According to the latest research from the Centers for Disease Control and Prevention (CDC), one in four American adults lives with a disability. That group includes as many as 61 million people, and a large proportion of them are in need of gynecological care.
Some adults live with physical disabilities that create mobility challenges, whereas others live with developmental disabilities. No matter their health status, these individuals are just as entitled to comprehensive healthcare as anyone else.
That said, caring for a patient with physical challenges or developmental disabilities may present an extra challenge for practicing OB/GYNs. Providers should educate themselves on ways to accommodate patients with disabilities to ensure they receive the best care possible.
Caring for a Patient With Physical Challenges
The American Institute of Physics notes that most diseases and rehabilitative states associated with physical impairments usually involve some degree of immobility. Patients may present to your practice with wheelchairs, walkers, canes, crutches, braces or other mobility devices.
Providing complete gynecological care for these patients begins with ensuring that your exam rooms are accessible. Patients with physical disabilities must be able to enter and exit the room easily. While those with assistive devices such as crutches or canes may be able to navigate through narrow doorways, people in wheelchairs may have more trouble. Standard wheelchairs range from 16 to 20 inches wide. As such, the most recent version of the Americans with Disabilities Act directs providers to ensure that entry door openings measure at least 32 inches wide when the door is open to 90 degrees.
There must also be enough clear floor space inside the room for the patient to safely maneuver their assistive equipment and transfer to the exam table. You should base the number of accessible exam rooms on the size of your practice — the larger the practice, the more accessible exam rooms you need.
If a patient cannot be examined while remaining in their mobility device, accessible examination tables are also necessary. Features of an accessible exam table include:
- A height that is adjustable to the level of a wheelchair seat, or 17 to 19 inches from the floor.
- Stabilizing or supportive elements that assist during transfer and examination, including rails, straps or wedges.
Patients should not be left alone to transfer to the exam table unless they decline help. Ask the patient how you can best assist their preparation and transfer. It may be necessary to help patients with limited mobility undress, position and stabilize themselves before the exam, but you should always prioritize their dignity and consent.
Recognizing Different Positions for the Pelvic Exam
Patients with mobility issues may not be able to assume the standard pelvic exam position on the exam table. In many cases, it is necessary to try other positions that keep the patient comfortable and minimally exposed while also ensuring adequate access to their anatomy. Providers may try one of several positions in order to complete a pelvic exam, including:
- The diamond-shaped position.
- The knee-chest position.
- The M-shaped position.
- The V-shaped position.
The American College of Physicians' Women's Health Handbook offers diagrams and tips for each of these positions.
If the patient can assume the usual stirrups position, it may be beneficial to move the stirrups so that they support each knee directly, rather than the patient's feet. This position allows you to perform your exam while the patient receives extra support for their legs.
Caring for a Patient With Developmental Disabilities
A 2018 study in BMC Public Health classifies intellectual disabilities, a type of developmental disability, as a significant general impairment in intellectual functioning acquired during childhood. The same study also found that most young women with these types of developmental disabilities have sexual intercourse by the age of 20.
Most women who are developmentally disabled have normal reproductive anatomy and breast development. As such, regular screening examinations should begin at age 18, or when they become sexually active. But in some cases, family members, caregivers and even some healthcare providers are reluctant to provide gynecological care for these patients. A survey published in Health Equity found that providers initiated contraceptive counseling less often with those who had an intellectual or developmental disability than they did with nondisabled patients.
Routine gynecological care is extremely important in this patient population, but you may struggle with finding effective methods of care. However, some basic techniques make routine examinations more comfortable and efficient.
Regardless of the patient's cognitive abilities, it is important for you to communicate directly with them in a manner they can understand. Research published in American Family Physician recommends using pictures, gestures and non-threatening behaviors in addition to speech or writing if your usual methods are inadequate. It may also be beneficial to allow extra time for patient interactions, allowing them to communicate in the manner best suited to their understanding. Doctors can demonstrate procedures, role-play, offer choices and reward participation to help enhance the patient experience.
A patient with developmental challenges may also benefit from a tour of the office and exam room before any procedure takes place. In some cases, having a familiar person accompany the patient throughout the exam may help keep the patient relaxed and receptive.
Altering Your Examination Technique
In some cases, it may be necessary to alter your examination technique to provide a positive patient experience while gathering all the information you need. The University of New Mexico suggests that if a pelvic exam is possible, you may try using a Q-tip to "blindly" sample the patient's os. You could also try using a narrow speculum for patients with developmental challenges, as this may be more comfortable and less intimidating.
In some cases, a pelvic exam is not possible. When this occurs, other diagnostic technologies may provide enough information to aid in the diagnostic or screening process. In some cases, transabdominal ultrasound can help you evaluate the patient's anatomy and detect problems such as fibroids or uterine adhesions.
In rare cases, sedation may be necessary for a thorough exam of a patient with developmental disabilities. This should be a last resort, but should not be excluded from consideration if an exam is not possible using other methods.
Every person with a physical or developmental disability should receive the highest standard of gynecological care possible. Accommodating patients of diverse physical and mental abilities is an important part of any medical practice. Since people with disabilities are still at risk for reproductive cancers and other problems, finding ways to adapt to their needs should be a part of every clinician's focus.
