August and September 2019. The survey recorded demographic data, experience with speculum examinations, opinions regarding the main purpose of the speculum examination, circumstances in which clinicians would offer a speculum examination, and the wording of their consent process based upon two detailed clinical scenarios (differing only in the hours elapsed since the assault (24 h vs 72 h)). A mixed method approach was used to analyse the data and was completed using SPSS and NVivo.

RESULTS

Of the 100 invited participants, there were 32 respondents. Twenty-eight respondents (87.5%) stated that the main purpose of a speculum examination is to both check for injuries and collect evidence. Clinicians were more likely to offer a speculum examination to patients presenting with symptoms (i.e., pelvic pain, bleeding) or presenting more than 24 h after the event. Twenty-seven participants (84.4%) stated that patient-centred factors (i.e., time of presentation, patient comfort with speculum examination) were the main influences in whether they would/would not offer a speculum examination. Clinicians felt more comfortable performing speculum examinations in a forensic setting if they felt comfortable performing speculum examinations in a non-forensic setting (p = 0.004) and less comfortable as time increased from introductory sexual assault training (p = 0.0029). Eight participants (26.7%) would not offer a speculum examination acutely (< 24 h post assault) but only one (0.03%) would not offer it 72 h post assault.

CONCLUSIONS

This study is the first to explore clinicians' attitudes towards the speculum examination component of the adult sexual assault forensic medical examination and provides foundations for future research. Current guidelines should be reviewed and updated to ensure that speculum examinations are routinely offered, rather than only when endocervical samples are being considered, to ensure potential injuries are not missed.