CERVICITIS

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Overview

• 

  Female reproductive system

Cervicitis is an inflammation of the cervix, the lower, narrow end of the uterus that opens into the vagina.

Possible symptoms of cervicitis include bleeding between menstrual periods, pain with intercourse or during a cervical exam, and abnormal vaginal discharge. However, it's also possible to have cervicitis and not experience any signs or symptoms.

Often, cervicitis results from a sexually transmitted infection, such as chlamydia or gonorrhea. Cervicitis can develop from noninfectious causes, too. Successful treatment of cervicitis involves treating the underlying cause of the inflammation.

Symptoms

• 

  Cervicitis

Most often, cervicitis causes no signs and symptoms, and you may only learn you have the condition after a pelvic exam performed by your doctor for another reason. If you do have signs and symptoms, they may include:

• Large amounts of unusual vaginal discharge
• Frequent, painful urination
• Pain during intercourse
• Bleeding between menstrual periods
• Vaginal bleeding after intercourse, not associated with a menstrual period

When to see a doctor

See your doctor if you have:

• Persistent, unusual vaginal discharge
• Nonmenstrual vaginal bleeding
• Pain during intercourse

Causes

Possible causes of cervicitis include:

• Sexually transmitted infections. Most often, the bacterial and viral infections that cause cervicitis are transmitted by sexual contact. Cervicitis can result from common sexually transmitted infections (STIs), including gonorrhea, chlamydia, trichomoniasis and genital herpes.
• Allergic reactions. An allergy, either to contraceptive spermicides or to latex in condoms, may lead to cervicitis. A reaction to feminine hygiene products, such as douches or feminine deodorants, also can cause cervicitis.
• Bacterial overgrowth. An overgrowth of some of the bacteria that are normally present in the vagina (bacterial vaginosis) can lead to cervicitis.

Risk factors

You're at greater risk of cervicitis if you:

• Engage in high-risk sexual behavior, such as unprotected sex, sex with multiple partners or sex with someone who engages in high-risk behaviors
• Began having sexual intercourse at an early age
• Have a history of sexually transmitted infections

Complications

Your cervix acts as a barrier to keep bacteria and viruses from entering your uterus. When the cervix is infected, there's an increased risk that the infection will travel into your uterus.

Cervicitis that's caused by gonorrhea or chlamydia can spread to the uterine lining and the fallopian tubes, resulting in pelvic inflammatory disease (PID), an infection of the female reproductive organs that can cause fertility problems if left untreated.

Cervicitis can also increase the risk of a woman getting HIV from an infected sexual partner.

Prevention

To reduce your risk of cervicitis from sexually transmitted infections, use condoms consistently and correctly each time you have sex. Condoms are very effective against the spread of STIs, such as gonorrhea and chlamydia, which can lead to cervicitis. Being in a long-term relationship in which both you and your uninfected partner are committed to having sex with each other exclusively can lower your odds of an STI.

Diagnosis

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  Pelvic exam

To diagnose cervicitis, your doctor will likely perform a physical exam that includes:

• A pelvic exam. During this exam, your doctor checks your pelvic organs for areas of swelling and tenderness. He or she may also place a speculum in your vagina to view the upper, lower and side walls of the vagina and the cervix.
• A specimen collection. In a process similar to a Pap test, your doctor uses a small cotton swab or a brush to gently remove a sample of cervical and vaginal fluid. Your doctor sends the sample to a lab to test for infections. Lab tests may also be performed on a urine sample.

Treatment

You won't need treatment for cervicitis caused by an allergic reaction to products such as spermicide or feminine hygiene products. If you have cervicitis caused by a sexually transmitted infection (STI), both you and your partner will need treatment, often with antibiotic medication. Antibiotics are prescribed for STIs such as gonorrhea, chlamydia or bacterial infections, including bacterial vaginosis.

Your doctor may offer antiviral medication if you have genital herpes, which helps decrease the amount of time you have cervicitis symptoms. However, there is no cure for herpes. Herpes is a chronic condition that may be passed to your sexual partner at any time.

Your doctor may also recommend repeat testing for cervicitis caused by gonorrhea or chlamydia.

To avoid passing a bacterial infection along to your partner, wait to have sexual intercourse until you're finished with the treatment recommended by your doctor.

Preparing for your appointment

Cervicitis may be discovered incidentally during a routine pelvic exam and may not require treatment if it's not due to an infection. If, however, you experience unusual vaginal symptoms that lead you to schedule an appointment, you'll most likely see a gynecologist or primary care doctor.

