Scar Tissue on Cervix - What Happens in Labor?

[ericaz]

I have quite a bit of scar tissue on my cervix following a LEEP in '04 - so much in fact that most docs have had a near impossible time giving me a pap. That said, I was succesfully inseminated so it's not completely jammed closed.

I'm wondering if any one can tell me what is the usual procedure for a cervix with scar tissue in cervix. Does it usually just break open on it's own or does a care provider typically need to manually break it open? If it's the latter, how is that done and how horribly does it hurt? I want to go natural again and am afraid that I'll either fail to progress and want an epidural OR that the pain of having to manually break open the cervix will throw me over the edge.

I should add that my first labor (also following another LEEP, although that one didn't seem to give me any scar tissue) was fabulous - six hours from start to finish, arrived at the hospital at 7cm and had no pain med.

TIA!

[JessicaE]

I had a student with scar tissue from a LEEP procedure. Her CNM broke it during labor. She said it hurt, but didn't seem overly traumatized by it. She had a natural birth that followed a very normal pattern. Immediately after the scar tissue was broken, she dilated several centimeters. Her doula is also in training to be a home birth midwife, and she told me privately that she felt breaking the scar tissue was unnecessary and it would have released on its own.

[Wittyone]

A common pattern for a scarred cervix seems to be a prolonged period of labor without dilation, and if an exam is performed in which the scar tissue is "broken up" it's not unusual for dilation to progress quickly after that. I think it really depends on mom's willingness to labor and labor and labor to see whether the tissue will release.

Yes, the exam in which the scar tissue is disrupted is pretty much guaranteed to be painful, but as with any intervention the experience of pain will vary between women and depending on who is performing it. It's is usually described as a "vigorous" cervical exam, in which the provider places their finger, or two fingers if there is enough dilation, into the cervical os (opening) and manually stretches it open to break up the adhesions. Once the exam is over the pain should be as well, though the cervical manipulation will release prostaglandins that may increase the strength of the next few contractions.

It would be good for you to bring this up with your provider prenatally and see what their experience/philosophy is with this procedure. I work in a birth center with no epidurals and have seen our midwives use this procedure very effectively.

[mwherbs]

the scar tissue needs to be broken up - you could wait till labor or at your due date you could have someone try working it out then-- if the doc has trouble doing a pap it may be very scarred and it may be that during labor it may be too uncomfortable for you to have it done if it isn't even open enough to be finger tip wide--- more often I have felt a 2cm opening in a laboring woman and when you break up the adhesions (sort of like stripping membranes)dilation will be 6- 8cm

[midwifemom3]

Usually what I see with my clients after Leep is a prolonged latent phase, the cervix gets paper this but feels like it is under pressure, once its thinned I can easily break the scar tissue with a cervical exam, and then moms dilate quickly. I have never seen it be an issue that led to section. I would use primrose oil vaginally though starting at 36 weeks to soften the cervix.

[kate3]

If your scarring is so extensive that pap smears are very difficult then it might also not be possible to break up the scar tissue without inflicting more damage.
As someone else posted a typical labor pattern is good contractions without cervical change. If the scar tissue cannot be released then a c/s is most often suggested for failure to progress.
Talk to your provider about measures to try and soften the cervix prior to labor-good luck.

[mwherbs]

there was another gal on MDC who was in labor several days and ended up with a c-section, her cervix was just a dimple of an opening...

[April422]

Originally Posted by ericaz

I have quite a bit of scar tissue on my cervix following a LEEP in '04 - so much in fact that most docs have had a near impossible time giving me a pap. That said, I was succesfully inseminated so it's not completely jammed closed.

I'm wondering if any one can tell me what is the usual procedure for a cervix with scar tissue in cervix. Does it usually just break open on it's own or does a care provider typically need to manually break it open? If it's the latter, how is that done and how horribly does it hurt? I want to go natural again and am afraid that I'll either fail to progress and want an epidural OR that the pain of having to manually break open the cervix will throw me over the edge.

