What should a healthcare provider do if a client dissociates from their body during a Pap (Papanicolaou) smear?

Managing Patient Dissociation During Pap Smear Examination

If a client dissociates during a Pap smear, the healthcare provider should immediately stop the procedure, help ground the patient through reassuring communication, and only continue when the patient has regained awareness and provided consent to proceed.

Recognizing Dissociation During Pelvic Examination

Dissociation during a Pap smear may present as:

• Sudden detachment or emotional withdrawal
• Glazed or unfocused eyes
• Unresponsiveness to questions or instructions
• Physical rigidity or unusual stillness
• Visible distress without verbal communication

Immediate Response Protocol

1. Stop the examination immediately

   • Remove the speculum if already inserted
   • Cover the patient with a drape to restore dignity
   • Move to a position where eye contact is possible

2. Help ground the patient

   • Speak in a calm, reassuring voice
   • Use the patient's name
   • Provide simple orientation statements: "You're at the clinic. You're safe."
   • Encourage slow, deep breathing

3. Assess patient status

   • Once the patient appears more present, gently ask how they're feeling
   • Determine if they wish to continue, reschedule, or stop completely

Continuing Care Options

After the patient has regained awareness, discuss options:

1. Continue with modifications

   • Offer additional support measures (see below)
   • Proceed more slowly with frequent check-ins
   • Consider using a smaller speculum

2. Reschedule the examination

   • Discuss potential accommodations for future visits
   • Consider referral to a provider with trauma-informed care experience
   • Document the experience to inform future care

3. Alternative approaches

   • Discuss self-collection options if appropriate
   • Consider anxiolytic medication for future visits (requires separate prescription)

Support Measures to Prevent or Manage Dissociation

• Before the examination:

  • Explain each step of the procedure in advance
  • Allow the patient to see and touch instruments if desired
  • Offer a support person to be present
  • Position the examination table so the patient can see the door

• During the examination:

  • Maintain continuous verbal communication
  • Use distraction techniques (conversation, breathing exercises)
  • Give the patient control through a clear stop signal
  • Provide regular updates on progress

• After a dissociative episode:

  • Allow recovery time before leaving the examination room
  • Provide written information about the experience and coping strategies
  • Schedule a follow-up call to check on the patient's wellbeing

Documentation and Follow-Up

Proper documentation is essential after a dissociative episode:

• Record the occurrence of dissociation
• Document interventions provided
• Note patient's preferences for future examinations
• Ensure clear communication with other providers who may see the patient

Special Considerations

The National Comprehensive Cancer Network and CDC guidelines emphasize the importance of cervical cancer screening 1, 2, but these must be balanced with patient wellbeing. Research shows that psychological distress is severe in women who receive abnormal Pap results 3, and bodily experiences are an intrinsic part of medical follow-up 4.

For patients with a history of trauma or previous dissociation:

• Consider scheduling a longer appointment time
• Discuss trauma-informed approaches before the examination
• Offer the option of bringing a support person
• Consider referral to mental health services for additional support

Remember that while cervical cancer screening is important for reducing morbidity and mortality, the patient's psychological wellbeing must be prioritized to ensure continued engagement with preventive healthcare.