We've had a run of high risk pregnancies lately (what else is new?), specifically women with cervical incompetence.
Cervical incompetence is when the cervix starts to prematurely efface (thin out) and dilate, usually resulting in premature delivery if measures are not taken to prevent the birth. We don't always know what causes cervical incompetence in women.
The first thing we look at is her history: has this happened before? Has she had losses or preterm births? Is this her first pregnancy? Has she had surgery on her cervix in the past? Could she have an infection that is causing premature labor/dilation/effacement?
One of the first things we, as nurses, need to do is keep this mom in bed. Any pressure from the presenting fetal part (or bulging membrane as is often the case) can cause further dilation and effacement of her cervix. Sometimes, her physician might be ok with her getting up to use the bathroom. As the nurse, however, we must constantly remain diligent to the possibility of worsening of her cervical status (and possible impending preterm birth). If you get mom up to use the bathroom, and she feels an increase in rectal/vaginal pressure, or gets very crampy, perhaps a bedpan will be more appropriate.
This mom is going to need baseline labs drawn. We'll check a CBC specifically for her white blood cell count. Elevated WBC could indicate an infection. Her physician will more than likely want to perform an amnioscentesis. The amniotic fluid will be assessed for the presence of WBCs, low glucose levels, and the presence of any bacteria or other organisms. Any of these three items can be indicative of an intrauterine infection, which would more than likely mean she needs to have her baby sooner, rather than later.
If all three items are negative/normal, then physicians will usually proceed with tocolytic therapy and/or a rescue cerclage. A rescue cerclage, also known as a McDonald cerclage, is a series of stitches that are placed around the cervix to help keep it closed for the duration of the pregnancy. A woman would need to be placed under general anesthesia or receive a regional block for placement of a cerclage.
The suture used for a cerclage is not like normal suture, which usually dissolves in 2-4 weeks. This is a much thicker, permanent suture, and has an appearance and width of a shoestring. This stitch will stay in place until such time that the woman and her physician have determined is a good time to remove it. Usually this would be when she is about 35 weeks, starting to labor, or is showing signs of an infection or a worsening maternal/fetal condition. It wouldn't be a good idea to labor with a stitch in place, as it could lacerate the cervix as her body tries to dilate and efface her cervix through contractions.
Removing the suture is very easy - a speculum is inserted, and long scissors are used to clip the suture in several places. Long forceps are then used to remove the suture. No anesthesia is needed. Most women might feel a little crampy, but otherwise, it's rather painless and easy.
As I said early, tocolytic therapy is usually indicated and utilized as well. Tocolytics are medications that are used to stop or slow down preterm labor. There are medications that can be given via an IV line, through subcutaneous injections, or in an oral form. Depending on individual circumstances, the woman and her physician will decide which medication(s) are best for her.
Once a woman is diagnosed with cervical incompetence, she can expect to be on some form of bedrest. Sometimes this necessitates a prolonged admission to the hospital. Other times she can maintain her bedrest while at home. It all truly depends on the specific situation/gestational age/membrane status.
19 comments:
Very interesting. I'm curious what exactly defines incompetence. I mean, I read what you wrote, but many upon many women both dialate and efface early AND have irritable u's so obviously there must be something that makes one women's problem a serious worry over anothers. I'm wondering if it's hard to diagnose clinically (I mean, some cases are obvious and I get that). How do you tell between a woman that *may* have an incompetent cervix over someone like me, who spends 50% of her pregnancy at 50-75% effacement, extremely frequent bh (and STRONG) cntx's and 3cm or so dilated?
Do you think there *is* something seasonal, or it just seems that way? Do you know if there have been any studies that look at, say, the rates of cervical incompetence or preeclampsia or miscarriage, to see if there are any patterns to these problems? The main reason I'm asking is that there seems to be a high rate of miscarriage among my friends just within the past month or two -- out of 4 pregnant women at my church, 2 (including me) had a miscarriage, and 1 had a threatened miscarriage; plus one other local friend who just had a miscarriage. Maybe I just am more aware of it, more women are talking about it, etc., but it just seems odd that there is such a high percentage of miscarriages among my friends. Obviously, not a valid and controlled study, but still -- curious. Then with this post, it makes me wonder if there might be a cyclical effect; and if so, what environmental factors might possibly be affecting things.
