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1. Medical assistant
2. Electronic records
3. Medical terminology and anatomy
4. The fundamentals of infection control
5. Introduction to vital signs
6. The patient interview and history
7. The physical examination
8. Appointment scheduling
9. Insurance billing
10. Diagnostic coding and the ICD-10-CM System
11. Procedural coding
12. Medical billing and reimbursement essentials
13. Assisting with medical specialties
14. Assisting with the musculoskeletal system
15. Assisting with the cardiovascular system
16. Assisting with the respiratory system
17. Assisting with the nervous system
18. Anatomy and physiology of the urinary system
19. Assisting in obstetrics and gynecology
19.1 Assisting in obstetrics and gynecology
19.2 Female reproductive system infections and menopause
19.3 Contraception methods
19.4 Medical assistant's role in gynecologic examinations: setup and preparation
19.5 Prenatal and postpartum care
19.6 Obstetric history and the prenatal record
20. Assisting in endocrinology
21. Assisting in ophthalmology & otolaryngology
22. Assisting in gastroenterology
23. Assisting in the immune & lymphatic systems
24. Assisting in pediatrics: the developmental stages and care
25. The medical assistant’s role in caring for the older patient
26. The role of the medical assistant in physical therapy examination and assessment
27. Preparing for minor surgery: room, solutions, and supplies
28. Introduction to the clinical laboratory
29. Urinalysis
30. Blood collection
31. Analysis of blood
32. Electrocardiography and heart structure
33. The principles of pharmacology
34. Essential calculations and measurement systems
35. Solid, liquid, & solutions medication doses
36. Administering medications
37. Metabolism and core nutrient roles
38. Medical emergencies in the healthcare setting
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19.4 Medical assistant's role in gynecologic examinations: setup and preparation
Achievable CCMA
19. Assisting in obstetrics and gynecology
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Medical assistant's role in gynecologic examinations: setup and preparation

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In this section, we discuss the medical assistant’s role in gynecologic and obstetric procedures. A medical assistant has two roles in these situations:

  • Assist the provider in any way needed
  • Be there for the patient by helping her to be as comfortable as possible during her time in the healthcare facility

When we make the patient feel comfortable, we help establish a trusting relationship with her. This enables her to share the information the provider needs to give her the best possible care.

Assisting with the gynecologic examination

The need for an annual pelvic examination is being debated in the medical community. Currently, the American College of Obstetricians and Gynecologists (ACOG) recommends that pelvic and breast examinations be performed when indicated by medical history or symptoms. This examination is done to evaluate the reproductive organs and diagnose and treat any abnormalities of those organs.

A breast examination is considered part of the gynecologic examination. A clinical breast examination should be done every 1 to 3 years. The provider examines the breast, underarm area, and just below the clavicle.

Setting up for a gynecologic examination

A medical assistant is responsible for setting up the examination room and making sure that all of the supplies are available for a gynecologic examination. The following is a list of supplies needed for a routine gynecologic examination:

  • Patient’s health record
  • Laboratory requisition slips
  • Patient gown and drape
  • Lubricant
  • Examination light
  • Cervical spatula or cytobrush
  • Microscope slides (direct smear method)
  • Fixative (direct smear method)
  • Plastic-fronded broom (liquid-based method)
  • Liquid preparation container (liquid-based method)
  • Vaginal speculum
  • Sterile swabs
  • Fecal occult blood test cards with developer
  • Biohazard waste container

All items should be placed within easy reach for the provider and organized in a logical manner.

Preparation for the gynecologic examination

At the time the appointment was made, the patient should have been advised not to douche or have sexual intercourse for 24 hours before the examination. This allows the vaginal discharge to be properly evaluated and ensures accurate results of cytologic studies. Before the provider begins the pelvic examination, the medical assistant should obtain a complete gynecologic history. After documenting the patient’s history and chief complaint, the medical assistant should prepare the room and the patient for the.

