Taking a Cervical Sample
Cervical Screening QARC Training
School
October 2012
Cervical Cancer Risk Factors
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Never had a cervical screen
Infection particularly HPV
Smoking
Contraception
Pregnancy
Sexual behaviour
Immunosuppression
Taking a Cervical Sample
• A Screening test should be taken in
such a way as to provide an
adequate sample for assessment
with the minimum of distress or
discomfort.
Cervical Screening RCN Guidance for Good Practice.
December 2006
The environment
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Privacy
Warmth
Lighting
Relaxed atmosphere
Comfort
Modesty blanket
The equipment
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Specula (Disposable)
Waste disposal
Sampler (check condition of brush)
Pot with Fixative solution (check the expiry date)
Lubricant
Ball point pen
Forms (Open Exeter)
Gloves (including latex free)
Leaflets including ‘The Facts’
Good light source
The woman
• Welcome
• Check identity – do not complete
form before woman is present
• Explanation
• Information
• Answer questions
• Obtain informed consent
Taking a history
• Obtain and record relevant details
• Any abnormal bleeding i.e. heavy periods,
post coital, intermenstrual or post
menopausal bleeding and/or unusual
vaginal discharge
• Consider if a cytology sample is still
appropriate – or should direct referral to
COLPOSCOPY be considered?
Taking a history cont …
• Check on contraception - is she taking
COC, POP, Depo Provera, IUCD, Mirena,
implant?
• Is she on HRT/Tamoxifen?
• If not using pre-populated form i.e Open
Exeter or Ice, details of past screening
hx/treatment/follow-up should be
recorded
Preparation of the form
• Woman’s current full name, previous name,
address with postcode, date of birth
• NHS number
• Name & address of GP and GP code
• Personal sample taker code
• Clinic number, if appropriate
• Date of last sample
• Past history of abnormal sample, and details
• First day of last period
• Abnormal bleeding
• Use of hormones, IUCD etc
• Clinical details, e.g post-natal status if less than
3/12
Labelling the sample
• Pre-printed labels maybe used (but
details must be clarified with patient and
initialled)
• Write clearly in ball point pen
• Surname & Forenames
• Date of birth
• NHS Number
To Print HMR from Open Exeter and view
screening history
Guidance for Practice Staff
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Adobe Reader has to be installed on your PC. You can download this for free by going to
https://nww.adobe.com/products/acrobat/readstep2.html and following the instructions
on screen
Quick tip – do remember to enable pop up boxes otherwise you will not be able to print
the form
Go to:https://nww.openexeter.nhs.uk/nhsia/index.jsp
Same password and log-in for Open Exeter
In Application drop down box choose Patient Details
Press CONTINUE box
Select Patient by inputting her NHS Number if available. Otherwise input her surname,
forename and date of birth
Press SEARCH
From the choice displayed in box situated top left hand corner of screen choose either
HMR101 form – editable or HMR101 form – A5PDF (2009)
Press CONTINUE box
If you have chosen HMR101 form A5PDF(2009), the form you wish to print will be
displayed on screen. You cannot make any amendments on screen to this form
Press the printer icon at the top of the page
You need to print the form at the top of a piece of A4 – remember to have the paper in
portrait, not landscape
Go to properties, Paper/Quality = A5, Effects = Print Doc on A5, Finishing = Portrait. This
last instruction applies to the printer used at the screening department – depending on
which printer you use, this could vary.
It is essential to
complete the following
fields on the form when
you have taken the
sample:
Source of sample
Sample Taker
Sample Taker code
Implement used
Specimen type
Condition
Clinical Data – 360
sweep, Cervix visualised
and Date of this Test
Choosing the speculum
Points to consider :
• Age of women
• Build of women
• Parity
• A range of sizes should be available
from virgin to Winterton
Visualising and assessing the cervix
• Positioning the woman
• Inspecting the vulva
• Locating the cervix by speculum or digital
examination
• What to do if you can’t find the cervix
• Visualising the cervix
• Assessing the cervix
• Interpreting what is seen
Choosing the sampler
• A Cervex brush must be used
• Consider using an Endocervical Brush IN
ADDITION TO A CERVEX BRUSH if there
is stenosis of the os, or to pick up
glandular cells when following up a
previous glandular abnormality
• An endocervical brush should never be
used on its own
• Consider the state of the os
• Look at the shape and contours of the os
• The transformation zone
• Any unusual features
Sampling the cervix
• Technique
• Lubricants – use sparingly, if at all –
water soluble single use sachet
• 360 degree sample x 5 with cervex
brush/cervex broom
• 90 degree turn with endocervical brush if
used
• Adequate pressure (pencil like)
• Transformation zone
Practical tips for difficult samples
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Ask woman to cough
Clenched fists or pillow under buttocks
Winterton speculum
Condom or glove
Digital examination
Seek help – it’s ok to ask!
