Cervical Laceration

Cervical laceration is a tear of the cervix during birth. It results from rapid dilatation, precipitate labour, forceps or vacuum, delivery through an incompletely dilated cervix, cerclage and macrosomia. It matters because it causes heavy bleeding from the cervix with a firm uterus, and large tears extend into the lower segment and broad ligament.

• Risk factors: precipitate labour, assisted delivery, pushing before full dilatation, previous cervical surgery or cerclage, large baby, young age.
• Most tears are 1 to 2 cm and bleed little.
• Tears over 2 cm need repair.

Women have steady bright red bleeding after birth with a well contracted uterus. Large tears give profuse bleeding and shock, and lower segment extension causes pain and an expanding broad ligament mass.

• Continuous bleeding with a hard, contracted uterus.
• Bleeding unresponsive to oxytocin.
• Differential diagnosis: uterine atony, retained placental tissue, vaginal laceration, uterine rupture, coagulopathy, uterine inversion.
• Complications: postpartum haemorrhage, shock, broad ligament haematoma, extension to the lower segment or uterine artery, infection, cervical stenosis, cervical insufficiency in later pregnancy, hysterectomy.

The diagnosis is made by direct examination of the cervix with good light after the placenta has delivered.

• Systematic inspection with two sponge holding forceps (ring forceps) grasping the cervix at 12 o'clock and moving clockwise, under good light, with an assistant and analgesia.
• Uterine tone and fundal height (a rising fundus suggests concealed bleeding).
• Pulse, blood pressure, blood loss measurement, haemoglobin, clotting screen.
• Ultrasound or CT for a suspected broad ligament haematoma.

The principle is to confirm that the uterus is contracted, expose the cervix, and repair the tear from the apex down.

• Supportive: resuscitate with two large-bore cannulae and Ringer's lactate 1 to 2 litres; transfuse for shock; bimanual compression while preparing; lithotomy with good light, an assistant and a speculum; bladder catheter; analgesia.
• Pharmacological: lignocaine 1 percent 10 to 20 mL (maximum 3 mg/kg, not above 200 mg) or spinal anaesthesia; oxytocin 10 IU IM and 20 IU in 1 litre Ringer's lactate at 125 mL per hour for 4 hours; tranexamic acid 1 g IV over 10 minutes, repeated once after 30 minutes if bleeding continues; cefazolin 2 g IV as a single dose; paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours); amoxicillin-clavulanate 625 mg oral 8-hourly for 5 days for large tears.
• Procedures: repair with continuous or interrupted absorbable suture (1 polyglactin) starting 1 cm above the apex of the tear and ending at the margin, without including the whole thickness of the cervix at the margin; laparotomy for a tear extending into the lower segment or broad ligament with uterine artery ligation or repair; hysterectomy for uncontrolled bleeding; balloon tamponade for oozing.
• Special groups: women with a repaired cervical tear are told to book early in the next pregnancy for cervical length scans and possible cerclage.
• Red flags: bleeding with a contracted uterus, rising fundus, expanding flank or pelvic pain, shock, fever above 38 degrees Celsius.
• Follow-up: pulse and blood pressure and bleeding every 15 minutes for 2 hours then 4-hourly for 24 hours; haemoglobin at 24 hours and ferrous sulphate 200 mg oral 8-hourly for 3 months if anaemic; review at 6 weeks with speculum examination.