Tray setup for a Pap smear procedure displayed
Pap tray set up
Wikimedia Commons
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CC BY-SA 4.0

The following should be included in the gynecologic history:

  • Age at menarche
  • Details about the regularity of the menstrual cycle, the amount and duration of menstrual flow, and a history of menstrual disturbances and their treatment
  • Any current indicators of infection, including vaginal discharge, pelvic pain, and urinary difficulties
  • Description of any breast abnormalities and the date of the patient’s last mammogram
  • Date of the last Pap test
  • Sexual history; sexually transmitted infection (STI) history
  • Number of times pregnant and the number of pregnancies carried to more than 20 weeks
  • Date of last menstrual period (LMP)
  • Lifestyle factors, including diet, exercise, smoking, and alcohol use

Medical assistant’s role in gynecologic and obstetric procedures

  • Assist provider as needed during exams and procedures
  • Support patient comfort and emotional well-being
  • Build trust to facilitate open communication

Assisting with the gynecologic examination

  • ACOG: pelvic and breast exams based on history/symptoms
  • Breast exam included as part of gynecologic exam
  • Clinical breast exam recommended every 1–3 years

Setting up for a gynecologic examination

  • Prepare and organize all necessary supplies:
    • Health record, requisition slips, gown/drape, lubricant, exam light
    • Cervical spatula/cytobrush, slides, fixative, broom, liquid prep container
    • Vaginal speculum, sterile swabs, fecal occult blood test cards, biohazard container
  • Ensure items are within easy reach and logically arranged

Preparation for the gynecologic examination

  • Advise patient: no douching/intercourse 24 hours prior
  • Obtain and document complete gynecologic history:
    • Menstrual history, infection indicators, breast abnormalities, last Pap/mammogram
    • Sexual/STI history, pregnancies, LMP, lifestyle factors

Assisting with an examination

  • Maintain professionalism, explain procedures, address patient concerns
  • Provide patient education in simple terms
  • Remain in room for reassurance and legal protection
  • Instruct patient to empty bladder, disrobe, and wear gown as per provider preference

Pap test and screening guidelines

  • Ages 21–29: Pap test every 3 years (no HPV alone)
  • Ages 30–65: Pap + HPV every 5 years (preferred), or Pap every 3 years, or HPV every 5 years
  • After hysterectomy: screening based on cervix removal and cancer history
  • Stop screening after age 65 if:
    • No history of moderate/severe abnormal cells or cervical cancer
    • Three negative Pap or two negative co-tests in past 10 years (most recent within 5 years)

Breast examination

  • Visual inspection (sitting), then palpation (supine)
  • Assist with positioning and modesty
  • Yearly mammograms recommended starting at age 45 (average risk)
  • Teach breast self-exam (BSE) technique and warning signs:
    • Skin changes, lumps, size/shape changes, nipple changes, persistent pain

Abdominal examination

  • Palpation to assess pelvic organ symmetry and detect masses
  • Observe for discomfort or pain

Pelvic examination

  • Patient in lithotomy position (assist as needed, maintain coverage)
  • Provider inspects external genitalia, perineal area, and cervix (with prewarmed speculum)
  • Collect Pap specimen; medical assistant labels and prepares for lab
  • Bimanual exam: assess uterus, tubes, ovaries (note position, size, consistency)
  • Digital rectal exam and possible fecal occult blood test

Post-examination duties

  • Assist patient to sitting/dressing room
  • Follow OSHA Standard Precautions for cleanup
  • Sanitize, disinfect, and restock room for next patient

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Medical assistant's role in gynecologic examinations: setup and preparation

In this section, we discuss the medical assistant’s role in gynecologic and obstetric procedures. A medical assistant has two roles in these situations:

  • Assist the provider in any way needed
  • Be there for the patient by helping her to be as comfortable as possible during her time in the healthcare facility

When we make the patient feel comfortable, we help establish a trusting relationship with her. This enables her to share the information the provider needs to give her the best possible care.

Assisting with the gynecologic examination

The need for an annual pelvic examination is being debated in the medical community. Currently, the American College of Obstetricians and Gynecologists (ACOG) recommends that pelvic and breast examinations be performed when indicated by medical history or symptoms. This examination is done to evaluate the reproductive organs and diagnose and treat any abnormalities of those organs.

A breast examination is considered part of the gynecologic examination. A clinical breast examination should be done every 1 to 3 years. The provider examines the breast, underarm area, and just below the clavicle.

Setting up for a gynecologic examination

A medical assistant is responsible for setting up the examination room and making sure that all of the supplies are available for a gynecologic examination. The following is a list of supplies needed for a routine gynecologic examination:

  • Patient’s health record
  • Laboratory requisition slips
  • Patient gown and drape
  • Lubricant
  • Examination light
  • Cervical spatula or cytobrush
  • Microscope slides (direct smear method)
  • Fixative (direct smear method)
  • Plastic-fronded broom (liquid-based method)
  • Liquid preparation container (liquid-based method)
  • Vaginal speculum
  • Sterile swabs
  • Fecal occult blood test cards with developer
  • Biohazard waste container

All items should be placed within easy reach for the provider and organized in a logical manner.