I should add that my first labor (also following another LEEP, although that one didn't seem to give me any scar tissue) was fabulous - six hours from start to finish, arrived at the hospital at 7cm and had no pain med.

TIA!

One thing that I've seen women do on the advice of their midwives is to use evening primrose oil vaginally (NOT orally) to help soften the scar tissue and make it more agreeable to change.

I have scar tissue and was a fingertip dilated the day before I had my baby and my provider asked me if I would be agreeable to see if she could stretch my cervix and see if it would release since I was already 90% effaced. With a gentle prod and quick (and thankfully) painless pop I was 3CM dilation progressed normally from there.

[ericaz]

Ok, now I'm worried. I have been told that my cervix is a dimple now.
And my big fear is that I'll have hard core contractions and won't dilate - and this sounds like what a lot of you have witnessed...

Will EPO really make all that much difference??? I have brought it up with my OBs and I've got varying answers from each of them...some have said that labor usually pops it open and others have said that they will insert a finger if possible and help prod it open. No one has said anything about what happens if those measures are ineffective.

I have other issues on my mind now (like my recently lanced thrombosed hemorhoids) so I'm trying to let my cervix worry me too much. Easier said than done, though.

mwherbs - any idea if that MDC mama you were referring to was birthing her first babe and if not, how her previous labors went?? My docs seem to think that since I had such a great labor and delivery with my first that the scar tissue shouldn't matter much.

And, I think one of the reasons why I've had such trouble with paps is because my cervix is also tipped way far back by my rectum. My reproductive endocrinologist told me in was simple to find when he inseminated me - all he had to do was raise the table I was lying on. And then a few weeks ago I went to the hospital because I was bleeding and the OB couldn't find my cervix with the speculum - it took her forever and it was quite painful as she poked and prodded despite me telling her repeatedly how far back it is. Maybe some practitioners are just less intelligent than others?!

[maxmama]

Originally Posted by ericaz

Ok, now I'm worried. I have been told that my cervix is a dimple now.
And my big fear is that I'll have hard core contractions and won't dilate - and this sounds like what a lot of you have witnessed...

Will EPO really make all that much difference??? I have brought it up with my OBs and I've got varying answers from each of them...some have said that labor usually pops it open and others have said that they will insert a finger if possible and help prod it open. No one has said anything about what happens if those measures are ineffective.

I have other issues on my mind now (like my recently lanced thrombosed hemorhoids) so I'm trying to let my cervix worry me too much. Easier said than done, though.

mwherbs - any idea if that MDC mama you were referring to was birthing her first babe and if not, how her previous labors went?? My docs seem to think that since I had such a great labor and delivery with my first that the scar tissue shouldn't matter much.

And, I think one of the reasons why I've had such trouble with paps is because my cervix is also tipped way far back by my rectum. My reproductive endocrinologist told me in was simple to find when he inseminated me - all he had to do was raise the table I was lying on. And then a few weeks ago I went to the hospital because I was bleeding and the OB couldn't find my cervix with the speculum - it took her forever and it was quite painful as she poked and prodded despite me telling her repeatedly how far back it is. Maybe some practitioners are just less intelligent than others?!

In late pregnancy, it is completely normal for the cervix to be extremely posterior. Your cervix has changed position since insemination.

Difficulty with paps is different from difficulty in finding a cervix. If I can find the cervix, I can get a pap, unless there is a LOT of scar tissue. Position of the cervix doesn't really affect the pap itself, just the ease in finding it.

A "dimple" cervix is a pretty normal finding for first babies until labor. It just means that the internal os is still closed, and the external os is pretty much closed as well.

[mwherbs]

here is one of her threads where she sums up her experience- not her first baby- her labor thread is on the UC forum--


http://www.mothering.com/discussions...d.php?t=617350

[SublimeBirthGirl]

Nobody did anything to me (I also had a LEEP procedure) but at 24 hours of labor I was 4 cm, and she was born at 27.5. That seems to be pretty common.

