Supericial lacerations of the cervix can be seen on close inspec tion in more than half of all vaginal deliveries. Most of these measure <0.5 cm and seldom require repair. Deeper lacera tions are less frequent, but even these may be unnoticed. Due to ascertainment bias, variable incidences are described. For example, with close inspection, the incidence of cervical lacera tions in the Consortium on Safe Labor database was 1 percent in nulliparas and 0.5 percent in multiparas (Landy, 2011). But, the overall incidence in a study of more than 81 ,000 Israeli women was only 0.16 percent (Melamed, 2009). Such lacera tions are more likely to be associated with vacuum-or forceps assisted vaginal delivery (Fong, 2014).
Cervical lacerations are not usually problematic unless they cause hemorrhage or extend to the vagina. Rarely, the cervix may be entirely or partially avulsed from the vagina in the anterior, posterior, or lateral fornices, an injury termed coporrhxis. Another rare injury is when the entire vaginal portion of the cervix is avulsed-annular or circular detachment. These injuries sometimes follow forceps deliveries performed through an incompletely dilated cervix with the blades applied over the cer vix. In some women, cervical tears reach into the lower uterine segment and involve the uterine artery and its major branches. They occasionally extend into the peritoneal cavity. More severe lacerations usually manifest as external hemorrhage or as a hematoma, however, they may occasionally be unsuspected. In the Israeli study just cited, almost 11 percent of women with a cervical laceration required blood transfusions (Melamed, 2009).
At times, the edematous anterior cervical lip is compressed berween the fetal head and maternal symphysis pubis. This usually is of little consequence and resolves spontaneously. Rarely, this causes severe ischemia, and the anterior lip may undergo necrosis and subsequently separate from the rest of the cervix.
As with vulvovaginal lacerations, cervical tears can be more fully appreciated with adequate exposure, which may be best attained with transfer to an operating room. An assistant applies irm downward pressure on the uterus, while the operator exerts gentle traction on the lips of the cervix with ring forceps. A second assistant can provide even better exposure with right-angle vaginal wall retractors or Breisky vaginal retractors. Use of suction devices can also aid viewing.
In general, cervical lacerations of 1 and even 2 cm are not repaired unless they are bleeding. Such tears heal rapidly and ultimately create an irregular, sometimes stellate appearing, external cervical os that indicates previous delivery.
FIGURE 41 -10 Repair of cervical laceration with appropriate surgical exposure. Continuous absorbable sutures are placed beginning at the upper angle of the laceration.
Deep cervical tears usually require surgical repair. When the laceration is limited to the cervix or even when it extends somewhat into the vaginal fornix, satisfactory results are obtained by suturing the cervix after bringing it into view as depicted in Figure 41-10. While cervical lacerations are repaired, any associated vaginal lacerations or an episiotomy may be tamponaded with gauze packs to arrest their bleeding. Because hemorrhage usually comes from the upper angle of the wound, the first suture using 2-0 chromic or polyglactin is placed in tissue above the angle. Subsequently, either interrupted or continuous locking sutures are serially placed outward toward the operator. If the uterus is involved and hemorrhage persists, some of the methods described later (p. 792) may be necessary to obtain hemostasis.