Because of the gravity of the situation, the emergency staff/ clinician who first sees a rape victim must be empathetic.
1)Written consent must be obtained for the gynaecological examination.
Photographs may also be taken if they are to be used as evidence. The written consent may be obtained either from the patient or guardian/next of kin.
The police should also be notified as soon as possible.
2)History should be obtained from the patient. Ideally it must be recorded in her own words. Important aspects of the history include the time, place, circumstances ,last menstrual period (LMP). It is also important to ask if she is pregnant and the time of the most recent coitus prior to the sexual assault.
Other details should include, which of the orifices were penetrated, use of foreign objects, number of assailiants.
Did the victim come directly to the hospital or did she bathe and change her clothing.
3)What is the general appearance of the victim? do you think drugs or alcohol may be involved? Is the victim calm, agitated or confused?
The patient should disrobe while standing on a white sheet. Any hair,dirt, underclothing must be kept as evidence. Torn and stained clothing should also be kept as evidence. The pubic hair should be combed for evidence. Material should also be scraped from beneath the finger nails. All evidence must be placed in separate bags/envelopes and labeled carefully.
The patient should be examined ,and traumatized areas should be photographed.
The body and genitals should be examined with wood’s light to identify semen. Positive areas will fluoresce .These areas should be swabbed with a moisened swab and air-dried in order to identify acid phosphatase.
Colposcopy may be used to identify small areas of trauma eg in the posterior fourchette.
4)A pelvic examination should be performed after explaining the procedure and obtaining the patients consent.
Only a narrow speculum should be used. In rape victims one should only use water as a lubricant.Sterile cotton swabs should be used to collect material from the cervix and upper vagina. These should be air dried on two glass slides after smearing.
Wet and dry swabs should also be collected and refrigerated for subsequent DNA and acid phosphatase evaluation.
If appropriate the mouth and the anus must be swabbed (eg in anal rape).
Secretions from the vagina,mouth,anus may be collected by a swab and placed on a slide. A drop of saline should be added and covered with a coverslip. This should be examined for motile and non motile sperms. The finding must be recorded. The percentage of motile forms must be noted.
5)Laboratory tests should be done to identify sexual transmitted diseases. Swabs may be taken from the vagina, anus or mouth and cultured for N Gonorrhoea and chlamydia. A wet mount for trichomonas vainalis and a papanicolaou smear should be done. A VDRL test (for syphilis) and a pregnancy test should be done.
A HIV antibody test should be done and repeated after 2 to 4 months later, if the initial test was negative.The pregnancy test must be repeated if the next menses is missed. Ideally the VDRL should be repeated in six weeks time.
Blood(without anticoagulant) and urine specimen should be obtained if there is a history of forced ingestion or injection of drugs .
6) Laboratory specimens should be transferred to the responsible clinical pathologist/technician in the presence of witnesses and never via a messenger, so that evidence is not breached.
Treatment /drugs administered to rape victims will be addressed in a subsequent post.
Pages 758 to 759. Chapter 17. Rape.Gynaecology. CMDT 2006. Current Medical Diagnosis and Treatment 2006.45 th Edition. Edited by Lawrence M. Tierney,Jr. Stephen J McPhee, Maxine A. Papadakis.
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