[ericaz]

Originally Posted by maxmama

In late pregnancy, it is completely normal for the cervix to be extremely posterior. Your cervix has changed position since insemination.

Then that doesn't explain why a previous Reproductive Endocrinologist coudln't locate my cervix easily. I'm sure my cervix has changed since then but I do know that prior to conceiving it wasn't exactly *normal*.

Difficulty with paps is different from difficulty in finding a cervix. If I can find the cervix, I can get a pap, unless there is a LOT of scar tissue. Position of the cervix doesn't really affect the pap itself, just the ease in finding it.

True, but I had a few different practitioners unable to get the pap once it was found - and all told me it was because of scar tissue. That was until I saw the doc who finally helped me conceive - he told me there was hardly any scar tissue. So, I've been told a bunch of different things.

A "dimple" cervix is a pretty normal finding for first babies until labor. It just means that the internal os is still closed, and the external os is pretty much closed as well.

This isn't my first baby...it's my second. I also had a very difficult missed abortion (almost 2 yrs ago - my only daughter is now 4 and I had the LEEP prior to the miscarriage) where I *thought* I had had a miscarriage at home but it turned out that all that pain wasn't the end of it. A month later my body finally *delivered* the clot. Does that change things??

[dianna11]

This is really interesting to me, I had a LEEP in 2000, before DD was born. I asked the midwife if it would be a problem during labour, and she said "not likely". I used EPO vaginally (not her suggestion, just an intuition to do so) from about 37.5 weeks, until DD was born at 38w4d. I dilated incredibly quickly, and gave birth in 4.5 hours from first twinge to baby.

I read a thread somewhere on MDC about how having had a LEEP procedure actually speeds things up because there is less cervix :
I had never thought of the scar tissue issue though... I would assume that any LEEP would leave a scar - I know they took a fairly substantial chunk out of mine.

[maxmama]

Originally Posted by ericaz

Then that doesn't explain why a previous Reproductive Endocrinologist coudln't locate my cervix easily. I'm sure my cervix has changed since then but I do know that prior to conceiving it wasn't exactly *normal*.


True, but I had a few different practitioners unable to get the pap once it was found - and all told me it was because of scar tissue. That was until I saw the doc who finally helped me conceive - he told me there was hardly any scar tissue. So, I've been told a bunch of different things.


This isn't my first baby...it's my second. I also had a very difficult missed abortion (almost 2 yrs ago - my only daughter is now 4 and I had the LEEP prior to the miscarriage) where I *thought* I had had a miscarriage at home but it turned out that all that pain wasn't the end of it. A month later my body finally *delivered* the clot. Does that change things??

Cervical position doesn't matter all that much in the grand scheme of things, and I honestly can't see how a LEEP would affect cervical position. For one thing, it's not a static thing. Cervices change position all the time.

A lot of docs, even REs, are not all that good at finding a cervix, and they sometimes don't know the tricks to locate a hidden one.

A stenotic os can make a pap hard to obtain, but I would not have expected you to have had a vaginal birth if your cervix were THAT stenotic. While it's more unusual for a multip to have a dimple cervix, it happens, and in no way means that a vaginal birth won't happen.

What I think you probably have when not pregnant is an anteverted uterus, which makes the cervix very posterior and tricky to locate, but is by no means abnormal. Tilting your pelvis (putting your fists under your hips), doing a bimanual first, and using a clear speculum rather than metal can help to locate a posterior cervix.

[wumanh]

Seems like everyone has some good suggestions. I have one for after you birth. Uterine massage (Rosita Arvigo teaches it) may place your uterus in a more favorable position so that getting paps would be easier.

