Cervical Incompetence and Cerclage - Before Your Procedure

What is a cervical incompetence?
In some pregnant women, the cervix, the hole of the uterus into the vagina, dilates (opens) too early in the pregnancy. Normally the cervix stays closed until labor starts and usually requires a lot of strong uterine contractions before it dilates. When the cervix is not strong enough to hold the growing fetus it is called cervical incompetence. We do not know why some women have a “weak” cervix, although there is some association with abnormal cervical structure (something that you are born with), scars in the cervix related to tears during previous deliveries or following cervical procedures, such as cone biopsy for an abnormal PAP smear.

What is a cerclage?
A cerclage is a strong stitch that is placed like a purse-string around the cervix to keep it closed so that the pregnancy can continue until the fetus is grown. The procedure is performed through the vagina in an operating room, usually with regional (spinal or epidural) anesthesia. This type of anesthesia (where you are awake) is the one preferred for pregnant women. There are three different types of cerclage – the McDonald, the Shriodkar (if it is necessary to place the stitch under the bladder) or the rescue cerclage (when the cervix is already effaced and the bag of waters is funneling into the cervix). The doctor performing the surgery will usually make this decision at the time of surgery, after looking more closely at your cervix.

Do you need a cerclage?
The diagnosis of incompetent cervix may be based on a history of previous pregnancy losses, ultrasound evaluation or a vaginal exam that noted a “short” cervix (which may dilate much easier than a “long” cervix). If your doctor has recommended that you have a cerclage, it is best performed between 12-16 weeks of pregnancy. At that stage, the risk of miscarriage is decreased and it is performed before there is a lot of strain on the cervix. When a “rescue” cerclage is done (usually around 20 weeks), the risk of infection, breaking the bag of waters and pre-term delivery is much greater.

If your cervix is determined to be “short”, soft (weak) or you are pregnant with more than one baby, your doctor may recommend a cerclage. Discuss the advantages, risks and alternatives with your obstetrician. You may also want to ask how much experience she or he has had with placing cerclages and the success rate.

Preparing for the procedure
Your cerclage will occur at the California Pacific’s California Campus, located at 3700 California Street, San Francisco. If your surgeon has ordered blood tests, you may have to come to the hospital a few days before your surgery. You must not have anything to eat or drink for at least 8 hours before your surgery (this helps prevent vomiting during the procedure).

What happens on the day of surgery?
You will be told when to come in to the hospital, register and report to the third floor Surgical Center. You will be assigned a pre-op nurse who will ask some questions and start your IV. Just before the procedure, you will be taken to the operating room on a gurney. You will meet your anesthesiologist who will discuss your health history and anesthesia options. Most patients prefer regional anesthesia, usually a “spinal.“ You will be numb (feel nothing) from your chest/stomach down to your toes and won’t be able to move your legs until about 1 hour after the surgery is over. A benefit to regional anesthesia is that the drugs are fairly well localized around your spinal cord so neither you (nor the baby) will get much systemic (whole body) side effects.

You will meet another nurse in the surgical area who will stay with you during the surgery. Once in the operating room, the anesthesiologist will place your anesthesia and your surgeon, an assistant and a scrub nurse will proceed with the surgery; the actual cerclage placement takes less than an hour.

What happens after the surgery?
Since your legs will still be numb, we will help you move back to the gurney and you will be taken to the recovery room. You will meet your recovery nurse and stay in there until the feeling and movement returns to your legs (about one hour). You will feel some pain and cramping as the anesthetic wears off and will be given medications to ease those discomforts. We will look at the baby’s heartbeat and amniotic fluid after the procedure with a portable ultrasound. In most cases, you will go home the same afternoon or evening. If you are having a “late” cerclage (after 18 weeks), you may stay overnight for more observation. You will receive a prescription for pain meds, antibiotics and anti-cramping medicine. We recommend that you take it easy for about 48-72 hours after you get home - meaning no lifting, long walks, traveling or intercourse. We will provide you with another set of instructions before you are discharged from the hospital that will give you more information on what to expect in the weeks following your cerclage.