Listed below is the step by step procedure of cervical cerclage surgery:
- What is Cervical Cerclage?
- Why is Cervial Cerclage Required?
- Pre-operative Preparation
- Day Before Surgery
- Procedure Day
- Methods/Techniques of Cervical Cerclage
- Post Procedure
- Risks and Complications
What is Cervical Cerclage?
Cervical cerclage is a surgery which includes tightening of cervical opening during pregnancy. During pregnancy fetus grows and develops in the mother's uterus (womb). At the time of delivery the muscles of uterus contract (shorten) and expand alternately to push the baby out. Uterus leads to cervix which leads to vagina through which the baby comes out.
Cervix is closed through out the pregnancy to protect the fetus developing within the uterus. In some women, the cervical opening might be lax or it may open up later during pregnancy. To correct this abnormality, cervical cerclage is performed. Cervix is closed or made tighter by stitching its opening with surgically designed thread or it is closed with a band.
Why is Cervial Cerclage Required?
As mentioned above, cervical cerclage is done only in pregnant women. However, it is not required in every case of pregnancy. Some of the indications that cervical cerclage is needed are mentioned below:
- Incompetent Cervix/ Cervical Insufficiency
Under normal circumstances, the cervix remains closed throughout the pregnancy and starts dilating (opening up) when labor pains begin Some women might have weak cervical muscles. These fail to keep the cervix tight. The cervix might start opening up in absence of labor pains in such conditions. This could lead to premature delivery. Sometimes the cervix might start opening up earlier during the pregnancy. This could lead to abortion (miscarriage).
- Short Cervix
Cervix is a passage between the opening of uterus to the vagina. It is about 3-5 cms in length. If it is shorter than 3 cms, there is possibility that it might open up earlier into the pregnancy and induce early onset of labor.
- Previous Miscarriage or preterm delivery
In women who have had a pregnancy previously, there might have been preterm labor or even an abortion due to cervical abnormalities. In such cases, the subsequent pregnancy is monitored more carefully. A prophylactic (something done as a preventive measure) cervical cerclage is done at a predetermined stage of pregnancy to prevent the recurrence of miscarriage or early delivery. if previous delivery has occurred without enough contractions, it could be an indication of an incompetent cervix. These conditions necessitate cervical cerclage.
- Early Effacement or Dilatation
During the normal course of delivery the cervical opening not only dilates (opens) but also becomes thinner (effacement). It widens up to 10 cms to help the baby to come out of the uterus. This happens after 9 months of pregnancy are completed. If it happens earlier, the cervical opening has to be secured to prevent early delivery.
- No Previous History
Cervical insufficiency, early dilatation of the cervical opening or early effacement (thinning of cervical walls) can occur in women with no past history of any cervical abnormality. During the first pregnancy it may not be possible to predetermine these conditions till they occur. Sometimes, it is also possible that the earlier pregnancies might have been normal and the above mentioned cervical abnormalities occur in subsequent pregnancies. In such instances also cervical cerclage can be performed to prevent complications in the pregnancy.
Cervical cerclage is performed at the opening of cervix during pregnancy. Therefore it has to be done very carefully with complete care not to harm the growing fetus in the slightest manner. The below mentioned pre-surgical preparations are advised to ensure that cervical cerclage is performed with minimal risks.
- Discussion: Prior to the surgery, thorough discussion about the necessity and end result of cervical cerclage are explained to the pregnant lady and her family. The gynecologist will highlight all advantages and drawbacks of the surgery. The patient is needed to submit a signed consent stating that she is willing to undergo the surgery.
- Counseling: Pregnancy is an important stage in the mother's life. Due care and precautions have to be taken throughout the surgery to ensure that the mother and baby are in good health. The idea that surgery might be necessary during pregnancy or that there could be potential harm to the unborn baby due to cervical incompetence could be a cause stress to the expectant mother. In some cases psychological counseling might help to deal with the situation.
- Physical Examination: The gynecologist will perform a complete physical examination for the patient prior to surgery. The uterus, vagina and cervix are observed and examined. If there are any other health conditions associated with pregnancy which get detected during physical examination, they will have to be treated separately. Blood pressure is monitored carefully. Sometimes, there could be hypertension (high blood pressure) associated with pregnancy. It is often present along with swelling of the body. It needs to be treated medically.
