THE PAP TEST PROCEDURE: LIQUID BASED CYTOLOGY (LBC)

1 Label the vial with the woman’s first 2 Insert an appropriately sized speculum 3 Take STI specimens if required. Gently
name, last name and PHIN (or RCMP, and inspect the cervix (warm water wipe away excessive discharge/mucous
military, other provincial/territorial, may be used to lubricate the speculum on the cervix with an oversized cotton
or passport number). The PHIN and if necessary). swab. This should be done as gently
name on the vial must match the as possible to avoid removing the
PHIN and name on the requisition. cervical cells to be sampled.

4 Insert the broom deeply enough For SurePath: Insert the broom into the larger opening
into the endocervical canal so that of the vial. Rotate the broom 90° to use the inner edge
the shorter bristles fully contact of the insert to pull off the broom into the vial.
the ectocervix. Rotate the broom
5 times in a clockwise direction.

For ThinPrep: Rinse the broom by pushing it into the

bottom of the vial 10 times, forcing the bristles apart.
Then, swirl the broom vigorously to release more material.

Place the cap on the vial and tighten firmly.

5
Any visual cervical abnormalities and/or symptoms
(i.e. abnormal bleeding or discharge) must be
investigated regardless of cytology findings.

Alternative collection method: A plastic spatula and cytobrush may also be used to collect LBC samples.

1 Spatula For SurePath: Snap off the head of the spatula

Insert the spatula into the (avoid touching the head of the device), and drop
cervical os and rotate 360° with into the liquid vial (avoid splashing).
firm pressure.

For ThinPrep: Rinse the spatula by swirling it

vigorously in the vial 10 times. Discard the spatula.

Cytobrush
2 For SurePath: Snap off the head of the cytobrush
Insert the cytobrush into the (avoid touching the head of the device), and drop
cervical os no further than the into the liquid vial (avoid splashing).
end of the bristles and rotate 90°.

For ThinPrep: Rinse the cytobrush by swirling it

vigorously in the vial 10 times. Discard the cytobrush.

Pregnant women
Screening pregnant women is unnecessary if the woman has had routine negative Pap tests, has no symptoms of cervical cancer
and/or no visual abnormalities of the cervix. If a Pap test is warranted, use the broom only in the first 10 weeks of pregnancy.
If the woman is over 10 weeks pregnant, the benefits of screening should outweigh the potential harms.
Only the plastic spatula should be used.
IDENTIFYING SPECIMEN TAKERS
ON THE CERVICAL CYTOLOGY REQUEST FORM
The specimen taker must be clearly identified on the cervical cytology request form in the “CervixCheck/Provider #” field.
Where nurses, clinical assistants (CA) and physician assistants (PA) perform Pap tests under a physician or nurse practitioner,
a CervixCheck provider number (issued by CervixCheck) should be recorded in the “CervixCheck/Provider #” field. The billing
number of the physician or nurse practitioner overseeing these Pap tests should be captured in the “Bill to (#)” field.

CERVICAL CYTOLOGY REQUEST FORM

Send specimen to:
± Gamma Dynacare Medical Laboratories ± Health Sciences Centre Cytology Laboratory ± Westman Laboratory
830 King Edward St, Ste #100, Winnipeg, MB R2H 0P4 820 Sherbrook St (MS337), Winnipeg, MB R3A 1R9 Unit 1-150 McTavish Ave, E, Brandon, MB R7A 7H8
Ph: (204) 944-0757 Fax: (204) 957-1221 Ph: (204) 787-1352 Fax: (204) 787-1790 Ph: (204) 578-4440 / 1-800-661-5458 Ext. 4467
Fax: (204) 578-2819
± St. Boniface Hospital Cytology Laboratory ± Unicity Laboratory Services, Cytology Department
409 Taché, Winnipeg, MB R2H 2A6 106-2200 McPhillips St, Winnipeg, MB R2V 3P4
Ph: (204) 237-2504 Fax: (204) 235-3423 Ph: (204) 633-2806 Fax: (204) 632-9236

Accession # Date received (dd/mmm/yyyy) Specimen collection date (dd/mmm/yyyy)

PATIENT INFORMATION PATIENT HISTORY

* Matching PHIN and first and last name required on vial (or slide in pencil)

Last normal menses (dd/mmm/yyyy) Last Pap test (dd/mmm/yyyy)

Last name First name

Previous abnormal Pap test (dd/mmm/yyyy)

PHIN (or military, other prov/terr #) MB Health #
± Pregnant ± Postpartum (# weeks)
±F ±M ± Menopausal ± Postmenopausal
Date of birth (dd/mmm/yyyy) Gender 3rd party billing
PREVIOUS TREATMENT:
± Colposcopy ± Laser ± Cryotherapy ± LEEP
Address ± Knife cone ± Irradiation ± Wide local excision

Date (dd/mmm/yyyy)
City Prov Postal code
HYSTERECTOMY: Previous cancer
SPECIMEN PREPARATION: ± Total ± Subtotal
± Liquid based cytology ± Conventional cytology PRESENT TREATMENT:
INSTRUMENT(S): Hormonal: ± HRT ± OCP ± IUCD
± Broom ± Spatula ± Cytobrush COMMENTS:
SOURCE:
± Cervix ± Vagina

PROVIDER INFORMATION DESIGNATION:

± Physician ± Nurse practitioner ± Nurse
Last name First name ± Physician assistant ± Clinical assistant ± Midwife

Providers should identify themselves on the form as follows:

CervixCheck/Provider # Bill to (#)
DESIGNATION CERVIXCHECK/PROVIDER #: BILL TO (#):

Send report to (street address) Clinical assistant 22### (CervixCheck provider #) Physician or NP billing #

Midwife M6### (Midwife provider #) Midwife billing #

City/Town Prov Postal code
Nurse practitioner Not applicable Billing #
Phone Fax
Nurse (RN, LPN) N### (CervixCheck provider #) Physician or NP billing #

Physician Not applicable Billing #

Copy report to (name)

Address Physician assistant 72### (CervixCheck provider #) Physician or NP billing #

FEBRUARY 2015

Specimen takers should identify themselves on the cervical cytology

request form as follows:
designation cervixcheck/provider #: bill to (#):
Clinical Assistant 22### (CervixCheck Provider #) Physician or NP billing #
Midwife M6### (midwifery provider #) Midwifery billing #
Nurse Practitioner Not applicable Billing #
Nurse (RN, LPN) N### (CervixCheck Provider #) Physician or NP billing #
Physician Not applicable Billing #
Physician Assistant 72### (CervixCheck Provider #) Physician or NP billing #

Contact CervixCheck for:

p CervixCheck provider numbers p questions about screening and patient management
p screening histories of women in your care p to host a Pap clinic in your community
p education and resources

Quick links:
Screening Guidelines
Screening History Request Form TellEveryWoman.ca/resources
CervixCheck Provider Number Request Form
Pap Clinic Registration TellEveryWoman.ca/papclinic
Pap Test Learning Module & Videos TellEveryWoman.ca/module
Education Opportunities TellEveryWoman.ca/education

[email protected]
5-25 Sherbrook Street, Winnipeg, MB R3C 2B1
Tel: (204) 788-8626 Fax: (204) 779-5748
Toll Free: 1-866-616-8805
TellEveryWoman.ca March 2015