For many women, pregnancy is a time of elation and excitement. The joy of discovering you’re pregnant and sharing the news with friends and loved ones is a special time. But for some women, the idea of pregnancy or the fear of miscarriage or pregnancy loss can over shadow the feelings of excitement.
For women who have experienced the devastation of miscarriage, gone into labor early, or who might have been told they have a weak cervix, pregnancy can be a worrying time.
If you’ve been diagnosed with cervical insufficiency or a weakened cervix, understanding your condition and knowing your options might help you to feel more in control during your pregnancy.
If you’re concerned about miscarriage, read our article Early Miscarriage – Signs Symptoms and What To Expect.
What is a cervical cerclage?
A cervical cerclage is a surgical procedure, also known as a cervical suture. A cerclage is a special type of stitch that is put around the cervix to keep the cervix safely closed. It is used in women who are at high risk of miscarriage, preterm labor, and birth.
Why is a cervical cerclage needed?
You might be offered a cervical stitch if you’ve had problems with your cervix, if you are showing signs that your body could go into labor early or if you’re at a higher chance of having a spontaneous preterm birth.
A cervical cerclage procedure might be performed in an attempt to prolong a pregnancy as long as possible. The aim is to try to get as close to 37 weeks as possible before your baby is born. This enables your baby to continue to grow strong inside the womb for as long as possible.
Premature babies will have more complications than babies born later; therefore it’s important to try to reduce the risk as much as possible.
To learn more about preterm birth and how to prevent it, read our article Preterm Birth | Ways To Reduce Preterm Birth.
Will I be offered a cervical cerclage if I’ve had a previous miscarriage?
There are a number of reasons why a cervical cerclage might be recommended.
Unfortunately, it’s thought that about 20-30% of pregnancies will end in miscarriage, with the majority of these occurring in the first trimester (before 12 weeks).
There are many factors that increase the risk of miscarriage, including: maternal age greater than 40: various health conditions, including diabetes and thyroid problems; and exposure to tobacco smoke. Sometimes the reason for a miscarriage remains unknown.
The most common reasons for miscarriage that occurs after 12 weeks of pregnancy are diagnosis of cervical insufficiency, a short cervix, or an incompetent cervix.
What is cervical insufficiency or an incompetent cervix?
Discovering you have what’s known as cervical insufficiency, a weakened cervix or an incompetent cervix might feel scary. The language around this terminology is disempowering and can leave you feeling as though your body is failing you.
However, this is not the case. The above terminology means that the cervical tissue has become damaged or weakened in some way, which can cause the cervix to shorten or open earlier than normal.
Cervical insufficiency can be a defect present from birth, or can be caused by injury or trauma to the cervix. Trauma to the cervix might be caused by lacerations to the cervix from childbirth, or scarring to the cervix from certain gynaecological procedures, such as an LEEP (loop electrosurgical excision procedure), a cone biopsy or artificial dilation of the cervix.
To learn more about the cervix, be sure to read our article Incompetent Cervix-Symptoms And Signs.
What is a short cervix?
Have you been told you have a short cervix? This means there have been changes to the cervix, which make it more likely that your baby could be born early. A cervical length of less than 2cm, confirmed by ultrasound, is considered a short cervix.
Who needs a cervical cerclage?
You might be offered a cervical cerclage, depending on your medical history.
Women carrying one baby with high risk pregnancies for premature birth will be offered the option of having a cervical suture.
Your healthcare provider might discuss or recommend a cerclage stitch if you have any of the following risk factors for preterm birth:
- Previous second trimester miscarriage
- Previous spontaneous preterm birth (<34 weeks)
- Premature rupture of membranes (<37 weeks)
- Previous surgery/treatment to the cervix
- Abnormally shaped uterus or cervix
- Short cervix/cervical incompetency.
To learn more about what to do if your waters break early, read our article Premature Rupture Of Membranes | When Your Waters Break Prematurely.
When should a cervical cerclage be done?
Ideally, a cervical cerclage procedure is performed around 12-14 weeks of pregnancy. This is a prophylactic treatment and is therefore referred to as an elective cerclage.
However, cervical cerclages can be done much later in pregnancy. The decision as to whether a cervical cerclage is required, and then placed, will largely depend on the risk factors for preterm birth and what signs are displayed.
Cerclage placement can be performed up to 24 weeks. The procedure isn’t normally done after 24 weeks, due to the increased risk of accidentally damaging the amniotic sac during the procedure.
Types of cervical cerclage
There are different types of cervical stitches. Discuss with your health care provider which might be best for you.
Types of cervical cerclage:
- Mcdonald cerclage. This is the most common type of cervical cerclage, performed in the second trimester and removed around 37 weeks
- Shirodkar cerclage. A cerclage placement in the wall of the cervix rather than the opening is thought to reduce the likelihood of infection. Research suggests that a Shirodkar suture is more effective than the Mcdonald cerclage in prolonging pregnancy, reducing rates of preterm births and improving neonatal outcomes. This suture is permanent, and will not be removed prior to birth, making cesarean birth necessary
- Abdominal cerclage. This is placed via an incision in the abdomen (transabdominal, or TA), rather than being inserted through the vagina. It is less common but might be necessary if the cervical length is already too short for it to be done vaginally (transvaginally, or TV), or if a previous TV stitch has not worked. A transabdominal stitch will not be removed and will remain permanently. Your baby will need to be born by cesarean section
Cervical sutures are sometimes referred to as being either ‘elective’ cerclage or ’emergent’ (or ‘rescue’) cerclage.
