- Cervical surgery and CIN – implications for birth
- Cervical tears
- Short cervix
- Cervical (anterior) lips – on a separate page
Cervical Surgery and CIN
I was feeling cautious about a mother’s history of cervical loop excision, which can slow dilatation down. I have heard of women being encouraged to have C/S without even trying for a normal birth with that.
From ‘failure to progress’
I’ve only had that intuitive feeling about something being seriously wrong about four times so far in 6 years. On two occasions, there was undiagnosed pinpoint cervical stenosis (narrowing of the os) both women having had laser treatment, unrecorded on the notes. Both I picked up fairly quickly after I took over care. Both women had been labouring several hours and one woman had been told that she was 5cms dilated and one woman was sent to the ward for the night. Both women needed emergency L.s.c.s.
I had laser surgery on my cervix for CIN 2, six months before getting pregnant for the first time. I asked my midwife whether this would affect dilation, and was told that it was unpredictable – in some cases the cervix was less elastic, but in others it could help dilation as there was less cervix to actually dilate. Certainly none of the midwives I saw made a big deal about it. I have since heard that some women have been advised to have elective c/s ‘just in case’ the cervix didn’t dilate well!!
I noticed that the shape of my cervix had clearly changed after the operation. Instead of a doughnut ring, it felt like a volcano crater. In pregnancy I developed cervical polyps which felt very strange – like soft mushrooms protruding from my cervix. Anyway, it did its job well enough in labour as the first stage was fine – I would do the first stage of labour any day. Not the second though! End result: 4.250 Kg (9lb 6oz) boy born at home. No cervical damage.
When I was researching treatments for CIN I read that loop diathermy was considered a better treatment than laser surgery in many cases – a lower recurrence rate, I think. I did not find any mention in the books I read about it being associated with a higher rate of complications in labour, but then most of the books aimed at patients were a bit sketchy in that respect.
There are some interesting observations about women’s cervixes occasionally not dilating well after cervical surgery on the US Midwife Archives, including suggestions for breaking up the scar tissue by what sounds like a stretch and sweep, and some case histories where this has been very successful. It’s at
I had a question today from a mother who was booked for a home birth which the midwife was happy about. The mum them mentioned that she had a cervical tear in the last delivery which was sutured. It sounded like a long labour, posterior baby and rotational forceps. She is still keen to deliver at home but the midiwfe is now less keen. I have looked in text books but there is little info about the next delivery following a cervical tear. Does anyone have any further info or experience of this?
I have no experience of this, but have been thinking about it, and for what it is worth, here is how I would be thinking if I were asked to be her midwife:
Perineal scarring from one birth does not necessarily lead to a repeat tear in another pregnancy, although some damage is more likely. I would reckon you could expect the same with a cervical tear.
So: it would be important to do everything possible with optimal fetal positioning to avoid a posterior lie in this pregnancy (we use OFP all the time, and it DOES WORK – only the woman has to be determined about it and committed to doing the postural exercises).
It would be important to avoid pushing on an anterior lip, so maybe suggest lying or all fours/knee chest for the last bit of first stage, if it seemed that the last centimetres of dilatation might be becoming a problem..
Careful monitoring of post-partum bleeding would also be needed, of course, with hospital transfer at that stage always a possibility. Adverse signs would be discussed beforehand, so that the woman knew the implications, and quick action could be taken if required. I believe there would be time to transfer into hospital should that become necessary.
Monitoring for vaginal bleeding throughout the birthing period, regular maternal pulse readings, calm and quiet and patience from everybody, and I would certainly be prepared to look after her at home. “Let’s wait and see” in this case might work very well.
I don’t know much about this (just a mum, not a midwife), but if you still can’t find any info specifically on birth following cervical tears, here are some points to think about:
A. Perhaps her midwife is worried the scar in the cervix tearing open and extending upwards into the uterus, causing a rupture? Could be some parallels with VBAC births there perhaps. It might be worth asking a VBAC mailing list if they have any ideas. You would need to look at comparative forces on the cervix as opposed to the main body of the uterus, I guess, as cervix has to do such a different job. I found one study on Medline which noted that a certain amount of obstetric hysterectomies were due to extension of a cervical tear into the uterus, but these were fresh tears, not old ones, as far as I could tell. I’ve tacked the study onto the bottom of this email.
