Gynecologic Office Procedures

See also Chapters 25 and 26. Paracervical Block

A paracervical block can be placed before any uterine procedure requiring instrumentation of the cervix or cervical dilation. Contraindications include current desired pregnancy, infection, and bleeding disorders. The local anesthetic used is determined by the length of anesthesia required, most often 0.5% lidocaine or bupivacaine for injection.

The patient is placed in a dorsal lithotomy position and a vaginal speculum placed to allow adequate visualization of the cervix. Two 10-mL syringes are drawn up of a 1:1 ratio of 1% lidocaine or bupivacaine and sterile saline. The cervix and vaginal canal is cleansed with chlorhexidine or povidone-iodine. An injection of 1 to 2 mL of this mixture is placed in the anterior cervical lip, where a single-toothed cervical tenaculum is placed. The cervix is lifted upward and deviated laterally to obtain access to the lateral posterior fornix. The 4 and 8 o'clock positions are identified on the cervix, and 8 to 10 mL of the mixture is injected at each site. This injection starts into the cervicovaginal reflection at the apex of the posterior fornix at these positions and is advanced 2 to 5 cm in depth along the external serosa of the uterus, to provide anesthesia to the uterine plexus of nerves near the uterine arteries. Intravascular injection is avoided by pulling back on the syringe plunger before infiltration.

Women have less pain during uterine intervention with paracervical block than with placebo injections (SOR: B).

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