Preparation for the gynecologic examination

At the time the appointment was made, the patient should have been advised not to douche or have sexual intercourse for 24 hours before the examination. This allows the vaginal discharge to be properly evaluated and ensures accurate results of cytologic studies. Before the provider begins the pelvic examination, the medical assistant should obtain a complete gynecologic history. After documenting the patient’s history and chief complaint, the medical assistant should prepare the room and the patient for the.

The following should be included in the gynecologic history:

  • Age at menarche
  • Details about the regularity of the menstrual cycle, the amount and duration of menstrual flow, and a history of menstrual disturbances and their treatment
  • Any current indicators of infection, including vaginal discharge, pelvic pain, and urinary difficulties
  • Description of any breast abnormalities and the date of the patient’s last mammogram
  • Date of the last Pap test
  • Sexual history; sexually transmitted infection (STI) history
  • Number of times pregnant and the number of pregnancies carried to more than 20 weeks
  • Date of last menstrual period (LMP)
  • Lifestyle factors, including diet, exercise, smoking, and alcohol use
Key points

Medical assistant’s role in gynecologic and obstetric procedures

  • Assist provider as needed during exams and procedures
  • Support patient comfort and emotional well-being
  • Build trust to facilitate open communication

Assisting with the gynecologic examination

  • ACOG: pelvic and breast exams based on history/symptoms
  • Breast exam included as part of gynecologic exam
  • Clinical breast exam recommended every 1–3 years

Setting up for a gynecologic examination

  • Prepare and organize all necessary supplies:
    • Health record, requisition slips, gown/drape, lubricant, exam light
    • Cervical spatula/cytobrush, slides, fixative, broom, liquid prep container
    • Vaginal speculum, sterile swabs, fecal occult blood test cards, biohazard container
  • Ensure items are within easy reach and logically arranged

Preparation for the gynecologic examination

  • Advise patient: no douching/intercourse 24 hours prior
  • Obtain and document complete gynecologic history:
    • Menstrual history, infection indicators, breast abnormalities, last Pap/mammogram
    • Sexual/STI history, pregnancies, LMP, lifestyle factors

Assisting with an examination

  • Maintain professionalism, explain procedures, address patient concerns
  • Provide patient education in simple terms
  • Remain in room for reassurance and legal protection
  • Instruct patient to empty bladder, disrobe, and wear gown as per provider preference

Pap test and screening guidelines

  • Ages 21–29: Pap test every 3 years (no HPV alone)
  • Ages 30–65: Pap + HPV every 5 years (preferred), or Pap every 3 years, or HPV every 5 years
  • After hysterectomy: screening based on cervix removal and cancer history
  • Stop screening after age 65 if:
    • No history of moderate/severe abnormal cells or cervical cancer
    • Three negative Pap or two negative co-tests in past 10 years (most recent within 5 years)

Breast examination

  • Visual inspection (sitting), then palpation (supine)
  • Assist with positioning and modesty
  • Yearly mammograms recommended starting at age 45 (average risk)
  • Teach breast self-exam (BSE) technique and warning signs:
    • Skin changes, lumps, size/shape changes, nipple changes, persistent pain

Abdominal examination

  • Palpation to assess pelvic organ symmetry and detect masses
  • Observe for discomfort or pain

Pelvic examination

  • Patient in lithotomy position (assist as needed, maintain coverage)
  • Provider inspects external genitalia, perineal area, and cervix (with prewarmed speculum)
  • Collect Pap specimen; medical assistant labels and prepares for lab
  • Bimanual exam: assess uterus, tubes, ovaries (note position, size, consistency)
  • Digital rectal exam and possible fecal occult blood test

Post-examination duties

  • Assist patient to sitting/dressing room
  • Follow OSHA Standard Precautions for cleanup
  • Sanitize, disinfect, and restock room for next patient

More from Assisting in obstetrics and gynecology

  • Assisting in obstetrics and gynecology
  • Female reproductive system infections and menopause
  • Contraception methods
  • Prenatal and postpartum care
  • Obstetric history and the prenatal record