Does the mum know, or her records say, how extensive the cervical tear was? Presumably a tear which was just on the inner surface of the cervix would be a lot less of a threat than one which went all the way through, like all c/s scars do.
B. It might be relevant to look at literature on childbirth after cervical surgery, which will mainly be for pre-cancerous changes, cancer, or polyps. I suppose that surgery on the cervix would differ from cervical tears as it’s usually done by laser or hot wires, so the wound is cauterized as it is created – this might reduce any propensity to reopen perhaps. Anyway, usually the only suggestion about problems with future births is that the scarred cervix might not be as stretchy as an unscarred one.
Interestingly, I found a couple of studies suggesting that cervical tears predispose the woman to cervical cancer or pre-cancer on the wound site, and that suturing reduces this risk. The studies are at the bottom of this message [2,3]. This makes sense as any exposure of parts of the cervix which are not ‘designed’ to be exposed in the vagina, can predispose to cervical cancer and pre-cancer, eg entropion or extropion (not sure which applies when) of the cervix so that cells from the middle of the cervical canal end up around the os.
C. The only useful mentions of cervical tears in my bookshelf say that a) they are usually only found after forceps deliveries, and b) from ‘Pregnancy’ by Gordon Bourne, “Small lacerations frequently happen but these are of no significance. A large laceration … can cause quite severe haemorrhage… Bleeding from a small laceration stops within a few minutes after delivery. If a large laceration is present then one or two small stitches may be inserted to repair the injury and stop the bleeding.”
D. If, for whatever reason, this lady does end up in hospital for the birth, I wonder if this would affect the suitability of prostaglandin gel if she was to be induced?
 HYSTERECTOMY DUE TO EXTENSION OF CERVICAL TEARS:
Obstetric hysterectomy: Ramathibodi’s experience 1969-1987.
AUTHORS: Suchartwatnachai C; Linasmita V; Chaturachinda K
AUTHOR AFFILIATION: Department of Obstetrics and Gynecology, Faculty of Medicine, Ramathibodi Hospital, Bangkok, Thailand.
SOURCE: Int J Gynaecol Obstet 1991 Nov;36(3):183-6
CITATION IDS: PMID: 1685451 UI: 92128658
ABSTRACT: Obstetric hysterectomy was performed on 121 women at Ramathibodi Hospital, Bangkok, between 1969 and 1987, an incidence of 1:875 deliveries. Of 88 women whose records were available, 91% had emergency hysterectomy, with uterine atony as the most common indication (32.5%), followed by placenta accreta (26.2%), uterine rupture (10.0%), extension of cervical tear to the lower uterine segment (8.7%), broad ligament hematoma (6.2%) and placenta previa (5.0%). The intraoperative and postoperative problems included febrile morbidity (52%), intraoperative hypotension (41%), and disseminated intravascular coagulation (5.7%). Late complications included Sheehan’s syndrome (3.4%), post-transfusion hepatitis (2.3%), hematoma (2.3%) and wound infection (2.3%).
 UNSUTURED CERVICAL TEARS POSE RISK OF PRE-CANCEROUS CHANGES
[Birth injury and colposcopic status of the cervix uteri following labor]
VERNACULAR TITLE: Geburtstrauma und kolposkopischer Zustand der Cervix uteri nach der Geburt
AUTHORS: Karagosov A
SOURCE: Zentralbl Gynakol 1976;98(1):56-8
CITATION IDS: PMID: 766499 UI: 76132785
ABSTRACT: A colposcopic examination is made of uterine cervix 3 to 4 months after delivery to 629 women divided into 4 groups: with Caesarian section and vaginal delivery without cervical rupture after inspection, with suture and without suture after cervical rupture. Higher incidence and severe colposcopic changes in the uterine cervix were found in unsutured cervical ruptures after delivery. Suturing of the cervical ruptures after delivery reduces these changes by 25 per cent. For this reason the author recommends cervical inspection and suturing of the existing cervical ruptures after every delivery.
 [Extended prevention of uterine cervix cancer]
VERNACULAR TITLE: Erweiterte Prophylaxe des Carcinoma colli uteri.
