Taking your hat off: A rare injury in obstetrics 

Pippa is an obstetrics and gynaecology consultant, recently returned from assignment with Médecins Sans Frontières / Doctors Without Borders (MSF) in Jahun, part of northern Nigeria’s Jigawa state – an area where high numbers of women and children die during childbirth. Here she writes about an unusual and traumatic injury...

My first case of the evening is crazy. 

Needing to describe the patient's injury to the team in theatre, I explain that she has “taken her cervix off”, just like you would do your hat. The hats that the Hausa men wear here are particularly cervix-like, so I think this a good analogy. 

During delivery of a very infected stillborn, the patient’s cervix (the neck of the womb) has been avulsed – a technical term – meaning it has torn. This time it has torn in such a way that it has almost completely come away. She has likely, in fact, delivered her baby through this tear, rather than through the normal dilatation of her cervix.  

This is so rare that you shouldn’t see it in a lifetime of obstetrics...

So again, I call my colleague in, feeling bad. She just finished the afternoon shift and I am always acutely aware of her need for rest, as well as mine. Our timetable is manageable, but I am three weeks into an assignment full of daily shifts that can be challenging. Despite the “paradise” we are in, it is taking its toll.

Never in a lifetime of obstetrics

Neither of us has seen this injury before, not unsurprisingly as it is rare… like, so rare that you shouldn’t see it in a lifetime of obstetrics. So, we are scratching our heads as to what to do. 

I think of what medicine used to be like and the way surgeons used to pontificate about operations written down on the back of envelopes at dinner parties. Less evidence-based. More about finding solutions to problems. 

We process a few ideas, thinking through them logically and most have a good reason not to do them. 

My colleague and I are trying to work out how to reattach the “hat”. But it’s difficult… In fact, at the moment, with a hugely inflamed, swollen cervix, and the tools we have, I might even say it is impossible (but there is a saying about workmen and their tools). 

To our relief the patient’s bleeding has settled, so we pack the wound and cross our fingers. 

Scratching our heads

I scurry home to get advice from our technical referent – an MSF consultant back home. I also do a quick search of literature on the internet and find the last case series from 1967, as well as a couple of other reports to get an idea about what we might do.

Some of these case studies report that the surgeons removed the patient’s womb. However, that is not acceptable in this environment. The lady (well, 18-year-old girl) has no children… and she can’t not have children. I witnessed the blood-curdling screams she gave at the mention of hysterectomy earlier. 

So, we will scratch our heads a bit more.

When the swelling subsides, we hope that it will be more straight forward to fix. As her uterus becomes “less pregnant”, her anatomy should correct itself and more of the cervix (that has shifted up during the end stages of pregnancy) will return to its original position. Hopefully leaving her with more cervix that it seems at the moment.

The cervix is an important piece of kit if you want to hold onto a pregnancy until full term, so we aim to leave the patient in a better place for future pregnancies. This aim is also a theme in the old case reports. They might be from over half a century ago, but they are very helpful to refer to.