a pair of cervical block is not a new concept to the gynecologist this is a technique that has been used for a variety of different office procedures including cervical biopsies individual biopsies and leak procedures this is the introduction of an anesthetic at the base of the uterus near the cervix near the Cardinal and neuter sacral ligaments to block the pain fibers leaving the uterus a wide variety of medications have been used for para cervical blocks most commonly we use lidocaine either with or without epinephrine the purpose of the epinephrine is to constrict the small blood vessels thus causing the anesthetic to remain locally for a greater period of time lidocaine has the advantage of being very rapidly acting therefore the effectiveness is very quick however its effect wears off relatively quickly as well this has led some patients to prefer the effect of marcaine which is a more long-acting anesthetic the disadvantage is that it takes a little longer to achieve an adequate block using this medication consequently many physicians will use a combination of both lidocaine and marcaine to get the advantages of a rapid onset and the advantages of a delayed action the nerves to the uterus are formed on either side by a continuation of the hypogastric plexus the sacral sympathetic efferent fibers from the second third and fourth sacral nerves and by a few filaments from the first two sacral ganglia the sensation for pain for the patient is mainly due to impulses passing by sensory pathways down the lateral and posterior portions of the cervix into the area of the Cardinal and Peter sacral nerves her cervical block injects a medication in this region to block the impulses leaving the uterus at this Junction because of this variation there is variability and the technique used to achieve a pair of cervical block this may range from a very simplistic to quadrant or four quadrant pair cervical block in which the bulk of the material is injected into the uterus a crow ligament region however it may be more complex where a component of the block involves an interest cervical injection as well I'd like to demonstrate for you here a very simple four quadrant technique for pair cervical block once the cervix is visualized the anterior lip can be grasped with a single tooth tenaculum for manipulation after which a small amount of anesthetic is injected at 2 o'clock 4 o'clock 8 o'clock and 10 o'clock and each case this is injected in the immediate submucosal region so that a small wheel of anesthetic is raised prior to injecting the anesthetic aspirating the syringe will ensure that you're not in the intravascular space after the injection the anesthetic will dissipate into the adjacent tissue thus delivering the anesthetic to the nerves experience has shown that patients undergoing an outpatient office based intimate relation can receive significant anesthetic benefits from impaired cervical block the medications prepare cervical Blanc are pre-mixed prior to the procedure initially the person of course medications are injected into the 12 o'clock position of the cervix after aspiration to allow the tenaculum be comfortably placed next a small wheel of medication is placed at the three o'clock nine o'clock five o'clock and seven o'clock positions of the cervix submucosa Lee great care is taken to aspirate to avoid any intravascular administration of the medication after the initial wheel has been placed then a second deeper administration of the same anaesthetic mixture is placed again at the three o'clock nine o'clock five o'clock its positions the total of approximately twenty to twenty five CCS will be administered throughout these four places upon the cervix after the dose had been successfully given the instruments will remove tenaculum removed speculum removed and patient has taken out the lithotomy position for five minutes or so to allow the patients be comfortable but also to allow medications to have full effect on the nerve fibers one of the considerations that we must at least think about with these medications is that they do have cardiovascular effects we use them intravascular ly in our cardiac protocols for ACLs and for cardio resuscitation we know that they have a wide variety of different cardiovascular actions thus you must be very cautious when you're doing a pair of cervical block not to introduce these medications directly into the vascular tree aspiration of your needle prior to injection can ensure that you're not intravascular you must also consider the total amount of anesthetic that you're using in relationship to the body mass of the patient calculate the cardiotoxic concentration can be sure that the amount that you administer is below that some of the side effects that you want to be aware of would be changes in blood pressure and in the case of using epinephrine with your lidocaine you may see rapid changes in blood pressure as well as changes in heart rate finally just the performance of a pair of cervical block itself can create a vagal response in many patients causing a decrease in consortium a decrease in blood pressure and a slowing of the pulse rate so anytime you're going to be using these in the office you need to be prepared with appropriate resuscitation technique and equipment there's a wide variety of technique used for pair cervical blocks the exact technique that you use for your patient is going to have to be a decision you will make based on the specific characteristics of your patient and your comfort level and the degree of intervention you're planning [Music] you