[mwherbs]

what I can suggest is to find a provider who will take your concerns seriously and give you straight answers. When I was pregnant with my first I asked the doc about a bump on my cervix and he and his nurse laughed at me and didn't really answer now I know better it is easy to be intimidated or shamed but it is also your body and getting clear accurate answers to questions you have is valid ---
if the problem was with your car and you wanted to know if you can break safely- and they didn't give you a straight answer you would find someone who would give you accurate advice.
it sounds like you may have enough scar tissue that making a plan for or before labor would be reasonable , but it can also be true that it was just cervical position that caused a problem with the pap then you would not have to worry about this at all--- who can give you the clearest answers? also get copies of the doc's records and see if there is a note about stenosis ....

[mamaspirit]

This is a question I too have... I had a vaginal, natural birth with my first. Than I had a LEEP and 2 cone biopsies. When I was pregnant with my second they told me I was at risk for incompetent cervix because of the surgeries on my cervix. They did bi-weekly vaginal ultrasounds from week 16 and manual cervical checks from week 28. I developed an intrauterine infection at 34 weeks and my water broke at 35 weeks, Sorry, I digress...

While I was in labor I dilated to about 5 cm and than I was stuck there for a while. One of the nurses said she felt a hard band around my cervix. I asked if they could do anything about it and she said she didn't know. My placenta ended up abrupting (from turning up the pit despite contractions lasting for 3 minutes long, with only 30 seconds between) and I had to have a c-section.

Now with this baby, I am 25 weeks pregnant. I am planning a home VBAC and have an awesome midwife. I am a little concerned that the reason I did not dilate past 5 cm with my last baby was from scar tissue from the LEEP. Will I have the same problem this time? How easy is it to break the scar tissue?

[LoveChild421]

If you want to read what my labor and birth experience with a scarred cervix was like here's ds1's birth story: http://www.mothering.com/discussions...d.php?t=269655

Basically after laboring with broken water and having strong minute long contractions 2-3 minutes apart for 9 hours and making no progress (was at 2cm when my midwife checked me, I went to bed and tried to sleep (yeah right) and then in the morning when she checked me again I was still 2cm), my midwife decided to manually break up some of the scar tissue. It didn't hurt, she just did cervical massage, and my contractions got SO much more bearable at that point and I started dilating. It was still a slow go and I never dilated past 8 cm but luckily ds1 had a small head and I was able to push him past what scarred cervix I had left and that broke up all of the scar tissue and I didn't have any problems with ds2's birth. If I had known better, I would have had my midwife go ahead and manually break up the scar tissue when she first arrived instead of waiting to see what would happen. BTW I took EPO orally but not vaginally.

Regarding posterior cervix- mine was posterior up until a day before labor started with ds2 and his labor was very "normal" with no issues at all.

[Turkish Kate]

Hi, Ericaz. I'm the gal that MWHerbs was referring to. I had an 80 hour labor with no cervical dilation *at all* that led to a completely unexpected c-section. I am now considering TTC #3 and am looking into what I can do differently this next time, and consequently what I could've done differently with #2. I've discovered that my cervix is incredibly stenotic and has been since before #2 was conceived. I found records that show that during my pap post-LEEP I had to be dilated for the sample to be obtained. The doctor never mentioned it and I honestly never read that part of the record, was only concerned at the time with the patho report.

I've discovered one thing that could've been done differently is the use of Cytotec (misoprostol) intravaginally during labor to assist with dilating the cervix. I'm not a fan of that particular drug as a labor inducer, seen too many horrid labors, but I think I would've rather had that horrid labor than the horrid C-section that followed. Another possibility is the use of laminaria to manually dilate the cervix once contractions start.

Now that AF has returned, I've found that my cervix is so stenotic that menstrual flow "backs up" in my uterus causing severe cramps and periods that last over three weeks. I will go to the hospital Wednesday for cytotec and manual dilation to try to overcome some of this. I've been searching for literature on this issue of cervical stenosis post-LEEP but haven't been finding much. Have you discussed this issue with your physician/midwife?

Feel free to PM me if you want more info.