Cervical Cerclage

Medically reviewed by Dr Darshana Ajmera, MBBS (Nair, Mumbai), MS ObGyn (Honours) - Obstetrician, Gynaecologist & Fetal Medicine Specialist

What it is

A cervical cerclage - what most families simply call a cervical stitch - is a strong suture placed around the neck of the womb during pregnancy to hold it closed. The cervix is meant to stay firm and shut until labour. In a small number of women it does not: it softens and opens quietly, without pain and often without warning, usually somewhere between fourteen and twenty-four weeks. The pregnancy is then lost or the baby is born far too early. The old name for this was an incompetent cervix; we now call it cervical insufficiency, which is both kinder and more accurate.

The stitch is mechanical support. It does not treat infection, it does not stop contractions, and it is not a cure for every cause of preterm birth. What it does, in the right woman, is buy weeks - and in the second trimester, weeks are everything.

Who needs it

The honest answer is: fewer women than are offered it. A cerclage helps a specific group, and in everyone else it adds risk without adding benefit. We consider it when:

• You have lost one or more pregnancies in the second trimester in a particular pattern - painless, with the waters going or the cervix found already open, rather than after days of bleeding or cramping.
• You have had a previous early preterm birth and a scan in this pregnancy shows the cervix shortening before 24 weeks.
• A routine scan shows a short cervix - typically under 25 mm - with a history that fits.
• Your cervix is found already open on examination in the second trimester, with the membranes visible. This is an emergency or rescue cerclage, done in far less favourable circumstances but still worth doing in selected cases.
• You have had surgery on the cervix - a large cone biopsy, a LEEP that took a lot of tissue, or a trachelectomy for cancer.
• You were born with an unusually shaped uterus or cervix, sometimes found during infertility investigation.

A short cervix in a twin pregnancy is a genuinely unsettled question, and in most twins a stitch is not the answer. If you are carrying twins and worried about your cervix, that deserves a proper conversation rather than a reflex.

“I lost my baby at nineteen weeks last year and nobody could tell me why. Was it my cervix?” It may have been, and that is exactly the question worth answering carefully before you conceive again. What I want to know is how it began - whether there was pain and bleeding first, or whether the waters simply went; whether anyone examined the cervix; what the placenta showed if it was examined. A loss caused by infection or a placental problem needs a completely different plan from a loss caused by a weak cervix. Bring every report you have, even the ones you think are unimportant.

How it is done

Most cerclages are placed through the vagina, and there are two common techniques.

The McDonald stitch is the usual choice. You are positioned as for an internal examination, the cervix is gently held, and a strong tape is passed in and out around it in four or five bites, like a purse string, then tied. The knot is left long enough to find easily at removal. There is no cut and no scar.

The Shirodkar stitch goes a little higher. The vaginal skin over the cervix is opened, the bladder pushed up slightly, and the tape placed closer to the internal opening before the skin is closed over it. It is used when the cervix is very short or a McDonald has failed before.

An abdominal cerclage is reserved for women whose cervix is too short or too scarred to hold a vaginal stitch, or who have had a vaginal cerclage fail. The tape is placed around the top of the cervix through the abdomen, most often by laparoscopy, either before pregnancy or in early pregnancy. It stays in permanently and the baby is delivered by caesarean.

Before any stitch we confirm the baby is alive and structurally normal on scan, check for infection, and make sure you are not already in labour. Placing a stitch into an infected or contracting uterus does harm.

Anaesthesia, duration and hospital stay

A vaginal cerclage is done under spinal anaesthesia in most cases - you are awake, comfortable and numb from the waist down. Short general anaesthesia is sometimes used instead. The operation itself takes twenty to thirty minutes.

Most women are admitted in the morning and go home the same evening, or stay one night for observation. A rescue cerclage on an already open cervix usually means a longer stay of a few days. An abdominal cerclage is a laparoscopic operation with a one to two day stay.

You will be asked to fast for six hours beforehand and to arrange someone to accompany you home.

Recovery

Day 1. Mild cramping and a small amount of spotting are expected and settle quickly. You may feel a dull ache low down. Paracetamol is usually enough. We will scan or listen for the baby’s heartbeat before you leave.

The first week. Take it quietly for two or three days. Light watery discharge is common as the cervix reacts to the suture. Avoid intercourse, swimming and internal examinations, and do not lift anything heavy. Most women return to desk work within three to five days.

Weeks 2 to 4. Life goes back to normal in almost every respect. You may be asked to come for a cervical length scan to check the stitch is holding. Some women are prescribed vaginal progesterone alongside the stitch.

