Introduction
Cervical laceration (CL) after vaginal delivery is one of the uncommon side effects with significant morbidity if undetected and unattended to promptly. The incidence of CL after vaginal deliveries ranges from 0.2% to 1.2%.1, 2 This is one of the common causes for postpartum haemorrhage (PPH). CL can range from superficial to deep with extensions to the vagina or the lower segment of the uterus. Occasionally, there can be complete avulsion of the cervix from the uterus leading to a bucket handle tear.
Materials and Methods
From January, 2018 to April, 2022 there were 38549 vaginal deliveries in our tertiary care centre. Of them eleven women were identified to have CL needing surgical intervention. In this article we are describing a summary of these eleven women who have had CL detected following vaginal delivery with detailed presentation of one of them who had a bucket handle tear of the posterior lip of cervix.
Case Presentation
Mrs. S a 26-year-old Primigravida, conceived with IVF after evaluation for 4 years of infertility. At 36 weeks and 5 days of gestation with risk factors of being gestational diabetes on medication and hypothyroidism. She had presented with prelabour rupture of membranes. Induction of labour was done using 2 doses of vaginal insertion of 25ug Misoprostol. The cervix was quite unfavourable at induction with a Bishop score of 2/13. Six hours from the second dose of misoprostol augmentation of labour was done when the Bishop score was 3/13. Labour progressed rapidly and within 6 hours of augmentation of labour she delivered vaginally a 2.8kg baby. Following delivery, she had PPH and exploration of the cervix revealed a five cm long CL along the posterior lip of cervix with the external cervical os being only one cm dilated. (Figure 1) The tear was sutured under anaesthesia. (Figure 2) She had a significant blood loss of about a litre needing blood transfusion.
The following tabular columns are a summary of eleven such patients who have had cervical tears following vaginal delivery. (Table 1, Table 2, Table 3)
Table 1
Patient characteristics
|
Characteristics |
Value |
|
Age |
20-30 (Mean 24.8 years) |
|
Parity |
|
|
Primigravida |
6 (55%) |
|
Multigravida |
5 (45%) |
|
Gestation age |
|
|
Term (≥ 37 weeks gestation) |
10 (91%) |
|
Preterm (≤ 36 + 6 weeks gestation) |
1 (9%) |
Table 2
Labour characteristics
Table 3
Details regarding cervical tear
Discussion
Cervical laceration although not very common, is known to cause PPH. Incidence of CL among primigravida was 1% while among multigravida was 0.5% according to study by Landy in 2011.3 The known precipitating factors for CL in literature being previous interventions on the cervix 6-14% (polypectomy, LEEP, cerclage), induction of labour (threefold increased risk), use of Prostaglandins for induction of labour, precipitate labour, operative vaginal deliveries and birth weight > 3500gms.1, 2, 3, 4, 5
However, in our experience of the known risk factors, the most common association were with induction of labour and operative vaginal delivery. In recent years the rate of induction of labour have exponentially increased.6 In literature induction of labour has been associated with increased risk of PPH, precipitated labour, need for operative delivery and uterine rupture.7 Instrumental delivery – both vacuum and forceps have been associated with increased maternal soft tissue injury including CL.8 Similarly precipitate labour, where the cervix rapidly dilates to accommodate the presenting part has also been enlisted as one of the reasons for CL.9 Hence, CL has to be anticipated and actively looked for in patients who undergo precipitate labour or have a rapid progression of labour or patients undergoing operative vaginal delivery and have associated increased bleeding.
Although the occurrence of cervical tear is rare, due to its associated increase in morbidity in terms of increased blood loss and the burden of increased need for blood and product transfusion, the occasional need for ICU care this complication following delivery has to be kept in mind and actively sought for especially in patients who have PPH.