Because appointments can be brief, and because there's often a lot of ground to cover, it's a good idea to be well-prepared for your appointment. Here's some information to help you get ready for your appointment.

What you can do

• Avoid using tampons.
• Don't douche.
• Know the name of your partner, and the dates you had sexual relations.
• Make a list of all medications or supplements you're taking.
• Know your allergies.
• Write down questions you have.

Some basic questions include:

• How did I get this condition?
• Do I need to take medicine?
• Are there any over-the-counter products that will treat my condition?
• Does my partner also need to be tested or treated?
• What should I do if my symptoms return after treatment?
• What can I do to prevent cervicitis in the future?

Don't hesitate to ask additional questions during your appointment if you think of something else.

What to expect from your doctor

Your doctor will likely perform a physical exam that may include a pelvic exam and Pap test. He or she may collect a fluid specimen from your vagina or cervix to send for testing.

Your doctor may also ask you a number of questions about your condition, such as:

• What vaginal symptoms are you experiencing?
• Are you experiencing any urinary problems, such as pain during urination?
• How long have you had your symptoms?
• Are you sexually active?
• Have you or your partner ever had a sexually transmitted infection?
• Do you experience pain or bleeding during intercourse?
• Do you douche or use any feminine hygiene products?
• Are you pregnant?
• Have you tried any over-the-counter products to treat your symptoms?

BACTERIAL VAGINOSIS

Overview

Bacterial vaginosis is a type of vaginal inflammation caused by the overgrowth of bacteria naturally found in the vagina, which upsets the natural balance.

Women in their reproductive years are most likely to get bacterial vaginosis, but it can affect women of any age. The cause isn't completely understood, but certain activities, such as unprotected sex or frequent douching, increase your risk.

Symptoms

Bacterial vaginosis signs and symptoms may include:

• Thin, gray, white or green vaginal discharge
• Foul-smelling "fishy" vaginal odor
• Vaginal itching
• Burning during urination

Many women with bacterial vaginosis have no signs or symptoms.

When to see a doctor

Make an appointment to see your doctor if:

• You have vaginal discharge that's new and associated with an odor or fever. Your doctor can help determine the cause and identify signs and symptoms.
• You've had vaginal infections before, but the color and consistency of your discharge seem different this time.
• You have multiple sex partners or a recent new partner. Sometimes, the signs and symptoms of a sexually transmitted infection are similar to those of bacterial vaginosis.
• You try self-treatment for a yeast infection with an over-the-counter treatment and your symptoms persist.

Causes

Bacterial vaginosis results from the overgrowth of one of several bacteria naturally found in your vagina. Usually, "good" bacteria (lactobacilli) outnumber "bad" bacteria (anaerobes). But if there are too many anaerobic bacteria, they upset the natural balance of microorganisms in your vagina and cause bacterial vaginosis.

Risk factors

Risk factors for bacterial vaginosis include:

• Having multiple sex partners or a new sex partner. Doctors don't fully understand the link between sexual activity and bacterial vaginosis, but the condition occurs more often in women who have multiple sex partners or a new sex partner. Bacterial vaginosis also occurs more frequently in women who have sex with women.
• Douching. The practice of rinsing out your vagina with water or a cleansing agent (douching) upsets the natural balance of your vagina. This can lead to an overgrowth of anaerobic bacteria, and cause bacterial vaginosis. Since the vagina is self-cleaning, douching isn't necessary.
• Natural lack of lactobacilli bacteria. If your natural vaginal environment doesn't produce enough of the good lactobacilli bacteria, you're more likely to develop bacterial vaginosis.

Complications

Bacterial vaginosis doesn't generally cause complications. Sometimes, having bacterial vaginosis may lead to:

• Preterm birth. In pregnant women, bacterial vaginosis is linked to premature deliveries and low birth weight babies.
• Sexually transmitted infections. Having bacterial vaginosis makes women more susceptible to sexually transmitted infections, such as HIV, herpes simplex virus, chlamydia or gonorrhea. If you have HIV, bacterial vaginosis increases the odds that you'll pass the virus on to your partner.
• Infection risk after gynecologic surgery. Having bacterial vaginosis may increase the risk of developing a post-surgical infection after procedures such as hysterectomy or dilation and curettage (D&C).
• Pelvic inflammatory disease (PID). Bacterial vaginosis can sometimes cause PID, an infection of the uterus and the fallopian tubes that can increase the risk of infertility.