By 6 weeks. You should have forgotten the stitch is there, which is exactly what we want. From then on it is ordinary antenatal care, with slightly closer attention to any change in discharge, pressure or bleeding, until removal at 36 to 37 weeks.

Come in immediately at any stage for fever, offensive discharge, leaking fluid, bleeding, or regular tightening pains.

Vaginal stitch or abdominal stitch

This is the comparison that matters here, since neither route is “keyhole versus open” in the usual sense.

• A vaginal cerclage needs no incision at all, can be placed in a few minutes, is removed just as easily at term, and leaves normal delivery possible. It is right for the large majority of women.
• An abdominal cerclage sits higher and holds better where there is almost no cervix left to stitch. But it is real abdominal surgery, it commits you to a caesarean, and the tape usually stays in for future pregnancies too.

We start with the vaginal route unless there is a clear reason not to. Choosing the abdominal route first, without that reason, means accepting a bigger operation for no extra benefit.

Risks and complications

I would rather you hear these from me than read them afterwards.

• Rupture of the membranes during or soon after the procedure - uncommon, but the most serious immediate risk, and higher when the cervix is already open.
• Infection of the uterus or membranes, which can itself trigger labour. This is why fever or a change in discharge is never something to wait on.
• Bleeding, usually minor.
• Contractions or miscarriage in the days after placement.
• Injury to the bladder, rare, and more relevant to the Shirodkar and abdominal techniques.
• The stitch cutting through or slipping, which sometimes means placing another one or accepting that it has not worked.
• Cervical tear if labour begins with the stitch still in place - the reason to come in early rather than late.
• Scarring of the cervix that occasionally makes later dilatation in labour slower.
• Anaesthetic risks, low but not zero.
• Failure. A stitch reduces the risk of very early delivery in the right patient. It does not abolish it, and it cannot repair a cause that was never mechanical.

Alternatives

Vaginal progesterone is the main one, and in many women with a short cervix and no previous loss it is the better first choice - effective, non-surgical, and easily stopped.

Serial cervical length scans from around 16 weeks, with a stitch placed only if the cervix actually shortens. For many women with an uncertain history this watch-and-act plan is the wisest route, and our fetal medicine service does exactly this monitoring.

A cervical pessary, a soft silicone ring that changes the angle of the cervix. Evidence is mixed; it is an option where surgery is not suitable.

Treating what else is treatable - infection, thyroid disease, diabetes, smoking - all of which affect preterm birth independently of the cervix.

Doing nothing surgical, with close follow-up. In a woman whose previous loss was clearly caused by something other than the cervix, a stitch is not neutral; it is an unnecessary risk. You can see all the procedures we perform, and our obstetrics and gynaecology department page explains how pregnancy care is organised here.

What it costs

We have not published a fixed price for cervical cerclage, and I would rather quote you accurately than quickly. What the final cost depends on:

• Which technique is used - a McDonald stitch, a Shirodkar, or a laparoscopic abdominal cerclage, which are quite different operations.
• Whether it is planned or a rescue procedure on an already open cervix, which needs more theatre time and a longer stay.
• The type of anaesthesia - spinal or general.
• How long you stay and the room category you choose.
• Scans and tests before and after - cervical length monitoring, infection screening, fetal anomaly scan.
• Medicines, including progesterone, antibiotics or steroids if they become necessary.
• Whether the stitch is combined with another procedure.
• Your insurance or TPA cover, and whether the admission is pre-authorised.

Call +91-8668954915 and we will prepare a written, itemised estimate for your own situation before you decide anything.

Preparing for your surgery

• Bring every previous record - discharge summaries from earlier losses, scan reports, any placental or histology report.
• Have the anomaly scan and infection screening done first, so we are not placing a stitch into a problem we have not looked for.
• Tell us all your medicines, including blood thinners, progesterone and anything ayurvedic or homeopathic.
• Treat any vaginal infection before the procedure, not after.
• Fast for six hours before admission, including water.
• Arrange company for the day - you will be drowsy and should not travel alone.
• Plan two or three quiet days afterwards, and arrange help at home if you have a small child.
• Save our number in your phone and know how you would reach the hospital at 3 am if you needed to.
• Ask your questions before the day, not on the trolley. Write them down; nothing is too small.

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If you have lost a pregnancy in the middle months and have been told it might be your cervix, please come and talk it through properly before you conceive again - the plan is far easier to make in advance than in a hurry. The obstetric team at Shubham Hi-Tech Hospital and Test Tube Baby Centre, Amravati, will go through your records with you and tell you honestly whether a stitch is likely to help. Call +91-8668954915 or get in touch here.

Disclaimer: This article is for general information only and is not a substitute for professional medical advice. Please consult a qualified doctor for guidance specific to your situation.