The insertion of a Shirodkar (high vaginal) cervical suture (cerclage)

What is the Shirodkar (high vaginal) cervical suture?

It is a suture, or stitch, which is placed around the cervix (neck of the womb) and tied in order to prevent the cervix opening too early in pregnancy. We reach your cervix through the entrance of your vagina (transvaginally).

Why should I have a Shirodkar suture?

If you have had a premature birth (before 37 weeks) in a previous pregnancy, a late miscarriage, or previous cervical surgery/trauma, you are more at risk of ‘cervical incompetence’ (or weakness). This is a painless shortening and opening of the cervix which can lead to miscarriage or premature (early) birth. You have been offered cervical cerclage because it reduces the likelihood of weakness within the cervix that can cause it to open too soon.

What are the risks?

After cervical cerclage your chance of miscarriage or early delivery reduces, but there is still a small chance of this happening. Like any surgery, the cervical cerclage procedure has some risks that you need to be aware of.

• Bleeding: Most women will experience increased vaginal discharge and light bleeding (spotting) for a few days after the procedure. If necessary, you should use a sanitary pad and not a tampon. If the bleeding is heavier (like a period), seek medical advice.
• Infection: You have a small risk (less than 5% chance) of developing a vaginal or uterine infection. We shall give you a course of antibiotics following the operation to reduce the risk of this happening.
• Bladder or cervix tearing: There is also a very small risk of damage to your bladder or your cervix (less than 1% chance). We would generally be able to repair any damage to the cervix immediately. A tear to the bladder would require another operation by a urologist (a medical doctor with specialist training in problems affecting the urinary tract). Both would require a few extra days stay in hospital.
• Rupture of membranes or miscarriage: There is a small risk (less than 5% chance) of this occurring during or shortly after the procedure. If this happens it is unlikely that the pregnancy will continue.

Are there any alternatives?

We shall discuss with you any alternatives to the procedure that may be relevant depending on your medical history. For example, we may advise some women to have weekly injections or daily pessaries which may reduce your chance of miscarriage and early delivery. You will still be followed up carefully by us throughout your pregnancy, even if you decide not to have a cerclage. If you are unsure about whether to have the procedure, please discuss your concerns with us.

How can I prepare for my Shirodkar suture?

Domestic arrangements:

If you have children, you will need to arrange for them to be looked after overnight as you require one night’s stay in hospital. Ideally you should have help at home for the first week or two as you will find lifting and domestic tasks difficult and should avoid exerting yourself. We would generally recommend two weeks off work following the procedure.

Fasting or ‘nil by mouth’ instructions on the day of your operation:

Fasting means that you cannot eat or drink anything (except water) for six hours before surgery (you are allowed to drink water up to two hours before the surgery). You will be given clear instructions if you need to fast. It is important to follow the instructions given below. If there is food or liquid in your stomach during the anaesthetic it could come up to the back of your throat and damage your lungs.

Giving your consent (permission)

We want to involve you in decisions about your care and treatment. If you decide to go ahead, you will be asked to sign a consent form. This states that you agree to have the treatment and you understand what it involves.

If you would like more information about our consent process, please speak to a member of staff caring for you.

What happens during a Shirodkar (high vaginal) suture?

Before the procedure, you will be seen by your obstetrician and an anaesthetist. A midwife will accompany you to the surgical theatre where the anaesthesia and the procedure will be carried out. Your partner, or companion, will be able to be with you in the theatre.

Once the anaesthetic is working you will lie on the surgical bed, your legs will be eased into supports, and the table will be tilted to give the surgeon a better access to your cervix. Although you are awake, you will not see the procedure, as a screen will obscure your view. You may be in the theatre for up to one hour, but the operation itself usually takes no more than 20 minutes.

Will I feel any pain?

We perform nearly all of our vaginal sutures under regional anaesthesia (spinal anaesthetic) because it is safer for you and your baby. This means you are awake during the entire procedure but should not feel any pain from the waist downwards. Feeling touch and pressure during the operation, however, is normal. If you feel pain, at any time, your anaesthetist will alter the treatment to make you comfortable. You will also need a drip which will be placed on your hand or wrist to allow us to give you fluid and medication if necessary.

On the day of the procedure, you will be seen by an anaesthetist who will explain the process in greater detail.

What happens after the Shirodkar procedure?

After the procedure, you will be taken to a recovery room where a midwife will care for you. Your legs will be numb and heavy for four to six hours and during that time you will need a urinary catheter. This is a small tube that is passed into your bladder to allow the collection of urine into a bag. This will usually be removed the following morning. You may also feel sick but you will be given medication to help with this.
Once you are able to move about, eat/drink, and able to pass urine, you may go home.

What do I need to do after I go home?

When you are discharged from hospital, you will need to rest for the first 48 hours. After the procedure, you may experience abdominal pain (‘tightenings’), increased vaginal discharge or bleeding for a few days. We will prescribe you painkillers to help relieve your pain. If the pain and the bleeding continue for longer than a week you should contact us. Within one to two weeks, you should be able to resume most of your normal activities. We shall advise you as to whether you need to restrict any activities. You can shower or bath as usual but do not add anything to the water. You should avoid sexual intercourse for two weeks after your surgery.

Will I have a follow-up appointment?

You will be given a follow-up appointment before you leave hospital. If you need to change or enquire about that date or time please phone our secretary on 0113 392 2729.

Will I need another procedure to remove the stitch?

Yes, the suture is usually removed at around 36 weeks into your pregnancy. Removing the suture is a simpler procedure than placing it. You will require a spinal anaesthetic again for its removal. You will usually be able to go home the same day once you are walking and able to pass urine. It is very unusual for you to go into labour around the time of the suture removal, it can be another few weeks before your baby is born.

The suture may need to be removed earlier if your waters break, or if you go into labour before 37 weeks. If you think this is happening, you must come to the hospital immediately.

Can I have a normal delivery after the suture has been removed?

Yes, once the suture is removed you will be able to have a vaginal delivery.

What if I was due to have a caesarean section?

We would usually recommend leaving the suture in and removing it at the time of caesarean section (usually at 39 weeks into your pregnancy).