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Summary Table

Category	Detail
Risk Factors	Precipitous labor, operative vaginal delivery (forceps or vacuum), macrosomia, pushing before full cervical dilation, prior cervical surgery (cerclage, conization), labor induction with cervical ripening agents
Etiology	Mechanical tearing of the cervix during rapid or forced dilation in the second stage of labor
Patient Presentation	Continuous bright red vaginal bleeding immediately after delivery despite a firm, well-contracted uterus
Classic Physical Exam	Uterine fundus is firm on palpation; steady stream of bright red blood from the vaginal canal; laceration visualized on cervical inspection with ring forceps
Key Diagnostic Results	Direct visualization of cervical tear on speculum/manual exam; no laboratory test confirms the diagnosis; CBC and coagulation studies obtained to assess blood loss severity
Management	Surgical repair with absorbable suture; begin suturing above the apex of the laceration; hemodynamic resuscitation as needed
Keywords	"Firm uterus with continued bleeding," "bright red bleeding post-delivery," "operative vaginal delivery," "bleeding despite fundal massage"

1. Pathophysiology

During labor, the cervix undergoes progressive effacement and dilation from a closed state to approximately 10 cm to allow passage of the fetal head. This process depends on coordinated uterine contractions, hormonal cervical ripening, and gradual mechanical stretching. When the forces applied to the cervix exceed its tensile capacity, a laceration results.

The cervix is supplied by descending branches of the uterine artery, which run primarily along the lateral aspects (3 o'clock and 9 o'clock positions). This vascular anatomy explains why lateral cervical tears are the most clinically significant, as they can transect arterial branches and produce brisk, continuous hemorrhage. The bleeding is arterial in character: bright red, steady, and not responsive to uterine massage or uterotonic agents, because the source is the torn cervical tissue, not an atonic uterine body.

The hallmark pathophysiologic distinction is that the uterus itself contracts normally. The myometrium clamps down on the spiral arteries at the placental site as expected. The problem lies downstream at the cervix, which is a separate anatomic source of bleeding. This is why the combination of a firm fundus with ongoing hemorrhage should immediately trigger suspicion for a genital tract laceration rather than uterine atony.

In severe cases, the laceration can extend superiorly from the cervix into the lower uterine segment, effectively becoming a uterine rupture. This extension is particularly dangerous because it can involve the uterine artery itself, leading to catastrophic hemorrhage and potential broad ligament hematoma formation.

2. Classification and Clinical Manifestation

Degree	Description	Clinical Significance
First Degree	Superficial laceration involving only the cervical mucosa, depth < 1 cm	Usually minor; may not require repair; bleeding is minimal or self-limited
Second Degree	Laceration extending deeper into the cervical stroma, typically 1 to 2 cm	Moderate bleeding; generally requires suture repair
Third Degree (Severe)	Deep laceration extending to or near the internal cervical os; may extend into the lower uterine segment	Significant hemorrhage; surgical repair mandatory; risk of broad ligament hematoma if lateral extension involves uterine vessels
Annular detachment	Circumferential avulsion of the anterior cervical lip, usually from prolonged entrapment between the fetal head and the pubic symphysis	Rare; associated with obstructed labor; presents with a detached ring of cervical tissue

Location-based risk

Location	Frequency	Hemorrhage Risk
Lateral (3 and 9 o'clock)	Most common	Highest (proximity to uterine artery branches)
Anterior	Less common	Moderate
Posterior	Least common	Lower, unless deep extension occurs

3. Diagnostic Workup

Test	Purpose	Key Findings
Systematic cervical inspection (Best Initial Test and Gold Standard)	Directly visualize the laceration	Visible tear in the cervix; active bleeding from the laceration edge
Complete blood count (CBC)	Quantify blood loss	Dropping hemoglobin/hematocrit (may lag in acute hemorrhage)
Coagulation panel (PT, aPTT, fibrinogen)	Rule out coagulopathy as a contributing or concurrent cause	Normal in isolated cervical laceration; abnormal values suggest DIC or consumptive coagulopathy
Type and crossmatch	Prepare for transfusion	Ordered when hemorrhage is significant
Ultrasound (if needed)	Rule out retained products of conception	Empty uterine cavity; may identify broad ligament hematoma if laceration has extended

The diagnosis of cervical laceration is clinical and made by direct inspection. There is no laboratory test or imaging study that confirms it. The diagnostic sequence follows a structured approach to postpartum hemorrhage known by the "4 T's" framework: Tone, Trauma, Tissue, Thrombin.

When a patient presents with postpartum hemorrhage, the first step is always to assess uterine tone by palpating the fundus. If the uterus is soft and boggy, the diagnosis is atony (Tone), and uterotonic agents are administered. However, if the uterus is firm and well-contracted yet bleeding continues, the examiner must immediately move to the second "T" and evaluate for Trauma, which includes cervical, vaginal, and perineal lacerations.

To inspect the cervix, the examiner uses ring forceps (sponge forceps) to grasp the cervical lip systematically. The technique involves placing one ring forceps at the 12 o'clock position and a second adjacent to it, then "walking" around the entire circumference of the cervix clockwise, repositioning the forceps sequentially. This ensures the complete circumference is visualized and no laceration is missed.