AUTHORS: Muller HG
SOURCE: Zentralbl Gynakol 1979;101(5):328-31
CITATION IDS: PMID: 463402 UI: 79227955
ABSTRACT: A transverse-oval os uteri or Emmet’ tear are the result of a tear at the mouth of the womb during final cervical dilatation. Furthermore, they are the cause of a more or less developed ectopia and combined cervical and vaginal fluor with concomitant colpitis. These alterations also represent the foundation not the cause, of a development of cervical carcinoma. In the sense of prophylactic reasoning the elimination of the symptoms mentioned above should be considered. — The use of the speculum and care of the suture of the nearly always torn os uteri after each delivery must be the first step to avoid the development of a collum carcinoma. — In the second place, electrocoagulation or shallow conisation with subsequent coagulation and cryo-surgical treatment of the ectopia has to be carried out. — Therefore the obstetrician decides whether the patient — in view of developing a collum carcinoma — becomes a risk patient. He has to ensure that an almost normal portio uteri returns without ectropion and Emmet’tear and also without cervical and vaginal fluor, which could trouble the patient considerably. — After every delivery, therefore, the speculum should be used. At the same time a cervix tear haemorrhage, one of the most frequent exsanguinations, can be avoided.
THIS STUDY TALKS ABOUT CERVICAL RUPTURE AND OXYTOCICS:
The effect of oxytocics on the human cervix during midtrimester pregnancy.
AUTHORS: MacKenzie IZ
SOURCE: Br J Obstet Gynaecol 1976 Oct;83(10):780-5
CITATION IDS: PMID: 990217 UI: 77045400
ABSTRACT: Observations of the effects of oxytocics on the human pregnant cervix have been made in vivo using a double open ended catheter technique. Prostaglandin E, prostaglandin F2alpha and oxytocin had similar but no specific effects upon the intracervical canal pressure; ergometrine caused contractions of the cervix. The significance of these findings is discussed in relation to cervical rupture and cervico-vaginal fistulae that have been reported following second trimester abortion induced with prostaglandins.
I have a little experience of cervical tears. I have cared for two women who have had fairly large cone biopsies and the Drs and some of the midwives concerned were also worried about the increased risk of cervical tears after this proceedure. I am a bit of a logical thinker myself and I think that the cervix will open and be ok as long as nature is the leader here and there is no directed pushing or any of that sort of thing.
I agree with all that Melanie and Angela said as well. Just to add that if there is a lot of bleeding immediately after the birth, and the uterus is contracted, then you need to have a speculum ready and have a look at the cervix. A cervical tear probably needs to be sutured in hospital, but you could put some pressure or a clamp on it because they bleed a lot when they happen. I have seen one during my hospital practice years ago.
I do think that the forceps were the probable cause last time for this mother, if it was mid- cavity even more probably. It should be outlawed because of the amount of morbidity it causes for mother and baby.
I agree with Melanie, if I were this woman’s midwife I would be happy with a home birth with simple preparation and discussions with the woman well in advance.
I’ve been following the thread about cervical tears. It is not one of my main areas of interest, so I’m not up on the current (if any) literature regarding this. But, from my professional experience about a year ago I cared for a gravida 2 who came into delivery suite at 5cms dilated. She was requesting a pool birth and apparently had had a previous normal labour and delivery. As she was ‘cracking on’ I got her into the pool. She voluntarily got out of the pool about half an hour later and was pushing with contractions. There followed a beautiful normal delivery with her sitting in a reclining chair. Following quite a brisk loss, the third stage was delivered complete.
Following this however, things changed dramatically. The brisk pv bleed developed into a gush – uterus was well contracted, bladder was empty yet extremely heavy bleeding continued. Medical aid was summoned and i.v. access was gained. The registrar repeated my actions in confirming contraction of the uterus and that the bladder was empty. She was unable to stem the flow. On further examination a cervical tear was noted and this was repaired in theatre under general anaesthetic due to the continued heavy blood loss. Total blood loss was a measured 3.5 litres, with at least a further litre on the floor. On careful reading of the notes of the previous labour and delivery, it transpired that there had been a previous cervical tear. Even if I had read this before delivery, I don’t think my management would be any different, although this second cervical tear would probably have been diagnosed more quickly, without the poor woman having to be catheterised twice!
If I were asked to care for a woman with a previous tear to her cervix, I have to say I would be very circumspect about delivery at home and would probably suggest that I accompany her into hospital and make the birth as low-tech as possible there. As a hospital midwife I know that it is possible (although sometimes difficult) to make a warm, comfortable, nest like environment.