Prevention

To help prevent bacterial vaginosis:

• Minimize vaginal irritation. Use mild, nondeodorant soaps and unscented tampons or pads.
• Don't douche. Your vagina doesn't require cleansing other than normal bathing. Frequent douching disrupts the vaginal balance and may increase your risk of vaginal infection. Douching won't clear up a vaginal infection.
• Avoid a sexually transmitted infection. Use a male latex condom, limit your number of sex partners or abstain from intercourse to minimize your risk of a sexually transmitted infection.

Diagnosis

• Pelvic exam

To diagnose bacterial vaginosis, your doctor may:

• Ask questions about your medical history. Your doctor may ask about any previous vaginal infections or sexually transmitted infections.
• Perform a pelvic exam. During a pelvic exam, your doctor visually examines your vagina for signs of infection and inserts two fingers into your vagina while pressing on your abdomen with the other hand to check your pelvic organs for signs that may indicate disease.
• Take a sample of vaginal secretions. This may be done to check for an overgrowth of anaerobic bacteria in your vaginal flora. Your doctor may examine the vaginal secretions under a microscope, looking for "clue cells," vaginal cells covered with bacteria that are a sign of bacterial vaginosis.
• Test your vaginal pH. Your doctor may check the acidity of your vagina by placing a pH test strip in your vagina. A vaginal pH of 4.5 or higher is a sign of bacterial.

Treatment

We treat bacterial vaginosis at Gyncentre Nairobi(under the flagship of Maryhill Healthcare Services).

It's generally not necessary to treat an infected woman's male sexual partner, but bacterial vaginosis can spread between female sexual partners. Female partners should seek testing and may need treatment. It's especially important for pregnant women with symptoms to be treated to help decrease the risk of premature delivery or low birth weight.

Take your medicine or use the cream or gel for as long as your doctor prescribes it — even if your symptoms go away. Stopping treatment early may increase the risk of recurrence.

Recurrence

It's common for bacterial vaginosis to recur within three to 12 months, despite treatment. Researchers are exploring treatments for recurrent bacterial vaginosis. If your symptoms recur soon after treatment, talk with your doctor about treatments. One option may be extended-use metronidazole therapy.

A self-help approach is lactobacillus colonization therapy — which attempts to boost the number of good bacteria in your vagina and re-establish a balanced vaginal environment — possibly accomplished by eating certain types of yogurt or other foods containing lactobacilli. While current research shows there may be some benefit to probiotic therapy, more research is needed on the subject.

CCauses

Bacterial vaginosis results from overgrowth of one of several bacteria naturally found in your vagina. Usually, "good" bacteria (lactobacilli) outnumber "bad" bacteria (anaerobes). But if there are too many anaerobic bacteria, they upset the natural balance of microorganisms in your vagina and cause bacterial vaginosis.

Risk factors

Risk factors for bacterial vaginosis include:

• Having multiple sex partners or a new sex partner. Doctors don't fully understand the link between sexual activity and bacterial vaginosis, but the condition occurs more often in women who have multiple sex partners or a new sex partner. Bacterial vaginosis also occurs more frequently in women who have sex with women.
• Douching. The practice of rinsing out your vagina with water or a cleansing agent (douching) upsets the natural balance of your vagina. This can lead to an overgrowth of anaerobic bacteria, and cause bacterial vaginosis. Since the vagina is self-cleaning, douching isn't necessary.
• Natural lack of lactobacilli bacteria. If your natural vaginal environment doesn't produce enough of the good lactobacilli bacteria, you're more likely to develop bacterial vaginosis.

Complications

Bacterial vaginosis doesn't generally cause complications. Sometimes, having bacterial vaginosis may lead to:

• Preterm birth. In pregnant women, bacterial vaginosis is linked to premature deliveries and low birth weight babies.
• Sexually transmitted infections. Having bacterial vaginosis makes women more susceptible to sexually transmitted infections, such as HIV, herpes simplex virus, chlamydia or gonorrhea. If you have HIV, bacterial vaginosis increases the odds that you'll pass the virus on to your partner.
• Infection risk after gynecologic surgery. Having bacterial vaginosis may increase the risk of developing a post-surgical infection after procedures such as hysterectomy or dilation and curettage (D&C).
• Pelvic inflammatory disease (PID). Bacterial vaginosis can sometimes cause PID, an infection of the uterus and the fallopian tubes that can increase the risk of infertility.

