Cervical Scar Tissue – A Cause of Preventable Cesareans

Dawn Thompson is the founder of ImprovingBirth.org. She has spent the past eight years on a mission to understand how scar tissue on the cervix affects women in labor, and to let the public know about it. In her article below, she identifies a variety of gynecological procedures that can potentially cause Cervical Scar Tissue, such as treatments for abnormal Pap smears.One procedure not mentioned that I feel is a concern is anyone whom has had an abortion, since a D & C is done and would cause cervical scarring.

Other resources on CST include:

an excellent article by O’Nell Starkey, doula and founder of The Beautiful Cervix Project
photographs of the cervix from The Singapore Family Physician(images are graphic but informative — see Figures 24a and 24b for scarring of the cervix); and
an article by Dr. Fred Licciardi of New York University, with drawings that demonstrate how gynecological procedures may cause scarring

Below, Dawn Thompson describes her investigation of the topic of CST, and the ways she has helped mothers with this condition avoid complications in labor.

My nephew just had his sixth birthday in February. Who knew his birth would mean so much to my career as a birth professional? It was the day I first heard the words “Cervical Scar Tissue.” How is it that I had been a doula for four years and had never heard of this before? Those words changed my life.

I sat down days later and wrote a blog post,http://doulaheidi.webs.com/d In the past six years, that article has circled the globe and has been read more than 50,000 times. People are now indeed “talking” about it. Some women have even found the blog during early labor, looking for a reason why their labor wasn’t progressing after days and days of surges.

Since that time I have dedicated most of my doula career to learning more about cervical scar tissue (CST) and, specifically, helping families who experienced a c-section with their first birth. I started working closely with a local ob-gyn who was very aware of cervical scar tissue. We referred all of our VBAC (vaginal birth after c-section) clients to each other. I kept track of the clients’ previous birth experiences, what kinds of procedures they might have had, and then what happened in their subsequent births.

The results were very clear. Out of 21 mothers, 3 had c-sections because of a breech presentation, while the other 18 were given the diagnosis “failure to progress” during their first birth. Seventeen of the 21 had a long, prodromal labor pattern. They also “seemed” to be having transition-like labor, but were only 4 to 6 centimeters dilated when they arrived at the hospital. In all 17 women, the doctor observed obvious scar tissue during their subsequent births. After the doctor treated the scar tissue in labor, the majority of these women went on to deliver between a few minutes and two hours later. In all cases, the labor progressed quickly.

Most interestingly, not all of these women had had the typical cervical procedures associated with scar tissue like LEEP, cone biopsy, or cryosurgery. The scar tissue also presented differently in some of these women. Some women had tight rubber band-type scarring on the interior of the cervix. Others had more granular-type scarring. I have since heard it described as feeling like a piece of uncooked rice on the outer part of the cervix. That leads to the question, do other procedures cause scarring?

After interviewing several midwives and ob-gyns, I believe the answer is “yes.” I found that the other women in our small group all had had procedures like a D&C or the placement of an IUD. For both of these procedures, in many cases, a cervical stabilizer (tenaculum) is used. This instrument pierces the cervix while it is being manually dilated. This seems to be what causes the granular-type scarring. Not all women seem to be affected by this type of scarring, or maybe some of them don’t scar much anyway. Some people naturally produce more keloids. Keloids are the excess growth of scar tissue at the site of a healed injury. This might explain why some people would be affected and others would not.

Signs of CST:

•           Prodromal labor
•           Dilation stall
•           High effacement/low dilation
•           Mom describes surges, but experiences no dilation
•           Mom appears to be in transition, but dilation reflects early labor
•           Overwhelming urge to push, but low dilation

The next question of course is – can it be removed and is it something that can be checked before labor? In most cases, it can be resolved. Unfortunately it can’t be detected before labor begins as a significant amount of effacement of the cervix is required. Some care providers recommend using either Borage Oil or Evening Primrose Oil vaginally after 36 weeks to help soften any scar tissue on the cervix. It’s not clear if this actually works and has never been studied for possible negative side affects. This would always be something to discuss with your care providers.

Once in labor, your care provider can do a vaginal exam (one reason I can think of that would be a good reason for a vaginal exam) and “massage” the cervix and help the scar tissue release. The word massage can be misleading – this is an uncomfortable procedure, but not unbearable. When the scar tissue is less severe, movement and time is often what is needed. Another option used is a Foley Bulb Insertion, where the tip of a foley blub is inserted into the cervix and then inflated gently. All of these things would require having a provider that is present during your labor (often ObGyns aren’t present until much later in a labor), is familiar with cervical scar tissue and knows to look for it.