An elective cerclage is one that’s performed as a planned procedure in high risk pregnancies. It is done as as a precaution – a method of preterm birth prevention.
An emergent cerclage is one that’s performed (usually later in pregnancy) after the cervix has already begun to make changes that would likely lead to preterm labor and birth. If an emergent cerclage is required, it is likely you will need one in future pregnancies.
Cervical cerclage procedure
A cervical cerclage procedure will be performed under sterile conditions, usually in theatre, and normally takes about an hour.
You’ll be given either a spinal or a general anesthetic to make you numb.
Once you’re comfortable, your legs will be put into stirrups.
Your doctor will do a physical examination with a speculum, to visualize the cervix. The cervix will be held in place while the suture is inserted through the cervix.
The stitch will be tightened, tied, and secured, to stop the cervix from opening.
You might require a urinary catheter while you recover from the anesthetic.
You’ll need to stay in hospital for a few hours, to recover from the anesthetic, but you’ll probably return home later the same day. You’ll need to take it easy for the rest of the day.
Your doctor will ensure you have adequate pain medicine, if needed.
How long does it take to heal from a cervical cerclage?
It’s important that you follow your after care instructions carefully to minimize complications. You’ll need to take it easy for 7-10 days after the procedure, to allow your body a chance to heal.
It’s normal to experience some cramping, light bleeding, minor spotting, or brown discharge for a couple of days afterwards.
What should I not do after a cervical cerclage?
Your care provider will advise you to avoid strenuous activities or exercise for about a week after the procedure
Do not insert anything into or around the vagina that could increase the risk of infection, including vaginal douches, feminine products, or sex toys.
Can I have sex after a cervical cerclage?
Your doctor will probably advise that you refrain from sexual intercourse for 1 week after the procedure.
You might also be advised to avoid sex for about 1 week prior to the procedure.
After your body has healed, then normal activities, including sex, can resume for the remainder of the pregnancy, as long as you feel comfortable and you have no signs of infection or premature contractions.
After your body has healed, there’s little evidence to suggest that bed rest reduces your chances of going into labor early, and it is therefore discouraged.
Cervical cerclage removal procedure
Removing a cervical cerclage is much quicker than putting it in. It might not require any anesthetic or pain medication. Removal of the stitch usually takes only a few minutes and is normally performed at a doctor’s clinic.
The procedure will be similar to when it was inserted. Your legs will be in stirrups and a speculum examination will be performed, so the cervix can be seen. Once visualized, the suture material will then be cut and the suture removed.
Cervical stitches are usually removed at about 37 weeks of pregnancy, if your body hasn’t already gone into labor. A cervical stitch can be removed earlier, if necessary, if your waters have gone or if you’re having regular contractions.
If you have a cervical cerclage, and begin showing signs of labor, it’s important to inform your doctor straight away, as the stitch will need to be removed to prevent damage to the cervix. If you have a permanent stitch in place, then your baby will need to be born by cesarean.
Cervical cerclage success rates
There is no guarantee that the procedure will be successful in preventing preterm birth; however, success rates for cervical sutures are relatively high.
Generally, a cervical cerclage procedure is successful at preventing preterm labor and birth in about 80-90% of cases.
Risks of cervical cerclage
As with all surgical procedures, there are a number of risks involved. Some women who have a cerclage procedure will still go on to have a late miscarriage or a preterm delivery.
The risks involved include:
- Damaged caused to the cervix or bladder
- Cervical infection
- Accidental or premature rupture of membranes
- Preterm labor and birth
- Cervical stenosis – permanent narrowing of the cervix
- Cervical dystocia, where the cervix does not dilate, possibly caused by scar tissue
- Damage to the cervix if labor progresses whilst the stitch is still in place
- The cerclage is not always successful
- Sometimes it’s not possible to perform the procedure – for example, if there is already advanced cervical dilation and the cervix is open too much, a stitch cannot be inserted.
A cervical stitch might not be appropriate for everyone. It might be contraindicated in the following circumstances:
- Cervical dilatation >4cm
- Significant inflammation to the cervix
- Vaginal bleeding
- Contractions have already begun
- Waters have already broken
- Premature labor or imminent preterm delivery
- If you’re pregnant with more than one baby; there is no clear evidence to show whether a cervical cerclage will prevent preterm birth in pregnancies with multiples.
Alternatives to a cervical cerclage
Taking vaginal progesterone in pregnancy might reduce the risk of preterm birth for some people and could be used as an alternative to cervical cerclage.
It might be appropriate for you if you have a singleton pregnancy and are known to have a short cervical length (2cm), as confirmed by ultrasound.
Progesterone is a hormone that helps the uterus to grow during pregnancy; it also prevents contractions. Progesterone can be given in various forms, such as a gel or vaginal pessary, and can be taken up to 24 weeks.
Speak to your health care provider if you feel progesterone might be right for you.
When should I be concerned?
Contact your midwife or doctor straight away if you experience any of the following:
- Intense pain
- Heavy bleeding
- Waters breaking
- Foul smelling or green discharge
- Fever (>100F or 37.7C)
If you have any of the above symptoms, the stitch might need to be removed or your baby might need to be born earlier than planned.
It’s important to discuss with your midwife or doctor any previous pregnancies or surgeries to the cervix that might affect your chance of giving birth to your baby early.