Written by Samantha Hyacinth
When we think of the pelvic exam, many of us picture a person lying on their back on an exam table with their heels in foot rests or leg rests, known as the lithotomy position. For some people, this position is not physically possible or comfortable.* There are many conditions that may prevent a person from being able to access these positions, such as pain, muscle weakness, spasticity, or joint stiffness. These conditions may be more common in people with the following diagnoses: cerebral palsy, spinal cord injury, multiple sclerosis, short stature, Ehlers-Danlos syndromes, and scoliosis, among others. It’s important to also acknowledge that some people may find the more commonly used positioning for pelvic exams to be emotionally challenging due to trauma that has occurred inside and/or outside of the exam room.
To perform a more inclusive pelvic exam, clinicians should consider alternative positions. Keep in mind that while all of the positions here require the patient to change position, it is important that clinicians be willing to change their position (eg. stand, kneel, squat) when able, and/or have adaptive and accessible equipment available. The positions listed here are not meant to be an all-inclusive list, finding the best position may require some trial and error. Consider asking patients what’s worked best in the past. Remember that some patients with tremors may be unable to be still during exams; requests to relax may be triggering.
The Knee Chest Position
The patient lays on their side, knees bent, with the top leg closer to their chest. A support person or clinic chaperone may help hold the top leg in position. The bottom leg can either be bent or straight. The clinician places the speculum with the handle directed toward the patient’s back while angling the bill of the speculum toward the patient’s lower back. This position may benefit from pillows or wedges for support.
The Diamond Position
The patient lays on their back and allows their knees to fall apart while keeping their heels together on the foot of the exam table, forming a diamond-shape with their legs. The speculum can be inserted with the handle pointing upward or downward, depending on the available space. Some patients may benefit from placing a cushion under their hips. This position may not be possible for patients with concerns for dislocations or with permanent subluxation.
The M Position
The patient lays on their back with their feet flat on the exam table. With their heels close to their buttocks, the knees are bent and able to fall away from each other creating an ‘M’ shape. A support person or clinic chaperone may support one or both knees during the exam. The speculum may be inserted with the handle pointing upward or downward. Some patients may benefit from placing a cushion under their hips. This position may not be possible for patients with concerns for dislocations or people with permanent subluxation.
The V Position
The patient lays on their back with their legs straight and separated toward either side of the exam table. They may need a support person or clinic chaperone to support each leg. This position can be used with or without foot rests. Alternatively, this position can be used with the person prone (or lying on their stomach).
With their abdomen facing the table, the patient rests on their hands and knees.
Prone Knee to Chest
While laying on their abdomen, the patient pulls their knees up toward their chest. Their torso rests on or between their thighs, using a pillow between the thighs may be helpful for some. This position can also be done with the patient lying on their back, holding their legs in place themselves or with the help of a support person.
Standing Forward Fold
The patient stands in front of the table and bends over the table so their torso touches. Some patients may benefit from resting their torso on a pillow.
*For more information on why the use of foot rests may be uncomfortable for patients please see the following video: This is How I Teach: Speculum Care Without Stirrups – Innovating Education in Reproductive Health
For a visual guide to some of the positions mentioned here written by two self-described physically disabled women, please see: Table Manners. A Guide to the Pelvic Examination for Disabled Women and Health Care Providers. Please keep in mind that this guide was published in 1982 and as a result uses gendered language and other terms that readers may find offensive. We at RHAP would also like to acknowledge that the images included in this guide are not representative of the racial/gender/size/overall diversity of the patients seen for pelvic exams.
Some clinics may consider purchasing assistive devices such as lifts to support patients with limited mobility:
What to expect when getting a pelvic exam social story by SexEdVA and the Health Education Design Group
The Reproductive Health Access Project does not accept funding from pharmaceutical companies. We do not promote specific brands of medication or contraception. The information in the Contraceptive Pearls is unbiased, based on science alone.
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