I’m sorry if this seems like a negative opinion, but like they say —- happens!
The difference in the case we are discussing of course is that the previous tear is already known about. Knowing would make a lot of difference. I would be encouraging the woman not to push for as long as she can avoid it – no need to hurry into second stage after all – and I would be encouraging her to birth on all fours to take the pressure off – gravity would not be needed to help with a second birth as much anyway.
Being on the watch for a bleed afterwards and taking prompt action as Elaine suggested to contain the bleeding, together with transport to hospital, would work I think.
If the woman wanted to birth at home, after having all the above implications explained and discussed with her, I would support her.
There is some evidence that physiological tears of the cervix are as common as those of the perineum, and are as likely to heal spontaneously, EXCEPT in the case of OP positions.
Here is the reference for a paper on the incidence of cervical trauma postnatally, which appears to suggest that it is widespread, physiological, and likely to heal spontenously. This is Fahmy et al 1990, Postpartum colposcopy of the cervix: injury and healing. Int J Gynaecol Obstet 34:133-7.
The study did implicate occiput posterior position and primiparity in increased risk of damage – however even in these cases, most women did not suffer long term damage. It is not clear from the paper how the early urge to push was handled.
The question of cervical tears is an interesting one. Checking the cervix for tears was never part of my training. If the blood loss was normal we left well enough alone. The one time I had a bleed which I could only ascertain as cervical both from the timing and amount, then transferred the woman where the doctor said it wasn’t worth suturing. Because having giving oxytocic drugs (can’t remember which one or ones) the muscles had contracted better, the tissues were aligned, she wasn’t bleeding and it wasn’t worth doing. That is the only cervical tear I have ever been aware of because I have never used a speculum to examine the cervix or used a sponge forceps to pull the cervix down for a careful inspection.
The reason I am describing this in so much detail is because I now work in amerika. Where it is standard medical policy to turn even the slightest case of hiccups into a major medical event requiring at least 3 doctors. So post-birth, every cervix is examined in one the ways I have described. And all tears are sutured. To what end, I don’t know. I have never seen or even heard of a cervix being sutured in the UK following birth.
Update from mother with a torn cervix
Back in February a list member posted a question on my behalf about cervical tears. I had been discouraged from having a home birth because it transpired that my cervix had torn during the forceps delivery of my daughter back in 1994. I was able to find virtually no information on this subject, particularly the likelihood of tearing again which was main concern. At the time of the question I didn’t have much information on the extent of the scarring apart from the fact the tear had required stitching. Your responses were the only info I was able to get hold of. I wanted to let you all know how it went.
My community midwife arranged for me to see the consultant at the local hospital who went through my pervious notes with me. It turned out that I’d had 2 tears to the cervix. One of the tears had bled profusely until stitched and she estimated I’d lost about 1 litre of blood. She wasn’t at all patronising and freely admitted that she had no idea about the likelihood of tearing again as this was such an unusual situation. Her main concern was that if I did tear again during a delivery at home I would lose a lot of blood – especially as there is no longer a “flying squad” here. In the end I decided to have a Domino delivery in hospital as there is an annexe attached to the L&D ward which is little used, except by community midwives. This was a much less “medical” setting than the regular rooms on the L&D ward.
I had incorporated many of your suggestions into my birth plan and discussed it at length with my Community midwives (they job-share). I was full of good intentions to remain on my hands and knees and to take the 2nd stage gently. I met my midwife, Amanda, at around 9:40 PM at the L&D ward having been in gentle labour since about midday. I’d been having contractions 10 mins apart all afternoon and evening, although they weren’t very painful and still quite short. Amanda examined me at around 10 pm and I was 3 cm dilated – I was quite pleased at this as this was further than I’d got on my own 1st time around. It was suggested that I have some pain-killers (co-codamol?) and try to rest for a few hours as it didn’t look as if anything exciting was going to happen soon. In the time it took Amanda to get the pills and return things had changed – the contractions were speeding up, becoming much more painful and lasting for longer. I seemed to lose all track of time and my memory of the next couple of hours seems to have been condensed into one big pain! The main things I remember are holding on to my husband for dear life and Amanda rubbing my back and keeping up a constant stream of encouragement and reminders about breathing. Apparently this was transition – by 12:55 am I was fully dilated and ready to push.