Prevention

To help prevent bacterial vaginosis:

• Minimize vaginal irritation. Use mild, nondeodorant soaps and unscented tampons or pads.
• Don't douche. Your vagina doesn't require cleansing other than normal bathing. Frequent douching disrupts the vaginal balance and may increase your risk of vaginal infection. Douching won't clear up a vaginal infection.
• Avoid a sexually transmitted infection. Use a male latex condom, limit your number of sex partners or abstain from intercourse to minimize your risk of a sexually transmitted infection.

auses

Bacterial vaginosis results from overgrowth of one of several bacteria naturally found in your vagina. Usually, "good" bacteria (lactobacilli) outnumber "bad" bacteria (anaerobes). But if there are too many anaerobic bacteria, they upset the natural balance of microorganisms in your vagina and cause bacterial vaginosis.

Risk factors

Risk factors for bacterial vaginosis include:

• Having multiple sex partners or a new sex partner. Doctors don't fully understand the link between sexual activity and bacterial vaginosis, but the condition occurs more often in women who have multiple sex partners or a new sex partner. Bacterial vaginosis also occurs more frequently in women who have sex with women.
• Douching. The practice of rinsing out your vagina with water or a cleansing agent (douching) upsets the natural balance of your vagina. This can lead to an overgrowth of anaerobic bacteria, and cause bacterial vaginosis. Since the vagina is self-cleaning, douching isn't necessary.
• Natural lack of lactobacilli bacteria. If your natural vaginal environment doesn't produce enough of the good lactobacilli bacteria, you're more likely to develop bacterial vaginosis.

Complications

Bacterial vaginosis doesn't generally cause complications. Sometimes, having bacterial vaginosis may lead to:

• Preterm birth. In pregnant women, bacterial vaginosis is linked to premature deliveries and low birth weight babies.
• Sexually transmitted infections. Having bacterial vaginosis makes women more susceptible to sexually transmitted infections, such as HIV, herpes simplex virus, chlamydia or gonorrhea. If you have HIV, bacterial vaginosis increases the odds that you'll pass the virus on to your partner.
• Infection risk after gynecologic surgery. Having bacterial vaginosis may increase the risk of developing a post-surgical infection after procedures such as hysterectomy or dilation and curettage (D&C).
• Pelvic inflammatory disease (PID). Bacterial vaginosis can sometimes cause PID, an infection of the uterus and the fallopian tubes that can increase the risk of infertility.

Prevention

To help prevent bacterial vaginosis:

• Minimize vaginal irritation. Use mild, nondeodorant soaps and unscented tampons or pads.
• Don't douche. Your vagina doesn't require cleansing other than normal bathing. Frequent douching disrupts the vaginal balance and may increase your risk of vaginal infection. Douching won't clear up a vaginal infection.
• Avoid a sexually transmitted infection. Use a male latex condom, limit your number of sex partners or abstain from intercourse to minimize your risk of a sexually transmitted infection.

Safe

OverviOverview

Bacterial vaginosis is a type of vaginal inflammation caused by the overgrowth of bacteria naturally found in the vagina, which upsets the natural balance.

Women in their reproductive years are most likely to get bacterial vaginosis, but it can affect women of any age. The cause isn't completely understood, but certain activities, such as unprotected sex or frequent douching, increase your risk.

Symptoms

Bacterial vaginosis signs and symptoms may include:

• Thin, gray, white or green vaginal discharge
• Foul-smelling "fishy" vaginal odor
• Vaginal itching
• Burning during urination

Many women with bacterial vaginosis have no signs or symptoms.

When to see a doctor

Make an appointment to see your doctor if:

• You have vaginal discharge that's new and associated with an odor or fever. Your doctor can help determine the cause and identify signs and symptoms.
• You've had vaginal infections before, but the color and consistency of your discharge seems different this time.
• You have multiple sex partners or a recent new partner. Sometimes, the signs and symptoms of a sexually transmitted infection are similar to those of bacterial vaginosis.
• You try self-treatment for a yeast infection with an over-the-counter treatment and your symptoms persist.

ew

Bacterial vaginosis is a type of vaginal inflammation caused by the overgrowth of bacteria naturally found in the vagina, which upsets the natural balance.