-Kathy
Rebekkah - good questions! I think it all depends on how early in the pregnancy that it's discovered. If it's discovered at 20 weeks, versus 35 weeks. At 20 weeks, especially if mom has a history of multiple losses/preterm births, she would be more apt to need for aggressive treatment/interventions to prolong her pregnancy. If at 35 weeks, more of a watch and wait thing.
Kathy - excellent points to ponder! I never really looked at seasons/clusters like that. Who knows...environmental causes? Seasonal causes? Genetic causes?
I lost a pregnancy at 22 weeks due to cervical incompetence which led to infection and an emergency D & E. Fortunately, a subsequent pregnancy progressed normally due to a McDonald cerclage put in at 14 weeks. The cerclage was removed at 36 weeks and my daughter was born at 37 weeks. That cerclage gave me great peace of mind throughout my pregnancy.
I recently read some study about tocolytics (spelling?) and autism etc. I don't know if it's a valid study. If there is a correlation, is it with the meds...or will a woman more likely have a preterm/late miscarriage with a child who has autism? Wish we knew more....
Blessings!
Dawn
Why, in the 21st century, is premature effacement still called cervical "incompetence"? It's not a matter of competence, which implies some level of control. *sigh*
The patriarchy, we're soaking in it.
Fabulous post!!! I have had 2 preemies due to cervical incompetence - a 26 weeker who passed in NICU and a 29 weeker who graduated NICU. I was able to get to 29 weeks with 6 weeks of strict hospital bed rest and aggressive tocolysis. I did not have a cerclage since my first was thought to be PTL as opposed to IC.
This is really interesting information. I was being monitored for potential cervical incompetence for the first 20 weeks of my pregnancy, as I received parallel care from a CNM group practice along with my home birth CPMs for part of my pregnancy (I eventually ditched the former altogether). The reason for these biweekly check was the fact that I had a cone biopsy performed 16 years prior to the pregnancy, as a result of dysplasia from HPV. Everything was fine throughout, thankfully, and no problems dilating during my 13 hour birth.
If I HAD started to efface and dilate prematurely, they said a cerclage would have been the recommended course of action. I'm really glad this was not the case on both counts - I had my proverbial hands full worrying about a placenta previa that persisted up to the 34th week! (No bed rest, but pelvic rest, no exercise, and lots of worry and grief.)
ANYWAY - my question is similar to womantowomancbe's. What could be behind this, and is it really just one time of year, or have you seen an increase in women with cervical incompetence overall? Do you know how many of them have had biopsies or the LEEP procedure? I know those numbers are increasing, as HPV spreads. Is this a factor, from what you've observed?
@Dou-la-la, @womantowomancbe
I'm not a nurse and certainly not an expert, but from what I was told, the cause is either previous trauma to the cervix (D&C, difficult birth, LEEP, etc) or basically a 'birth defect' or anomaly. I was actually asked by my perinatologist whether my mother had taken a drug to dry up her milk with any of her previous children - she did. He didn't say much more about it, but it seemed that they may be looking into that as a cause of IC. I'm not a medical professional though - just a gal with a diagnosis of IC!
@HauteSingleMama,
"I was actually asked by my perinatologist whether my mother had taken a drug to dry up her milk with any of her previous children - she did."
Interesting!! I have a cockscomb cervix, which is unusual, and almost always associated with DES (which was a hormone commonly added to prenatal vitamins from the 30s to the 60s, but discontinued in the 70s after it was discovered to cause a rare type of female cancer in adolescents; after that, it was also discovered to cause an increase in numerous other ways, mostly to the male and female genital tract). My mother was given a "little black pill" to dry up her milk after she gave birth the first time even though she had told them that she was going to be breastfeeding!!! [After a few days, she noticed that it wasn't being given any more, asked why, and was told, "Oh, we found out you were breastfeeding." Sigh, and roll eyes!]
