Cervical cerclage

If you have had a spontaneous preterm birth (before 37 weeks) in a previous pregnancy, a late miscarriage, surgery or trauma to the cervix (neck of the womb) you are more likely to have a weak cervix, sometimes called “cervical insufficiency”. This is a painless dilation and shortening of the cervix during the second trimester (weeks 12 – 24) of pregnancy. It means that your cervix may shorten and open more easily, which can cause a late miscarriage or spontaneous preterm birth.

To prevent or treat a weak cervix, you may be offered a cervical cerclage, suture or ‘stitch’. If this is inserted through the vagina it is called a transvaginal cervical cerclage. If it is inserted in the abdomen it is called a transabdominal cervical cerclage. To insert this cerclage an operation is performed by an obstetrician.

If you are expecting twins (multiple pregnancy), cervical cerclage may be less successful in preventing preterm birth because the risk of preterm birth may not always be related to problems with your cervix. However in some cases a cervical cerclage may be indicated and your obstetrician will discuss this with you.

What your obstetrician aims to do when performing a cervical cerclage is to keep the neck of your womb closed by placing a stitch into and around your cervix like a ‘purse-string’. This will mean that your cervix is less likely to undergo changes that can cause it to open. Your baby is therefore held inside the womb and your chances of getting an infection or going into spontaneous preterm labour are also reduced.

Transvaginal cervical cerclage

This type of cerclage is placed through the vagina, and is most commonly used. There are two slightly different types of transvaginal cervical cerclage, known as the McDonald and the Shirodkar procedures. Both appear to be equally safe and successful. Your obstetrician will discuss with you which is the best type for you.

Transabdominal cervical cerclage

Occasionally women have had a ‘failed’ transvaginal cervical cerclage where they have delivered very preterm in a previous pregnancy despite having a cerclage. In this situation your obstetrician may recommend a transabdominal cervical cerclage. This type of cerclage is placed at the very top of your cervix, from above. Abdominal cervical cerclages can be placed before you get pregnant using a laparoscope or small camera. If you are already pregnant, an abdominal cervical cerclage can be placed by doing a small ‘bikini-line’ cut in your abdomen. Your obstetrician will discuss separately the risks and benefits of this type of procedure.

We recommend that you have the transvaginal cervical cerclage inserted after week 12 of your pregnancy and before week 24.

Before week 12, the risk of spontaneous miscarriage unrelated to changes in the cervix, is still high. We therefore wait until you have passed this time and you have had a detailed scan, before inserting the stitch. It is not clear at the moment whether there is any benefit of having the procedure after week 24 of pregnancy.

Elective procedure

If it is suspected that your cervix may shorten in the future, your obstetrician will plan for you to have the cerclage soon after the 12th week of pregnancy.

Ultrasound-indicated procedure

In some cases, small changes to your cervix can be detected on the ultrasound scans you have when being monitored in your pregnancy. In this case we may book you in at short notice to have a cervical cerclage. The cerclage would then be performed as soon as possible to reduce the risk of any further changes.

Elective and Ultrasound Indicated cerclages are carried out on dedicated operating list by experienced team of Obstetricians.

Emergency procedure

Sometimes cervical cerclage can be done when your cervix has already changed significantly and when it is believed that you are likely to miscarry or give birth preterm in the very near future. An emergency cerclage may prolong your pregnancy and allow your baby to continue growing and gaining weight. But there are more risks associated with the procedure when it is done in an emergency, including the risk of infection or of rupturing your membranes early. To rule out the presence of an infection before the procedure you may be offered an amniocentesis. This is a test where a needle is inserted into your womb to take a sample of amniotic fluid to be tested for infection.

Cervical cerclage is not recommended if the amniocentesis test shows that you have an infection, you are bleeding heavily, if the bag of fluid around your baby has already opened too soon, known as premature rupture of the membranes (PROM) or you have started labour. In these situations, cervical cerclage will not help to prevent late miscarriage or spontaneous preterm birth and may not be safe.

After cervical cerclage your chance of late miscarriage or spontaneous preterm birth reduces considerably but does not go away completely. Your obstetrician may be able to tell you in more detail what the likelihood of this is, based on your personal medical history. Like any surgery, the cervical cerclage has some risks that you need to be aware of, that are listed below.