Women in their reproductive years are most likely to get bacterial vaginosis, but it can affect women of any age. The cause isn't completely understood, but certain activities, such as unprotected sex or frequent douching, increase your risk.

Symptoms

Bacterial vaginosis signs and symptoms may include:

• Thin, gray, white or green vaginal discharge
• Foul-smelling "fishy" vaginal odor
• Vaginal itching
• Burnin

  Overview

  Bacterial vaginosis is a type of vaginal inflammation caused by the overgrowth of bacteria naturally found in the vagina, which upsets the natural balance.
  Women in their reproductive years are most likely to get bacterial vaginosis, but it can affect women of any age. The cause isn't completely understood, but certain activities, such as unprotected sex or frequent douching, increase your risk.

  Symptoms

  Bacterial vaginosis signs and symptoms may include:
  • Thin, gray, white or green vaginal discharge
  • Foul-smelling "fishy" vaginal odor
  • Vaginal itching
  • Burning during urination
  Many women with bacterial vaginosis have no signs or symptoms.

  When to see a doctor

  Make an appointment to see your doctor if:
  • You have vaginal discharge that's new and associated with an odor or fever. Your doctor can help determine the cause and identify signs and symptoms.
  • You've had vaginal infections before, but the color and consistency of your discharge seems different this time.
  • You have multiple sex partners or a recent new partner. Sometimes, the signs and symptoms of a sexually transmitted infection are similar to those of bacterial vaginosis.
  • You try self-treatment for a yeast infection with an over-the-counter treatment and your symptoms persist.
  g during urination

Many women with bacterial vaginosis have no signs or symptoms.

When to see a doctor

Make an appointment to see your doctor if:

• You have vaginal discharge that's new and associated with an odor or fever. Your doctor can help determine the cause and identify signs and symptoms.
• You've had vaginal infections before, but the color and consistency of your discharge seems different this time.
• You have multiple sex partners or a recent new partner. Sometimes, the signs and symptoms of a sexually transmitted infection are similar to those of bacterial vaginosis.
• You try self-treatment for a yeast infection with an over-the-counter treatment and your symptoms persist.

 abortion and post-abortion care

Providing access to safe abortion and post-abortion care is at the core of our mission.

VAGINAL DISCHARGE

Definition

Vaginal discharge is a combination of fluid and cells continuously shed through your vagina.

Normal vaginal discharge helps keep vaginal tissues healthy, provide lubrication and protect against infection and irritation. The amount, color and consistency of normal vaginal discharge varies — from whitish and sticky to clear and watery — depending on the stage of your reproductive (menstrual) cycle.

Abnormal vaginal discharge — for instance, fluid with an unusual odor or appearance or discharge that occurs along with itching or pain — may be a sign that something's wrong.

Causes

Most causes of abnormal vaginal discharge — such as yeast infection, bacterial vaginosis or menopause symptoms — are relatively harmless, but they can be uncomfortable.

Abnormal vaginal discharge can also be a symptom of certain sexually transmitted infections (STIs). Since these can spread to involve the uterus, ovaries and fallopian tubes, and can be passed on to sexual partners, detection and treatment of STIs is important.

Rarely, a brownish or blood-tinged vaginal discharge could be a sign of cervical cancer.

Possible causes of abnormal vaginal discharge include:

Bacterial Vaginosis

1. Bacterial vaginosis
2. Cervicitis
3. Clamydia Trachomatis
4. Gonorhoea
5. Forgotten (retained) tampon
6. Pelvic Inflammatory Disease
7. Trichomoniasis
8. Vaginitis
9. Yeast Infection

Other causes

1. Certain hygiene practices, such as douching or using scented sprays or soaps
2. Cervical cancer
3. Pregnancy
4. Vaginal atrophy (genitourinary syndrome of menopause) 
5. Vaginal cancer
6. Vaginal fistula

Only rarely is vaginal discharge a sign of cancer.

When to see a doctor

Schedule a doctor's visit if you have:

• Greenish, yellowish, thick or cheesy vaginal discharge
• Strong vaginal odor
• Redness, itching, burning or irritation of your vagina or the area of skin that surrounds the vagina and urethra (vulva)
• Bleeding or spotting unrelated to your period

For self-care at home:

• Try an over-the-counter antifungal cream for a suspected yeast infection.
• Use a cold compress, such as a washcloth or ice pack, to relieve itching, swelling or discomfort of the vulva.
• Have your partner use a condom for a week after beginning treatment, or wait a week before having sex.
• See your doctor if your symptoms don't go away after a week or so.