This was where my good intentions flew out of the window! I had an overwhelming urge to be on my left side and ended up on a bean bag on the floor with a heroic hospital midwife holding my right leg up in the air for me. I’m afraid I couldn’t have not pushed if my life had depended on it – it felt like it took for ever, but was actually only 20 minutes and at 01:17 my son Ewan was born. Incredibly the only damage was a small, superficial tear to the perineum which didn’t need to be stitched. The only slight hitch was that Ewan passed meconium as he was born, probably due to the speed of events – this meant that we had to stay in hospital for that day, but we were discharged at tea-time.
Ewan is now 8 days old and we’re both in fine fettle. I still can’t believe how different my two experiences of childbirth have been. I ended up with post-natal depression after having my daughter and I’m sure that, to a large extent, this was due to the long and stressful delivery. This time it feels like I have a head-start as physically there are no problems and emotionally I’m not dealing with the aftermath of a traumatic delivery. I also noticed the difference in Ewan – My daughter cried non-stop for 3 hours after she was born, whereas Ewan only cried when the paediatrician sucked him out. He was very calm and alert and I was able to start nursing him within a few minutes of him being born.
I have followed the board with interest for the last couple of months. I am full of admiration and respect for your profession and for those of you who work so hard to let women like me have the birth we’re capable of. I know I couldn’t have achieved this birth without my midwife’s constant support and encouragement – she didn’t mention “epidural” once, bless her! In spite of my aspirations, I had no real confidence in my ability to give birth naturally – especially once the issue of the cervical scarring came up. I’m very glad that you’re all out there helping women like me have the most incredible experiences of our lives.
(Reproduced with permission)
I moved over here from Germany and am 28 weeks pregnant. I have been in the UK since January and since week 18 after walking or sitting for a while I feel pain and pressure between my legs. I told the GP and the midwife ( so far, every time I go to the health center I see somebody else – so far I haven’t seen the same person twice) and they said they heard about it before but they don’t know what it is. I had to go to Germany on a business trip two weeks ago and my ob/gyn there diagnosed a shortened cervix (26 mm) and an incompetent cervix. He said I would be assigned to bedrest in Germany now and I should consult a doctor in the UK as soon as possible.
I went to the GP and had to wait 2 weeks for an appointment with a consultant. He wasn’t there that day so I went to the hospital since I was already more than worried. In the hospital they checked that the baby was OK, but nobody really checked my cervix. I was told that only the consultant could make a decision what to do and now I got another appointment next week. My vaginal discharge increased a lot in the last two weeks (maybe it is normal anyway) – it is white-yellowish. This is my first pregnancy, but I have a history of endometriosis and ovarian cysts. It took me nearly 5 years to become pregnant.
I don’t know whether I am too worried and how to deal with the medical system here. I even have private insurance but I can not find any private health care in this region (Milton Keynes, Bucks). Any advice would be greatly appreciated!
I read your story with my mouth open. Here you are with a long awaited pregnancy and instead of being able to celebrate it you are being stressed by a series of events;
-No continuity of care-giver
-A “diagnosis” of incompetent cervix (IC) – and the response to your situation i.e if the diagnosis is correct somewhat questionable.
-How was the diagnosis of IC made- by scan? or by by a cervical check?
-It seems like you have had a distinct lack of any useful information. Did the German obst. state whether your cervix was thick and fully closed or thin and open and did they explain any of the associated concerns with incompetent cervix?
-Did they know at the NHS hospital that you had been told that you had an IC and about your fears and concerns?
It is great that you are now 28 weeks plus in the pregnancy. What do you think is going on? Are you able to eat nutritiously and find some space for relaxing? Is your baby moving okay? Have you stopped travelling now and settled into one place? Do you know what to do if you have any signs of early labour?
It is normal to have an increased white-yellowish vag. discharge at this stage of your pregnancy so I would stop worrying about that.
Having endometriosis and ovarian cysts in the past won’t stop you having a completely wonderful normal birth and outcome.
Have you a source of trusted emotional support? Someone who can attend the next appointment with you with the NHS obst. You have a right to be treated with respect and sensistivity in the health care system here and even though you may be feeling very vunerable it is important to assert yourself. This is part of preparing to be mother. You are wanting the best for your baby and yourself NOW.