• Bleeding. You may experience bleeding, like having a very heavy period (menstruation) after the surgery. This happens in approximately 1 in 100 procedures. If this happens, use a sanitary pad, not a tampon, and seek medical advice. Most women will only experience some light bleeding (spotting) for a few days after the procedure and you should also use a sanitary pad (not a tampon).
• Bladder or cervix tearing. There is a risk that through the procedure you may have some tearing of your bladder or your cervix. This happens in only 1 in every 100 procedures. Your obstetrician would generally be able to repair any tearing to the cervix immediately. A tear to the bladder would require another operation by a urologist (a medical doctor with specialist training in problems affecting the urinary tract). Both would require a few extra days stay in hospital.
• Infection. You have a small risk of a vaginal or uterine infection. Your obstetrician may take a swab from your vagina before the procedure and if there is evidence of an infection give you a course of antibiotics.

If you have any complications from the surgery such as these, you will be offered appropriate treatments and care. Your obstetrician will speak with you more about the risks and benefits before you decide to have the procedure.

If you are unsure about whether to have the procedure, please discuss your concerns with your obstetrician. If you decide not to have cervical cerclage, there is still a chance that you could give birth to a healthy baby at term. Your obstetrician will discuss with you any alternatives to the procedure that may be relevant to your specific medical history. For example, it may be possible for you to take vaginal progesterone pessaries (dissolvable medication that is inserted into your vagina) to reduce your chance of late miscarriage and preterm birth. You do not put your health at risk by deciding not to have cervical cerclage and you will still be followed carefully by your obstetrician and midwife throughout your pregnancy.

1. Anaesthetic referral

You may need to see an anaesthetist (a medical doctor with specialist training in inducing numbness or sleep during surgery) before the day of your procedure to plan your anaesthesia. Your obstetrician will discuss with you whether this is necessary.

2. Domestic arrangements

If you have children, you will need to arrange for them to be looked after overnight even if you are scheduled to go home after the procedure as you will be tired and need to rest. There is also a chance that you will be asked to stay in hospital overnight after your procedure, so you will need to be prepared for that. You should preferably have help at home for the first few days as you will find lifting and domestic chores difficult and should avoid exerting yourself.

3. Vaginal swab

Your obstetrician may take a vaginal swab before the surgery to check for infections and arrange treatment.

4. Medication before the operation

You may be advised to take a tablet called omeprazole (20mg) and one called metocloperamide (10mg) on the night before your procedure and first thing when you wake up on the day of the procedure. The omeprazole counteracts the acid in your stomach so that if there are any problems with vomiting during the surgery, the risks of inhalation are reduced. There is only a very small chance that this will happen. The metaclopramide reduces the chance of you vomiting. The obstetrician will give you a prescription if you need the tablets. Both of these tablets are used widely in pregnant women and are not known to be harmful to you or your baby.

5. Eating and drinking

You should have nothing to eat or drink for at least six hours before the procedure (from midnight the night before if your procedure is in the morning, or from 6am on the day of the procedure if it is in the afternoon).

Please continue to take any prescribed medication as usual and bring it with you into hospital. You can have a small sip of water with any tablets you take, if necessary.

Anaesthesia prevents you feeling any pain during the procedure. The procedure can be done using general anaesthesia where you are asleep during the procedure; this is safe in pregnancy. Alternatively, you may be offered a local or regional anaesthesia in the form of a spinal block or an epidural. This means that you are awake during the procedure but will not feel any pain from the lower half of your body.

On the day of the procedure, you will be seen by an anaesthetist who will explain the process in greater detail, before agreeing which type of anaesthetic you should have.

We want to make sure that you fully understand your condition and the options available to you. Before you receive any treatment, the doctor will explain what he or she is recommending and will answer any questions you may have. You will be asked to sign a consent form. A consent form confirms that you agree to go ahead with the surgery. No treatment is carried out without your consent.

On the day of the procedure you will be asked to report either to the Day Surgery Unit (2nd floor of main UCLH building) or to Labour Ward (2nd floor of the EGA Obstetric Wing at UCLH). Your Doctor or Midwife will tell you where to attend and at what time. Because cervical cerclage procedures are often performed at short notice, we may have to coordinate your procedure with other planned procedures already in our diary. For women having surgery on Labour Ward, occasionally there may be a delay to the procedure if there is an emergency case.

Once you arrive you will stay in the waiting area or be admitted to a room. When your surgery is to be done, a Midwife will accompany you to the surgical theatre where the anaesthetic and the procedure will be carried out.