- Investigations: USG (Sonography) is done before cervical cerclage to observe development of the growing fetus. The fetal heart rate is calculated, uterus is observed and any abnormalities in the pregnancy are looked for. If the USG is normal the gynecologist will proceed with cervical cerclage.
Other investigations include white blood cell count. Elevated levels is diagnostic of infection. It needs to be treated with antibiotics before proceeding with the surgery. A condition known as gestational diabetes (diabetes developing during pregnancy) is known to occur is many women. Blood sugar levels will help to determine diabetes. If it is diagnosed, surgery is rescheduled till blood sugar levels are brought down to normal with medicines.
Day Before Surgery
Cervical cerclage can be done as a preventive measure during pregnancy when there are known abnormalities of the cervix. In such cases the procedure is usually done around the 3rd month of pregnancy. The procedure can be performed on outpatient basis. The patient does not need to stay at the hospital before or after surgery.
General anesthesia is used for the procedure. Therefore it is advisable for the patient to keep an empty stomach since one night before surgery. This precaution is taken because under the effect of general anesthesia, entire digestive tract is temporarily paralyzed. If patient has eaten just before surgery, the food might regurgitate (come out of the esophagus) during surgery and enter the lungs. This could lead to respiratory complications.
Regional anesthesia is also used to perform the surgery. The nerves providing sensation to pelvic area is numbed. This way, patient remains conscious during the surgery but does not feel any pain. The patient is advised to avoid undue mental stress right before surgery. Activities which will cause physical strain are strictly not allowed. The patient should take care not to strain her abdominal and pelvic muscles.
Sometimes however, cervical cerclage could be an emergency procedure. Sudden onset of cervical dilatation or thinning of cervix could occur in pregnant women with such previous occurrence. In such cases there is hardly any time for pre-operative preparations. Surgery is preferably done at the earliest in such cases.
On the day of surgery, patient is advised to be present at the hospital well in advance of the decided schedule. She is asked to dress in a surgical gown which is sterilized to get rid of all microorganisms. All the equipment used for surgery is sterilized. Blood pressure, pulse rate, breathing and body temperature are checked. Dose of anesthetic agent to be administered is determined depending on these parameters and the patient's general health. Anesthesia is given in the form of an intravenous injection. General anesthesia can also be administered in the form of respiratory fumes.
Cervical cerclage is done through vaginal route in most cases. Therefore the patient is positioned in such a way that her legs are spread apart and the vagina is easily accessible. If however, vaginal route cannot be used, the surgery is performed by abdominal route. In this case, the patient is made to lie down flat on the back and legs are kept straight. Skin over the abdominal wall is cleaned with an antiseptic solution. All hair over the abdominal skin is shaved. A catheter is inserted through the urethra to empty the urinary bladder. After the anesthetist confirms that patient is completely under effect of anesthesia, surgery may begin.
Methods/Techniques of Cervical Cerclage
There are two methods of cervical cerclage through vaginal route. Both these methods along with abdominal cervical cerclage have been explained below:
- McDonald's Cerclage
- Shirodkar Cerclage
- Transabdominal Cervical Cerclage
This is an old method. It is a tried and tested procedure, and its efficacy has been proved over time. An instrument known as speculum is inserted through the vagina. It is used to widen the cervix and vagina and helps to visualize the field of surgery well. The cervix is adjusted with the help of speculum in such a way that all its 4 walls can be seen clearly.
Using a medically designed thread and needle, the internal os is stitched together like the mouth of a closed purse or pouch. Internal os is the junction of uterus and cervix. The speculum is removed after the procedure is completed.
It is a slightly different method in comparison to McDonald's cerclage. A speculum will be used to retract the cervical and vaginal walls, as mentioned in the above procedure. At the junction of cervix and vagina, small incisions are made in the front as well as back, using surgical tools. A needle attached to a surgical tape is introduced inside these incisions. The cervix is tightened by passing the needle from front to behind or vice versa through the incisions. For this procedure, the vaginal wall, urinary bladder, rectum are retracted to expose the cervical walls appropriately. Vaginal tissue which subjected to surgical incisions is repositioned by closing the incisions with surgical thread.