Prepare a list of questions about everything you wish to know. For starters, it would really be helpful to know about the opinion of you having IC and then the likely incidence of premature labour. If it seems that you may have your baby early then it would be worth finding out about neo-natal facilities in MK for this sitaution. Tell the NHS obstetrician who you see that you have seen a number of different care-givers, and you are you needing some consistency and honest information.
Have you considered contacting an independent midwife? She can provide continuity of caregiver from a midwifery perspective. If it transpires that there isn’t any concerns with your cervix and you go beyond 36 weeks gestation then you may consider that you would be much better off away from the NHS or private hospital system and you may consider opting for a home birth with a midwife you can get to know and trust.
Sorry to hear that you have had such a difficult time since coming to the UK. The first thing I would do in your situation is contact the local community midwives and ask if you can meet a midwife to discuss your fears. You can do this by calling the local hospital (get the number through Directory Enquiries on 192 or through a phone book) and asking for the Community Midwives’ office or the Supervisor of Midwives.
Once you get through you can ask someone there how you would go about seeing a midwife ASAP as you are very worried and unused to the healthcare system here. They may try to fob you off with a request that you see your GP again – but if you say that you really need to see a midwife, you should be able to get an appointment. It is worth asking your GP surgery if they have a midwife who visits there too. This is worth doing even though you’re seeing a consultant next week, as a midwife can offer you a different sort of very valuable support.
A shortened cervix is associated with an increased risk of preterm labour, but I do not know what the cut-off points for being considered ‘short’ are. There is a study on this link going on at the moment in London, co-ordinated by King’s College Hospital.
Their literature says that about 1 in 50 women have a ‘very short’ cervix, and of these women, 1 in 2 will give birth very prematurely, ie before 33 weeks. Unfortunately they don’t specify on the leaflet I have what ‘very short’ is, so you may or may not fit into this category.
In the trial they are assessing cervical length with a vaginal ultrasound scan. I declined to participate in the study because I did not want unnecessary ultrasound scans, but if you might be in a high-risk category for premature labour then you might think it a sensible step to take. A scan would probably give you a more accurate assessment than the doctor’s examination that you’ve already had.
Women here who are found to have a very short cervix are being offered a stitch in the cervix which may help prevent premature labour. Unfortunately this carries risks of infection or inducing labour. They are also being offered steroid injections to prepare the baby’s lungs in case you do go into premature labour.
The contact number for the trial is Dr Meekaj To, on 020 7346 4301
You could perhaps call this number yourself if you are worried, or ask your GP or obstetrician to contact them for you as they may be able to provide more information even if you don’t want to participate in the trial.
Thanks for your replies – it feels good to know that I am not totally overreacting. Yes, my doctor in Germany measured the length of the cervix with ultrasound and said this is the only way to actually check it. He also talked about the steroid injections to help the baby mature faster (this is how I interpreted it), but he said I should discuss it with my health care provider here since I wanted to return to the UK. And yes I have told them in the hospital about the diagnosis from my German doctor.
My German doctor confirmed that the cervix was still closed but he said it needs to be closely monitored and bedrest would be the best way to slow down the process (don’t get me wrong – I do not want to be put on bedrest, I love my work and it distracts me from worrying – but right now the health of my baby is my top priority and I want to ensure that I do everything right). He also talked about the possibility of a cerclage but he said this procedure is usually done before week 20.
My husband (he is American) will come with me to the doctor’s appointment for emotional support. Hope my concern will be taken seriously this time around.
Thanks again for your kind words
I’ve been doing some asking around. Those I’ve asked have said that actually 26mm sounds ok – what’s important is whether it is shortening, or whether it is always this length! One person also said that in Germany, there is much more medical intervention and that this sounded like an example, but I’m not in a position to judge, just to pass the comment on.
He also talked about the possibility of a cerclage but he said this procedure is usually done before week 20.
Maybe so, but it can certainly be done later, because the London trial is based on scans carried out at 23 weeks, after which cerclage may be offered. Perhaps at your late stage they might think the risks were higher than the potential benefits.
Links to other sources of information:
Cervical (anterior) lips
US Midwife Archives page on stalled labour after cervical surgery
AH updated 12 December 2001