One person can stay with you during the procedure if you are having a spinal/epidural anaesthetic (i.e. you are awake). Children are not allowed to be present in theatre.

The theatre team will be there to welcome you and take care of you. Once the anaesthetic doctor decides that the anaesthetic is working (i.e. you are asleep if

you are having a general anaesthetic, or you feel numb on the lower part of your body if you are having a local/regional anaesthetic), you will lie on the surgical bed, your legs will be eased apart and into stirrups, and the table will be tilted to give the surgeon a better access to your cervix. You will be wearing a gown, and sterile drapes will ensure minimal exposure. Although you are awake, you do not see the procedure. There will be a screen in front of your face and you will be able to talk to your companion and medical staff if you are having a local/regional anaesthetic. You may receive a dose of antibiotics into your drip (intravenous access in your arm) during the procedure. Your blood pressure will be monitored throughout. The whole procedure may take up to one hour.

After the procedure, you will be taken to the recovery area next door to the operating theatre.

If you had a general anaesthetic, you will have an oxygen mask on your face when you wake up. The oxygen helps to clear the anaesthetic from your body while you are recovering. You will probably feel a bit drowsy on waking up. You may also feel sick and will be given medication to help with this. You will be given painkillers too, as required. You will remain in the observation bay where you can rest and recover. A companion should attend hospital to take you home. Although you might feel fine, your reasoning, reflexes, judgment, coordination and skill can be affected for 48 hours after a general anaesthetic. You should not be left alone and should not drive.

If you had a local / regional anaesthetic (spinal block or epidural), you will rest in the observation area where a midwife will care for you. Your legs will be numb for four to six hours and during that time you may need a urinary catheter. This is a small tube that is passed into your bladder to allow the collection of urine into a bag. You may also feel sick and will be given medication to help with this. Once you are feeling well enough to leave the observation bay, you may go home with a companion, or you may spend the night in hospital if your procedure was in the afternoon or if the doctors have decided it is best to keep you for observation.

If you go home on the day of your procedure, you will need to rest for the first 48 hours. After the procedure, you may experience abdominal pain (“tightening”) and vaginal bleeding for a few days. We will prescribe you painkillers to help relieve your pain. If the pain and the bleeding continue for longer than 48 hours you should contact your obstetrician or GP. Within a week, you should be able to resume most of your normal activities. We advise you to avoid sexual intercourse and also to not lift any heavy objects such as shopping bags until after your first follow-up visit.

The cerclage is usually removed at around 37 weeks into your pregnancy. Removing it is a simpler procedure than placing it and usually takes approximately 5 minutes. Less than 5% of women need an anaesthestic for the cerclage removal. If an anaesthetic is required then this would be a spinal/epidural technique described above. You are unlikely to go into labour immediately after your cerclage is removed and you can usually go home after its removal.

If your waters break before 37 weeks, you must come to the hospital immediately as it may be a sign that you are about to go into labour. If this happens your obstetrician will discuss with you the risks and benefits of removing the stitch. If you do go into labour, the cerclage needs to be removed to prevent the cervix from tearing and allow you to give birth to your baby through your vagina.

If you are planning elective Caesarean delivery, the cerclage will be removed at the end of procedure.

If you have an abdominal cervical cerclage, this is usually left in for further pregnancies, and you will be offered an elective Caesarean delivery.

Yes, the removal of the cerclage at 37 weeks does allow you to have a vaginal delivery. Very rarely, scar tissue can form around the stitch, which prevents the cervix from dilating (opening) enough during labour and makes a vaginal delivery more difficult. However, less than three percent of women need to have a caesarean section because of cervical scarring.

If you have any more questions about cervical cerclage you can:

Contact the Midwife emergency hotline in Maternal Fetal Assessment Unit –​​ 020 3447 9400 (Please choose option 2) OR 020 3447 6141

Contact the Preterm Birth Clinic midwife via the Fetal Medicine Unit Midwives – 0203 447 6162/6163

Contact the Labour Ward – 020 3447 6203/6204

PALS

If you require information, support or advice about our services, you can contact our Patient Advice and Liaison Service (PALS). Ask a member of hospital staff to direct you to the PALS office, email PALS@uclh.nhs.uk or phone 020 3447 3042.

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Tel: 0845 4647.