Only in cases where vaginal approach cannot be used for cervical cerclage, abdominal approach is used. This procedure can be done by open or laparoscopic methods. A single incision or multiple small incisions are made on the lower abdominal skin. During open surgery the uterus can be visualized directly as the surgical incision is big enough. Smaller incisions are given for laparoscopic approach. A laparoscope (video camera attached to a long flexible tube) is inserted inside the pelvic cavity to visualize the internal organs and have better precision during surgery.
The abdominal muscles and uterus are retracted till cervix can be seen. A tape is placed around the cervix and tightened to prevent the opening from widening before labor pains start. The uterus is rearranged at its original position and abdominal incisions are closed with surgical thread.
After cervical cerclage surgery is completed the patient is transferred to a recovery room. Once the effects of anesthesia wear off, patient is thoroughly examined. Post-procedure steps mentioned below are followed to achieve fast recovery after the surgery:
- Hospital Stay
- Physical Activity
- Sexual Intercourse
- Removal of Cervical Sutures
The will be kept under observation for a few hours after surgery and then discharged to go home. In some cases, if the gynecologist feels it necessary, the patient might be kept in the hospital overnight for observation. The catheter placed before surgery will be retained for some hours. If surgery has been performed under general anesthesia, solid and liquid food is withheld till the gynecologist ensures that normal intestinal movement has resumed. After this happens, the patient is allowed to consume soft and solid food which is easy to digest. Before discharge from the hospital, patient is examined again, the cervical sutures are checked and the catheter is removed urinary bladder.
A USG (sonography) is repeated after surgery to monitor fetal movements and fetal heart beat. If there has been any damage to the uterus or fetus during surgery, it can be detected during USG. Necessary treatment measures can then be implemented for rectifying the damage, if any.
The patient will be advised to take as much rest as possible after the surgery. A lot of physical activity or strain over the pelvic or abdominal muscles might loosen the cervical opening again and induce uterine contractions which could lead to miscarriage or early labor.
The gynecologist will advise the patient to abstain from sexual intercourse for at least one week after surgery. Afterwards the patient is advised to be very careful during sex, so as to prevent rupture of the cervical stitches.
Follow up visit to the doctor once a week or once in 15 days is recommended. Physical examination is done to look for changes in the cervical opening of thinness of cervix.
Cervical cerclage is a temporary procedure and is reversed before onset of labor. If labor pain begins before the expected due date, the cervical stitches or tape are removed to assist easy delivery of the baby. However, if the woman keep good health and does not go into preterm labor, cervical sutures or tape are removed after 9 months of pregnancy are completed. The patient may resume normal physical activity afterwards till she goes into labor. Abdominal cervical cerclage is removed by performing another surgery which will require another abdominal incision.
If Shirodkar cerclage is used, it can be retained by women who plan to have further pregnancies as well. There is not need to remove it prior to labor. However, delivery will be done by C-Section in such cases. A gynecologist has to be consulted for this decision.
Risks And Complications
Following are the risks and complications associated with cervical cerclage:
- Cervical Tear
- Vaginal Bleeding
- Urinary Troubles
While performing the surgery, surrounding healthy part of the cervix, vagina, uterus urinary bladder or rectum may get damaged. Another corrective surgery might be needed to repair these defects. If this is not possible due to advancing pregnancy, symptomatic relief can be provided with medicines. Surgery can be carried out after the woman delivers her baby.
Stitches or tape which keep the cervical opening narrowed and tight may get infected. This could lead to pain and swelling inside the cervix and fever. Antibiotics are prescribed to treat the infection. Pain and fever are also treated with medicines.
If there is premature onset of labor after cervical cerclage, the membranes covering the fetus will rupture and the amniotic fluid will gush out. Cervical sutures could get torn apart due to the force of amniotic fluid and cervix could get damaged. Cervical tear can be repaired with surgery.
Bleeding during pregnancy always needs to reported immediately to the gynecologist. There could be a number of causes for it. After cervical cerclage bleeding might occur if there is injury to the vagina or cervix during the procedure. The patient must contact her gynecologist immediately is this happens.
Dysuria (painful urination) could be experienced for the first few days after cervical cerclage. This is a normal consequence of the procedure and will subside in a few days. Pain killers may be prescribed if the symptoms are unbearable. However, if pain persists for a long time, the doctor must be consulted with immediately as this could be a sign of infection.