Cervical Cerclage: Procedure, Meaning, Risks, Recovery & Removal

What Is Cervical Cerclage?

In obstetric practice, it is a purse-string suture threaded around the cervix and tied to prevent premature opening. The suture is non-absorbable as it stays in place until removed.

Two main techniques are: 

• McDonald cerclage: The most commonly used, places the suture high on the ectocervix (the outer cervix visible on examination) and can be inserted and removed without general anaesthesia. 

• Shirodkar cerclage: It is placed higher, requiring a small incision; it is preferred when McDonald cerclage has failed previously. 

Transabdominal cerclage is placed through the abdomen by laparoscopy or open surgery, reserved for women in whom vaginal have failed.

Purpose and Indications for Cervical Cerclage

Cerclage is indicated in three clinical scenarios:

• History-indicated: Placed at 12–14 weeks based on a history of second-trimester pregnancy loss or preterm birth attributed to cervical insufficiency - diagnosed on clinical history

• Ultrasound-indicated: Offered when mid-trimester ultrasound shows a cervical length below 25 mm in a woman with a prior spontaneous preterm birth; cerclage substantially reduces risk in this group

• Emergency (rescue): Placed when the cervix is found to be dilating silently in the second trimester, sometimes with membranes visible at the cervical os. Technically more challenging, but can extend the pregnancy by several weeks in selected cases

Cerclage is not offered for a short cervix alone without a prior preterm birth. Assessment by a maternal-fetal medicine specialist is required before proceeding.

Cervical Cerclage Procedure 

McDonald cerclage is a day procedure under spinal or general anaesthesia. The cervix is visualised with a speculum; a tape-like monofilament is passed through the cervical tissue in four or five bites at the cervicovaginal junction, then tied to close the os. The procedure takes 15–30 minutes.

Before placing the stitch, the surgeon checks for infection, contractions, and fetal viability by ultrasound. Antibiotics are given during the procedure. Fetal heart activity is confirmed afterwards, and most patients are discharged. The next Day Transabdominal cerclage requires laparoscopy or open surgery, placed before pregnancy at the uterine isthmus. Delivery must be by caesarean section in all such cases.

Recovery, Daily Activities, and Precautions After Cerclage

Most women return home within the next day of a McDonald cerclage. Light spotting and mild cramping are expected for 24–48 hours. 

Pain relief: Paracetamol is sufficient for pain.

• Pelvic rest: No intercourse or vaginal examinations for at least two weeks.

• Activity: Light daily tasks are permitted; heavy lifting over 5 kg, vigorous exercise, and prolonged standing are restricted

• Monitoring: Regular cervical length checks by transvaginal ultrasound continue after cerclage

• Infection awareness: Fever, unusual discharge, or foul smell must be reported immediately as stitch-site infection can trigger preterm labour

• Progesterone: Many units prescribe vaginal progesterone alongside cerclage until 36–37 weeks

Cervical Cerclage Removal Process

McDonald cerclage is removed at 36–37 weeks or earlier if a patient goes into preterm labour as an outpatient procedure. One end is cut and the thread pulled out in a single motion. No anaesthesia is required as the procedure is under five minutes, causing brief discomfort rather than pain.

Emergency removal before 36 weeks is needed for preterm labour, chorioamnionitis, membrane rupture, or significant bleeding as leaving the stitch in place in these situations risks cervical tearing.

Risks and Complications of Cervical Cerclage

Cerclage carries surgical risks that must be weighed against prolonging the pregnancy:

• Preterm labour

• Premature rupture of membranes (PROM)

• Ascending infection from the vagina 

• Cervical trauma

•  while suturing 

• Minor bleeding at placement 

• Risk of pregnancy loss (rare).

Is Normal Delivery Possible After Cervical Cerclage?

Vaginal delivery is possible after McDonald or Shirodkar cerclage removed at 36–37 weeks. Cerclage does not affect the mechanism of labour or cervical dilation. Most women with a vaginal cerclage deliver normally at term.

Transabdominal cerclage is the exception: all deliveries require caesarean section, and the stitch can be reused in future pregnancies.

When to See a Doctor

After cerclage placement, contact the obstetric unit immediately if:

• Fever above 38°C - may indicate stitch-site infection or ascending chorioamnionitis

• Regular contractions or cramping that does not settle with rest

• Watery vaginal discharge or a sudden gush of fluid suggests membrane rupture

• Heavy vaginal bleeding

• Pelvic pressure or a sensation of something protruding from the vagina

• Reduced fetal movements after 28 weeks.

FAQs

1. Who may need a cervical cerclage during pregnancy?

   Women with a history of second-trimester loss or spontaneous preterm birth from cervical insufficiency are the primary candidates. Those with a cervical length below 25 mm on mid-trimester ultrasound and a prior preterm birth are also offered cerclage. 

2. At what stage of pregnancy is cervical cerclage usually performed?

   History-indicated cerclage is placed at 12–14 weeks, once first-trimester risk has passed. Ultrasound-indicated cerclage follows a short-cervix finding, typically between 16 and 24 weeks. Emergency cerclage can be placed up to 24 weeks if the cervix is dilating but membranes remain intact.

3. Is cervical cerclage a painful procedure?

   The procedure is performed under spinal or general anaesthesia as no pain is felt during placement. Mild cramping and spotting are normal for 24–48 hours after. Removal at 36–37 weeks needs no anaesthesia; it takes under five minutes and causes discomfort rather than pain, comparable to a smear test.

4. How long does the cervical cerclage procedure take?

   A McDonald cerclage takes 15–30 minutes from the start of anaesthesia to completion. Including preparation, recovery, and fetal heart check, the total stay is 4–6 hours. Most women go home the same day. Laparoscopic transabdominal cerclage takes longer and usually requires an overnight stay.

5. Can cervical cerclage prevent premature birth completely?

   No - cerclage reduces the risk but does not eliminate it. In women with the right indication, it lowers birth before 34 weeks. It is one part of a plan that may include progesterone, activity restriction and surveillance.

6. What precautions should be followed after cervical cerclage?

   Pelvic rest for at least two weeks. Avoid heavy lifting, vigorous exercise and prolonged standing. Take vaginal progesterone if prescribed. Attend all follow-up scans. Report fever, unusual discharge, contractions, or fluid loss immediately. Long-haul air travel is generally advised against.

7. Is bed rest necessary after cervical cerclage?

   Strict bed rest is not routinely recommended and has not been shown to improve outcomes. Light activity is permitted from the day after the procedure. Prolonged bed rest carries its own risks - DVT, deconditioning and psychological strain. Activity limits are set individually by the obstetrician.

8. Can a normal delivery happen after cerclage removal?

   Yes vaginal delivery is expected after McDonald or Shirodkar cerclage removal at 36–37 weeks. Labour typically begins within one to three weeks of removal. Prior cerclage alone does not increase caesarean section rates. Transabdominal cerclage requires caesarean delivery in every pregnancy.

9. What warning signs should be reported after the procedure?

   Fever above 38°C, regular contractions, watery or foul-smelling discharge, heavy bleeding, pelvic pressure, or reduced fetal movements after 28 weeks all need immediate assessment. These may indicate infection, membrane rupture, or preterm labour each a potential emergency requiring urgent obstetric care.

10. Can a woman have cervical cerclage in more than one pregnancy?

    Yes. A vaginal cerclage is placed and removed with each pregnancy. After two or more cerclage-supported pregnancies, a transabdominal cerclage may be recommended (placed between pregnancies, left in for all future ones, with caesarean delivery each time).