Vaginal pH

What does this test do? This is a home-use test kit to measure the pH of your vaginal secretions. 

What is pH? pH is a way to describe how acidic a substance is. It is given by a number on a scale of 1-14. The lower the number, the more acidic the substance.

What type of test is this? This is a quantitative test -- you find out how acidic your vaginal secretions are.

Why should you do this test? You should do this test to help evaluate if your vaginal symptoms (i.e., itching, burning, unpleasant odor, or unusual discharge) are likely caused by an infection that needs medical treatment. The test is not intended for HIV, chlamydia, herpes, gonorrhea, syphilis, or group B streptococcus.

How accurate is this test? Home vaginal pH tests showed good agreement with a doctor's diagnosis. However, just because you find changes in your vaginal pH, doesn't always mean that you have a vaginal infection. pH changes also do not help or differentiate one type of infection from another. Your doctor diagnoses a vaginal infection by using a combination of pH, microscopic examination of the vaginal discharge, amine odor, culture, wet preparation, and Gram stain.

Does a positive test mean you have a vaginal infection? No, a positive test (elevated pH) could occur for other reasons. If you detect elevated pH, you should see a doctor for further testing and treatment. There are no over-the-counter medications for the treatment of an elevated vaginal pH.

If test results are negative, can you be sure that you do not have a vaginal infection? No, you may have an infection that does not show up in these tests. If you have no symptoms, your negative test could suggest the possibility of chemical, allergic, or other noninfectious irritation of the vagina. Or, a negative test could indicate the possibility of a yeast infection. You should see a doctor if you find changes in your vaginal pH or if you continue to have symptoms.

How do you do this test? You hold a piece of pH paper against the wall of your vagina for a few seconds, then compare the color of the pH paper to the color on the chart provided with the test kit. The number on the chart for the color that best matches the color on the pH paper is the vaginal pH number.

Is the home test similar to your doctor’s test? Yes. The home vaginal pH tests are practically identical to the ones used with doctors. But your doctor can provide a more thorough assessment of your vaginal status through your history, physical exam, and other laboratory tests than you can be using a single pH test in your home.

PAINLESS POST ABORTION CARE

Paracervical local anaesthesia for cervical dilatation and uterine interventions

PARACERVICAL BLOCK anesthesia is a  simple, safe and effective means of relieving pain eliminates the need for depressing amounts of analgesic drugs. It involves injection of local anaesthetic around the cervix to numb nearby nerves. Cervical dilatation and uterine interventions such as: -hysteroscopy,endometrial biopsies, fractional curettage, and suction terminations, they can be performed without any analgesia or anaesthesia; with regional anaesthetic injections as with paracervical block; using oral or intravenous analgesics and sedatives; or under general anaesthesia. Many gynaecologists use paracervical block for uterine intervention

No serious maternal or fetal complications have been reported. The principal use of paracervical block anesthesia is in relieving the pain of the first stage of labor ,dilatation and curettage and in patients with an incomplete abortion where the relief it affords is quicker and greater than that produced by drugs which act on the central nervous system. 

