Cervical Cerclage

Indications

• Creasy & Resnik's Maternal-Fetal Medicine, p. 890

Absolute Contraindications

• Non-viable pregnancy
• Unexplained vaginal bleeding
• Ruptured membranes
• Active preterm labor
• Acute cervical or intrauterine infection

Relative Contraindications

• Known or suspected fetal abnormality
• Prolapsed fetal membranes through the external os (higher risk of iatrogenic membrane rupture)
• Placenta previa with cervical dilation
• Pfenninger and Fowler's Procedures for Primary Care, p. 932

Pre-Procedure Work-Up

• Confirm viable intrauterine pregnancy by ultrasound
• Screen for cervical infection (gonorrhea, chlamydia) - treat before proceeding
• Consider amniocentesis for exam-indicated and ultrasound-indicated cases to rule out subclinical infection
• Perioperative indomethacin is used for exam-indicated cerclage; consider for ultrasound-indicated
• Fetal heart rate monitoring before and after the procedure

Equipment

• Bladder catheter
• Weighted vaginal speculum
• Deaver or right-angle retractor
• Ring forceps
• No. 5 Mersilene band (non-absorbable) with curved needle - the standard suture material. Do not confuse with 5-0 suture
• Pickups (e.g., Russian forceps)
• Metzenbaum scissors
• Needle driver

Anesthesia

Procedure - McDonald Cerclage (Transvaginal, Most Common)

1. Obtain informed consent; document intrauterine fetal viability.
2. Administer general or regional anesthesia.
3. Position the patient in dorsal lithotomy; prep and drape in sterile fashion.
4. Drain the bladder (a Foley catheter is not mandatory).
5. Place a weighted speculum in the posterior vagina.
6. Insert a Deaver or right-angle retractor anteriorly for exposure; have an assistant hold it carefully to avoid bladder injury.
7. Grasp the anterior lip of the cervix with ring forceps and displace it superiorly.
8. Start at the 6 o'clock position - place the first bite at the mid-portion of the cervix at the cervicovaginal junction (equidistant between the ectocervix and the vaginal reflection). Pass the needle through mid-cervical stroma - do not enter the cervical canal. Direct needle toward 3 o'clock.
9. Proceed counterclockwise (clockwise if left-handed): pass suture from 6 o'clock → exit at 3 o'clock → reinsert → exit at 12 o'clock → reinsert → exit at 9 o'clock → reinsert → exit back at 6 o'clock.
10. Cinch down the suture as a pursestring, without drawing too tightly. Tie with three knots at 6 o'clock, leaving tails long enough to be grasped for later removal.
11. Inspect for bleeding. Remove weighted speculum and ring forceps.
12. Transfer to recovery with fetal monitoring to confirm viability.

Common error: Placing the suture too shallowly - it will tear out when tightened. Ensure each bite passes through mid-cervical stroma.

• Pfenninger and Fowler's Procedures for Primary Care, p. 932-933

Operative Note Key Points

Postoperative Care

• Observe on fetal monitor post-procedure before discharge
• Acetaminophen is usually adequate for pain control
• Antibiotics are not routinely recommended; tocolytics have no proven benefit
• Pelvic rest: no vaginal intercourse for at least 1 week (often for the entire pregnancy)
• Limit physical activity for at least 1 week
• Expect possible significant vaginal discharge for weeks after the procedure
• Increased frequency of prenatal visits for the remainder of pregnancy
• Bed rest is NOT recommended (as per the perioperative considerations table)

Cerclage Removal

• Routine removal at 37 weeks in the office setting
• Technique: place speculum, grasp the knot with pickups (e.g., Russian forceps), elevate the knot, cut with Metzenbaum scissors, and remove
• If removal is difficult, proceed to the operating room - do not force it in the office
• If preterm labor occurs and tocolysis fails, remove the cerclage promptly to avoid cervical laceration

Complications

Urgent or emergent cerclage carries significantly higher complication rates. Scheduled, elective cerclage with clear indications is preferred.

Evidence Summary

• Cochrane review: overall cerclage use reduced risk of early and late preterm birth (average RR = 0.77; 95% CI 0.66-0.89)
• HIC benefit is primarily seen in women with 3 or more second-trimester losses or early preterm births
• For patients with a prior failed transvaginal HIC: transabdominal cerclage is superior to repeat transvaginal for prevention of preterm birth <32 weeks (one RCT)
• Cerclage is not beneficial in multiple gestations regardless of history or cervical length
• Creasy & Resnik's Maternal-Fetal Medicine, p. 890-891

• What cerclage is and why it's done (plain language explanation)
• Tests needed beforehand: ultrasound, infection screening, possible amniocentesis
• Night-before instructions: fasting, hygiene, no jewelry, arrange a driver
• Day-of instructions: medications, clothing, what to bring
• What to expect in the operating room (anesthesia type, positioning, how the stitch is placed)

• Side-by-side table: first 24-48 hours vs. first week expectations
• Ongoing pregnancy expectations (no routine bed rest, increased discharge, follow-up visits)
• Cerclage removal at 37 weeks - how it's done in the office
• Risks reminder table (membranes, infection, preterm labor, bleeding)
• Prominent red/orange warning box listing emergency signs requiring immediate care
• FAQ section (work, travel, whether cerclage is guaranteed to work, C-section)
• Fillable contact block for the care team's details

• Pre-op: What cerclage is, required tests (ultrasound, infection screening, possible amniocentesis), fasting/hygiene/night-before instructions, day-of checklist, and what to expect in the OR
• Post-op: First 24-48 hours vs. first week expectations (side-by-side table), ongoing pregnancy guidance, cerclage removal at 37 weeks
• Safety: Emergency warning box (bleeding, fever, ruptured membranes, contractions), risks table, FAQ section
• Contact block: Fillable fields for provider name, phone, after-hours line, and next appointment

Note: This is a clinical template. Have your institution's legal or risk management team review it for local regulatory compliance before use.

1. "Art of Cerclage - McDonald Cerclage" - Dr. Sara Rahman

2. "Cervical Cerclage: McDonald Procedure"

3. "Cervical Cerclage (McDonald's Procedure)" - Prophylactic + Therapeutic

4. "McDonald Stitch Application - Cervical Cerclage Insertion Technique"

5. "Cervical Encirclage - McDonald Procedure"

6. "Cervical Cerclage - McDonald's Technique" - Dr. Shilpa GB

Note: I cannot embed or play videos directly here - clicking each link will open YouTube. For learning purposes, the Dr. Sara Rahman "Art of Cerclage" video is particularly recommended given its high view count and detailed narration.