Adapted from RHAP Contraceptive Pearl: Trauma Informed Pelvic Exams 2015
If the patient has never experienced a pelvic exam, take extra care and time to explain what will happen, what a speculum is, what the procedure may feel like, and how to best position and relax their body. Consider using a pediatric speculum if available when a patient has had very limited sexual experience. Explain that future pelvic exams or pap tests will only involve speculum placement so they do not anticipate the additional experiences of the abortion.
A pelvic exam can often trigger a trauma response related to past sexual trauma (Sharkansky 2014). Many people will not ever report or disclose abuse to their healthcare provider. It is helpful to perform a trauma-informed exam with every patient, and not just those who disclose a history of assault or abuse. Ask the patient if they have had difficulty with pelvic exams in the past or if they have had any sort of sexual experience or exam which was painful or forced. Clinicians should use the following patient-centered techniques to lower patients’ anxiety.
|Establish rapport||Introduce yourself and take a seat to demonstrate respect and ease anxiety.|
|Invest in patient’s experience||Prioritize the patient’s experience rather than the outcome. This may mean doing the exam at a separate visit.|
|Allow a support person||Allow a support person to accompany the patient, such as a partner, friend, family member, or trained doula. Those receiving doula support are less likely to require additional clinic support resources, although pain and satisfaction are unchanged (Chor 2015). Where possible, encourage institutional policies allowing presence of a support person and allow the patient to choose a female examiner if they would like/are available.|
|Support the patient’s comfort||Keep the patient’s body covered, exposing only areas being examined, use the smallest possible speculum, use lubricant, offer frog leg position without stirrups, and call stirrups “foot-rests.”|
|Review relaxation techniques||Discuss distraction and breathing techniques (see Chapter 5), before focusing on details of the consent, which may be scary.|
|Invite the patient to take control||Ask what would make the exam more comfortable. Let them know they have control over the pace and can stop the procedure if uncomfortable. Offer self-insertion of the speculum.|
|Keep the patient informed||Tell the patient about each step right before it happens. Alert them to what they might feel to avoid alarming them. It can also be helpful to say, “We’re about two-thirds through” or “This part takes about one minute.”|
|Use your intuition||Assess what will be most helpful and follow the patient’s lead: sometimes quiet, sometimes humor, and sometimes talking about work, kids, school or goals will resonate well with a patient.|
|Go at the patient’s pace||If the patient asks to stop, do so adding “Do you need a break now? Let’s try taking some deep breaths, and let me know when you are ready to proceed.”|
|Check in frequently||Check in about whether they want physical and/or emotional support during the procedure, offering an assistant’s reassurance or hand to squeeze.|
|Use supportive statements||Say “Everything is going really well” or “You are doing a good job relaxing your bottom into the table.”|