Neuroanatomy 

First stage labor pain is due mainly to dilatation of the cervix and to a lesser degree to uterine contractions.3 The sensation of pain is due to impulses passing by sensory and sympathetic nerve pathways down the lateral and posterior portions of the cervix into the area of the uterosacral ligaments. The impulses travel through the uterine, pelvic and hypogastric plexuses into the lumbar and lower thoracic chain to the rami of the eleventh and twelfth thoracic nerves to reach the spinal cord. This route has been substantiated clinically by the complete relief of pain afforded when spinal, caudal, epidural, upper lumbar sympathetic, lower thoracic, paravertebral, uterosacral or paracervical block is used. Pain of the second stage is produced primarily by distension of the lower birth canal, vulva and perineum and is conveyed by sensory pathways of the pudendal nerves, which enter the spinal cord via the posterior roots of the second, third and fourth sacral nerves. Paracervical block, therefore, is not sufficient for delivery. Procedure Most anesthesiologists feel that any anesthesia, even a local anesthesia, works more smoothly if premedication is used. This is true with the paracervical block. I use meperidine hydrochloride (Demerol®), promethazine hydrochloride (Phenergan®) and occasionally secobarbital sodium (Seconal®). They are unnecessary after the block. The Brittain Transvaginal Needle Guide* facilitates injection. This is a stainless steel tube with a ball on one end to prevent injury to maternal tissues and a funnel on the other end to allow easy access for the 6-inch 20-gauge needle. The needle protrudes from the guide only 7 mm. This eliminates the danger of too deep an injection and reduces the danger of hematoma formation to nil. The block is performed with the patient in bed under sterile drapes but without surgical preparation. The cervicovaginal fornix is located with the examining finger and the guide is placed at the 5 o'clock and 7 o'clock positions (Figure 1). It is important to sweep the guide away from the cervix in order to get into the posterior lateral fornix. The needle is then inserted through the guide, aspiration is made and the solution injected. I use chiefly a 1 per cent solution of lidocaine hydrochloride with epinephrine 1:1,000,000. This is prepared by mixing 50 ml plain 1 per cent lidocaine with 5 ml 1 per cent lidocaine with epinephrine 1:100,000. Epinephrine is contraindicated in the presence of diseases such as diabetes, hyperthyroidism, peripheral vascular disease, hypertension, nephritis and cardiac disease. The addition of epinephrine makes the mixture much safer than plain lidocaine hydrochloride and allows a longer duration of effect, but at the expense of uterine inertia in a certain proportion of cases, sometimes requiring use of an oxytocic agent. The usual dosage of anesthetic agent is 8 to 10 ml on each side. The maximum dosage is 50 ml-that is, 500 mg of lidocaine hydrochloride with epinephrine. Only 300 mg is allowed without epinephrine. If complete anesthesia is not obtained within two or three contractions, 5 ml is repeated on either or both sides. Sometimes there remains an unanesthetized coin area in the lower abdomen on one or both sides. This can be anesthetized by injection of 5 ml at the 10 o'clock or the 2 o'clock position. I keep one guide curved to allow easier introduction to these anterior locations. Failure is unacceptable. Repeated efforts should be made until the desired effect is achieved, but with care to stay within the limits of safe dosage. It must be emphasized that the greatest danger is overdosage. The block is given in the accelerated phase of labor, usually at about 5 cm cervical dilatation. Using lidocaine hydrochloride with epinephrine, the duration of anesthesia is approximately one hour and twenty minutes. The quality of uterine contractions after the block might seem poor and yet the progress in cervical dilatation be dramatic. This is because the cervix has become so soft and free of tone that even the mild contractions lead rapidly to complete dilatation. Because of atonicity, cervical lacerations are rare. We have done over four thousand blocks using this material in private practice. There have been no serious maternal complications. An occasional patient has complained of feeling faint or apprehensive from too rapid absorption, but these complaints have been very transient. Temporary numbness of one or both legs noted by some patients, disappears as the paracervical anesthesia abates. There have been no instances of hematoma, thrombosis, infection, hypersensitivity reaction or lumbosacral plexus neuritis. The only untoward effect is fetal bradycardia, noted in 4.7 per cent of cases. This should not be viewed with alarm; it is probably due to a vasovagal reflex, and must be distinguished from fetal distress. Infants have been delivered during the period of bradycardia in some cases and after its disappearance in others, and in none of them has fetal depression been present. On the contrary, the infants are breathing and crying before the delivery is completed. The important point, therefore, is that a careful evaluation must be made to distinguish the cases of fetal bradycardia due to fetal distress from the transient bradycardia observed following paracervical anesthesia.

Gynecologic Use 

Paracervical block for anesthesia for curettage is carried out without the Brittain Guide. A 3- or 4-inch 21-gauge needle is adequate, and 5 ml of the anesthetic solution is infiltrated at the 4 o'clock position, 5 ml at 8 o'clock and 5 ml directly into each uterosacral ligament. This provides the ideal anesthetic for completion of abortions and it is excellent for curettage in many other circumstances. The method is not recommended in the presence of vaginismus of any cause. It is indicated where general anesthesia or sophisticated forms of conduction anesthesia are either unavailable or contraindicated. It is especially useful if the patient has anemia, has too recently eaten or has a respiratory problem or is in borderline shock. Many patients with incomplete abortions fall into this category. Paracervical block can also be used in other minor procedures such as cervical repair, conization and Shirodkar or Wurm operations, although in such cases it is probably better to reserve it for the exceptionally poor risk patients. Paracervical block has also been recommended as an aid in the differential diagnosis of dysmenorrhea. 

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