Anyway... There were 4 of us, each born about 2 years apart -- My oldest sister, born 19 months after my mom received that medication, had a septate uterus which apparently caused 3 miscarriages (two at 10-13 weeks); my other sister, born 2 years after the first, had an abnormal pap with some pre-cancerous cells frozen off just a few years ago; and I have a cockscomb cervix. Coincidence that all three of us have weird female things??
I'm "too young" to have been exposed to DES (supposedly!), but according to all I've read, a cockscomb cervix is only associated with in utero DES exposure. But reading your comment made me wonder if perhaps there were lingering effects from the drugs my mom had. If so, that's scary because who knows how many women were given pills to dry up their breastmilk that was "inferior" to formula {rolling eyes again!}, and how that may have affected a whole generation or two of women! Perhaps increases in cancer, infertility, reproductive tract anomalies?
Ok, I'm getting seriously irritated again -- every time I think about it, it p*$$es me off! Whatever happened to "first, do no harm"?? Grrr....
-Kathy
At my hospital in Oregon we noticed a huge influx of miscarriages and fetal demises, ranging from 16 weeks (earliest we see) to 40. We noticed one weekend in particular that was just full of them in early November. A doctor I work with mentioned that this all happened the week of and after China seeded their clouds and then Beijing got snowed on. This doctor looked at the fronts and even made a sattelite image of how that could have affected us.
Anywho, it's a stretch but something to think about. It was a very sad couple of weeks.
Ps: We looked up the "ingredients" they seed their clouds with and many of them were incredibly toxic and known to cause birth defects.
Thank you so much for your understandable information. I really appreciate the education complete with pictures!
@April -- this saddens and shocks me. Do you have any more information, so that I might be able to look into this more in-depth?
-Kathy
Just quick: I have a genetic condition that increases (slightly) my chance for an 'incomplete cervix' (my first OB/midwife said they don't call it 'cervical incompetence' anymore wonder if its a reginal thing, this was in Portland, OR), and my OB told me, after stating they would have to watch for it and might put in a stitch if they started to see an incomplete cervix "we perscribe bedrest but recent studies show that doesn't actually help, so maybe in the future we won't be doing that anymore" have you heard of this?
Don't have much to add except that your posts are great for reminding me to keep my knowledge updated because L&D is not an area I know a lot about.
I had two first trimester miscarriages and 3 D&C's to clear what didn't pass from me naturally. When I conceived again I carried to 23w6d at which point I went to the ER because I just felt "funny". I was found to be completely dilated and the amniotic sac was protruding into the upper vagina. I had had no contractions whatsoever (at least none that I could feel). My son died 3 days later from complications. I also had PTL with subsequent pregnancies. I believe the difference between IC and PTL is that IC is an almost painless dilation/effacement whereas PTL is noticeable contracting. I went on to have 3 healthy babies with the help of a cerclage.
I too lost my son at 22 weeks due to IC. It was handled very poorly at the time by my OB. With my next pregnancy (twins) I had a cerclage, strict bedrest, and P-17 shots weekly. I made to to 35 weeks. I read your blog faithfully while I was on bedrest and now I have my own. In it I tell the whole story of both my pregnancies. (Mason's story and Noah and Mina's story) as well as my struggle with grief. If any woman is looking for other's stories please check it out.
www.shawfortwins.blogspot.com
Couple quick comments:
As an alternative to the perjorative "incompetence," some people are using the term "cervical insufficiency."
Although cerclage is a treatment that is often recommended for CI, it is important to note that no clinical trial has EVER demonstrated any benefit to cerclage. When randomized studies are done comparing cerclage to no cerclage, there is no difference in the outcomes between the two groups. In particular, cerclage has never been demonstrated to increase the duration of pregnancy, decrease preterm birth, or improve newborn outcomes.
Of course we all have individual (personal or clinical) anecdotes where it certainly does appear that cerclage was helpful. If this is the case, it is probably also the case that some women deliver early due to complications with cerclage and the overall harm/benefit cancels out.
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