If the cervix and vaginal canal are intact and the uterus is firm, the workup proceeds to evaluate for retained placental fragments (Tissue) with ultrasound and for coagulopathy (Thrombin) with a coagulation panel.

4. Management and Treatment

Clinical Scenario	Intervention	Details
Small, non-bleeding laceration (< 2 cm, superficial)	Observation	No repair needed if hemostasis is adequate
Actively bleeding cervical laceration	Surgical repair with absorbable suture	Use 0 or 2-0 chromic gut or polyglactin (Vicryl); running locked or interrupted figure-of-eight technique
Hemorrhagic shock	Fluid resuscitation and transfusion	Crystalloid bolus; packed red blood cells; activate massive transfusion protocol if indicated
Laceration extending into the lower uterine segment	Operative repair (may require laparotomy)	Uterine artery ligation or internal iliac artery ligation if bleeding is uncontrollable
Refractory hemorrhage despite surgical repair	Interventional radiology or surgical ligation	Uterine artery embolization; hysterectomy as last resort

The first priority is hemodynamic stabilization. Establish two large-bore IV lines (16- or 18-gauge), initiate crystalloid resuscitation, send blood for type and crossmatch, and begin blood product transfusion if the patient shows signs of hypovolemic shock (tachycardia, hypotension, altered mental status).

Once the laceration is identified, the critical technical point for the exam is that suturing must begin above (cephalad to) the apex of the laceration. The apex is where the torn tissue retracts, and a bleeding vessel often retracts above the visible edge of the tear. If the first suture is placed at the visible edge rather than above it, the retracted vessel continues to bleed, and the repair fails. This is a consistently tested concept.

The suture technique involves a running locked stitch or interrupted figure-of-eight sutures using absorbable material. The repair proceeds from the apex downward toward the external os, ensuring full-thickness bites to achieve hemostasis.

For lacerations that extend into the lower uterine segment or parametrium, repair in the delivery room may be insufficient. These patients may require transfer to the operating room for exploratory laparotomy, uterine artery ligation, or, in the most severe cases, hysterectomy. Uterine artery embolization by interventional radiology is an option in hemodynamically stable patients when surgical expertise and facilities are available.

Antibiotic prophylaxis with a broad-spectrum agent (e.g., cefazolin 1 g IV or ampicillin-sulbactam) is reasonable when extensive repair is performed, particularly if there is concern for contamination or if the repair required operative exploration.

5. Differential Diagnosis and Distractors

Differential	Why It Looks Similar	Key Discriminator
Uterine atony	Also presents as postpartum hemorrhage immediately after delivery	Uterus is boggy and soft on palpation; bleeding responds to fundal massage and uterotonics. In cervical laceration, the uterus is firm.
Retained placental fragments	Can cause ongoing postpartum bleeding; may occur alongside lacerations	Uterus may be subinvoluted or tender; ultrasound shows echogenic material in the uterine cavity; placenta was noted to be incomplete on inspection
Uterine rupture	Severe hemorrhage during or after labor; can coexist with cervical extension	Typically presents with sudden cessation of contractions, fetal distress, loss of fetal station, and abdominal pain during labor; more common with prior uterine scar (previous cesarean)
Vaginal or perineal laceration	Visible bleeding from the genital tract with a firm uterus	Source of bleeding is below the cervix; identified on vaginal wall and perineal inspection before cervical exam
Coagulopathy (DIC)	Diffuse bleeding that does not respond to local measures	Bleeding from multiple sites (IV sites, mucosal surfaces); abnormal coagulation studies (elevated PT/aPTT, low fibrinogen, elevated D-dimer, thrombocytopenia)
Uterine inversion	Acute postpartum hemorrhage with hemodynamic instability	Fundus is not palpable abdominally; a mass is felt or seen at the vaginal introitus; associated with excessive cord traction during the third stage

6. Traps and High-Yield Pearls

The single most common way students miss this diagnosis on an exam is by defaulting to uterine atony for every case of postpartum hemorrhage. Atony is indeed the most common cause, and students learn this early and anchor to it. The exam exploits this bias by presenting a vignette where the uterus is clearly described as firm and well-contracted, yet the student still selects "administer oxytocin" or "fundal massage" because they associate postpartum bleeding with atony reflexively. The critical reading skill being tested is recognizing that a firm uterus eliminates atony from the differential and redirects the workup toward traumatic causes.

A second common trap involves the management sequence. Students may correctly identify the cervical laceration but then select "obtain an ultrasound" or "send coagulation studies" as the next best step. On the exam, once a firm uterus with ongoing hemorrhage is established, the next best step is direct cervical inspection, not imaging or labs. Inspection is both the diagnostic and the immediately therapeutic intervention (it leads directly to suture repair).

The third pearl concerns the technical detail of suturing above the apex. This appears in exam questions as a "what went wrong" scenario: a cervical laceration was repaired, but the patient continues to bleed. The answer is that the repair was started at the visible edge of the tear rather than above the apex, missing the retracted bleeding vessel.

Finally, students must recognize the clinical profile of a patient at risk: a vignette describing a precipitous delivery, forceps- or vacuum-assisted delivery, or a patient who was pushing before complete cervical dilation should immediately raise suspicion for cervical laceration, even before the physical exam findings are described. The risk factor in the stem is the first clue; the firm uterus with continued bleeding is the confirmation.

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