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.