Refer to Colposcopy
Bi-manual examination
• Bi-manual examination is NOT necessary when
undertaking cervical screening and is not a prerequisite for the sample taker. Digital examination
may only be necessary to assist in the location of
the cervix, and not as a means of physical
assessment that will aid diagnosis.
Cervical Screening RCN Guidance for Good Practice, December 2006
• Further training must be undertaken prior to
performing Bi-manual examination.
The sample
• A high cellular yield will be achieved with correct use of
the Cervex brush
• Rinse the Cervex brush into the Thin Prep vial using a
vigorous swirling motion
• Agitate the brush forcefully at least 10 times in the
preservative liquid
• Check the brush to ensure that no material is clinging
to the fronds.
• Screw the lid on until the black marks meet or just
beyond
• Ensure fluid level in vial is visible – do not completely
obscure with the label
• Ensure vial is correctly and clearly labelled
Basic Sample Method
• Insert longer central
bristles into cervical
os
• Turn in clockwise
direction pushing
onto the cervix X 5
rotations
• The lateral bristles
will splay over the
ectocervix
Stenosed Os
• MUST be used TOGETHER
1st
then
2ND
Endocervical Canal Sampling
• AFTER Cervex
Brush – insert
endocervex brush
until flange is at
entrance to canal
Rotate 1x90° in
clockwise direction
• Samples from
BOTH brushes go
into the same vial
and should be
clearly indicated on
the form
Wide Ectropian
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• Use cervix brush first to sample
• If required a second Cervix Brush
can be used to sample the wide
transformation zone – this should
be collected by sweeping the
transformation zone at least twice
• Material sampled from both brushes
should be put in the same vial and
clearly indicated on the form
Transformation Zone
Post-menopausal Women
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Difficult to sample
Thinner squamous epithelium
Atrophic changes
Painful for the Patient
SCJ difficult to visualise
Ending the consultation
The woman must understand • That a sample has been taken
• How she will receive her result
• A brief outline of the possible
results and follow up
• That help, support and written
information are available
• Double check details and
completion of form and pot!!!
Completion of the sample request
form (HMR101)
• On the sample form note if the sample is
cervical or vault
• Tick that you have visualised the cervix
and taken a 360 degree sweep x 5
• Note the appearance of the cervix
• Abnormal bleeding on taking the sample
• Abnormal discharge
• Use of additional sampler (endocervical
brush)
• Insert your Sample Taker Number
(mandatory)
• Sign own name and date form
Documentation
• Record in notes &/or computer
• Visualisation of cervix & sampling of
TZ
• Date sample taken and by whom
• Any pertinent comments related to
the procedure or what you have
seen
• Audit
General points for discussion
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Cervical mucus and vaginal discharge
High vaginal & chlamydia swabs
Ectropion
Lubrication
Pregnancy
Post menopausal samples
Vault samples
Inadequate samples
Woman with special requirements
Inadequate samples
Specimens that are technically inadequate at screening:
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Heavily blood stained specimen – insufficient cells seen
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Insufficient cells present – possibly due to specimen contamination with lubricant
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Insufficient cells present
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Mostly endocervical cells (EC) present, insufficient squamous cells
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Squamous cells only – insufficient EC cells for follow-up
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Squamous cells obscured by polymorphs/debris
Specimens that are inadequate due to Paperwork/Technical reasons
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Unlabelled vial arrives with form
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Vial contains brush head
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Specimen leaked insufficient for processing
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Sample taken more than 6 weeks prior to receipt in laboratory
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No specimen received - Lab will contact sample taker - if sample with clear identifiers
found, will screen as usual
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Incorrectly labelled vial/partially incorrect identifying information - Lab will give sample
taker opportunity to correct identifying information if appropriate
Speciments that are inadequate due to Sample Taker id number issues
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Sample takers must be aware of the necessity for training evidenced by valid sample
taker id numbers and the sample taker must be identifiable on all samples screened.
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Sample Taker id number absent - Sample takers will be asked to provide a valid sample
taker number. If they are unable to do this, the matter will be referred to the local PCT.
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Sample Taker id number not recognised