Kristen Morgan, a mother from Memphis, Tennessee, had the third time a double stitch to get her babies, but she says it was worth every bit of pain.
Cerclage, a procedure where a woman’s cervix is literally sewed shut, is typically done between 16 and 20 weeks gestation to prevent pre-term delivery when a mother shows signs of going into labor too early. “A cerclage is done when a woman has, or is suspected of having, an incompetent cervix, meaning that it is too short or has begun to open too early,” explains Sarah Yamaguchi, M.D., an ob-gyn at Good Samaritan Hospital in Los Angeles. The doctor uses sutures—normally one but in some cases more — to cinch the cervix shut to keep the baby in. If all goes well, the stitches are removed at 37 weeks to allow the woman to give birth vaginally.
Cerclage may sound like a medieval torture practice, but it was actually developed in the 1950s. And even though it’s a fairly rare procedure—less than 1% of pregnant women need one, according to the American Pregnancy Association—it has been credited with saving thousands of babies lives over the years.
Morgan got pregnant with twins at age 27. It was her first pregnancy, and when her doctor discovered at her 18-week check-up that her cervix was nearly 100% effaced (meaning the cervix had already entirely thinned out in preparation for delivery) and was beginning to dilate, she was terrified. If the babies were born that early, their chances of survival would be very small. At that point, Morgan had to act fast if she had any hope of keeping her babies in.
Unfortunately, this is an all-too-common scenario. “Once this process of dilation and effacing starts, it can’t be reversed—the more dilated the cervix is, the less effective the cerclage will be, so time is of the essence,” Yamaguchi explains. “There’s not a lot of options at that point. There are no medications to stop the dilation and effacing, so it’s cerclage or nothing.”
Cerclage may sound like a medieval torture practice, but it has been credited with saving thousands of babies lives over the years.
Morgan agreed to the cerclage and the doctor put the stitch in, using just spinal anesthesia. It wasn’t too painful, she recalls. “I had mild cramping for a few days and felt a little sore deep inside, but that was it,” she says. “I’d get a sharp pain every once in a while. It was more annoying than anything else.”
Unfortunately, the procedure wasn’t enough to stave off labor, and at 24 weeks gestation, Kathryn, the older twin, tore through Morgan’s thinned cervix; William was born shortly thereafter.
“Ironically, the cerclage actually held. The pressure from Kathryn was too great and she tore a new hole through my cervix,” she says. “They had to go in and remove the cerclage after they were born to get the placentas out.” Tragically, neither baby survived.
Why exactly a cerclage fails is a controversial topic. In Morgan’s case, it was likely because her cervix had already thinned and shortened too much. “There is a point where it simply becomes too late,” Yamaguchi says.
But in other cases, the failure may be due to the type of cerclage performed. Cerclages done with a thick “braided” suture can easily become infected and accelerate a pre-term birth rather than prevent it, according to a new study published in Science Translational Medicine, whereas those done with a thinner, microbe-resistant “microfilament” thread can lead to more successful outcomes.
But even if the stitches hold and no infection develops, emergency cerclages still may not make much of a difference in preventing infant death. One study of nearly 4,000 woman, published online by Cochrane Pregnancy and Childbirth Group, found that even though an emergency cerclage could delay the onset of labor, it still didn’t affect the overall outcome of that labor.
“When cerclage was compared with no treatment, there was no clear difference in the number of babies dying before or at birth (a miscarriage or stillbirth) or around the time of birth or from illness, despite a clear reduction in the number of preterm births,” explains lead author Zarko Alfirevic, M.D., a professor in the department of Women’s and Children’s Health at The University of Liverpool. He adds that the women who receive a cerclage were also more likely to need a C-section and experienced other side effects like vaginal discharge, bleeding, and fever, although they weren’t generally serious.
These findings have made some question whether or not the procedure is a good idea, with some doctors refusing to perform emergency cerclages all together. Alfirevic advises that rather than making it the standard treatment for preventing pre-term delivery, it should be “personalized” and evaluated on a case-by-case basis.
For Yamaguchi, however, it’s not so black and white. “I do them—I guess you can say I’m ‘pro-cerclage’—but I have a very serious talk with the mother first. She has to accept the risk; it’s a very tricky situation,” she says. “I tell them, ‘You’re not looking at a full-term baby, that’s not realistic. And premature babies aren’t as healthy.’ A lot of women envision having the baby and taking it home the next day, but that’s not always reality and I want them to be prepared for something going wrong.”
When a baby’s life is at stake and the choice is to do nothing or to do something, most mothers will choose to do something. Which begs the question: Why are there no other options?
But while the medical community debates emergency cerclages, one thing is clear: Preventative cerclages do help. In a woman with a history of premature labor, a short cervix, or a previously incompetent cervix, a preventative cerclage can be put in before the cervix has a chance to thin or open. These have a very high success rate, with about 80% of babies making it to full term and 93% surviving, according to a study published in the Journal of the Royal Society of Medicine.
This is why, despite her bad experience with her first cerclage, Morgan opted to have a preventative cerclage put in early the next two times she got pregnant. “I just felt much more comfortable knowing it was there,” she says. And it worked: She’s now a mother to Riley, 13, and Ella, 8.
But cerclage is not a cure-all for pre-term birth—it won’t help at all if the cause is unrelated to the cervix—and both emergency and preventative cerclages come with risks. “There are immediate risks, like the bag of water being accidentally ruptured or the cervix becoming irritated, both of which can cause immediate labor,” Yamaguchi says. “In the long-term, the woman is more likely to have a C-section, get an infection, or sustain serious damage to her cervix from the stitch.”
Until other treatments are developed, however, these are necessary risks. When a baby’s life is at stake and the choice is to do nothing or to do something, most mothers will choose to do something, Yamaguchi says. Which begs the question: Why are there no other options? Women desperately need more research into what causes an incompetent cervix and what can safely be done to protect the health of both baby and mother.
As researchers work to answer those questions, more effort needs to be made to screen women earlier in their pregnancy for an incompetent or inefficient cervix, especially in women with a history of pregnancy loss, uterine abnormalities, or surgery on or injury to the cervix. While there is no direct test for an incompetent cervix, doctors may be able to detect it during a pelvic exam or with a transvaginal ultrasound, according to the Mayo Clinic. In some cases, an amniocentesis or MRI scan may also be ordered. Early detection allows for a preventative cerclage, without the pain of having to lose a baby first.
Despite the risks, Morgan says she doesn’t regret any of her cerclages. “I’d do it again in a heartbeat if I had to,” she says. “But we’re done! I think three cerclages and four births is enough damage to my poor cervix!”