The Cerclage!

I had a cerclage placed about two weeks ago due to my incompetent cervix caused by my unicornuate uterus. (I guess I’m extra, extra special?) Today I write about the cerclage as well as some data I collected about pregnancy outcomes of women with unicornuate uteruses and cerclages. Cover photo source: here.


About two weeks ago, I had a cerclage.

If right now you’re thinking, “Cerclage? What is that? Like a fancy cheese or a new type of massage?” then you probably should pause reading this post and check out my post from May 31st: Who are you calling an “incompetent cervix?” Come back and finish this post after you catch up!

My maternal fetal medicine (MFM) doctor recommended a McDonald cerclage, the most common type of cerclage, because my cervix had shortened to an unsafe length. At its current length, it had the potential to trigger pre-term delivery (think 20-24 weeks), a major no-no for only being 18 weeks pregnant at the time. (Learn more about cerclage at the Mayo Clinic.) My incompetent cervix is most likely related to my unicornuate uterus. Since there is less room in my half uterus, there may be less cervix to begin with and/or more pressure pushing down on the cervix, causing it to shorten faster than it would with a whole uterus.

This all sounds pretty stressful to me. Pre-term delivery. Shortening cervix. Surgery. So I coped the way I cope best, first by venting to Cory, my mom, and my sister, next by writing a blog post, and finally by turning to the research!

To the research!

Too bad the available research is kind of a bummer.

I Googled “unicornuate uterus and incompetent cervix” or “unicornuate uterus and cerclage,” and hardly anything popped up. It was really disheartening, especially for a woman who calms her anxiety by reading meta-analyses and making charts with beautiful data. According to one study I found by Chifan and colleagues (2011), an incompetent cervix could be associated with congenital uterine malformations like a unicornuate uterus (oh really? no duh, science). In their retrospective study, they reviewed the cases of 316 women with uterine malformations. The researchers found that, even with a cerclage, “All patients had preterm delivery” (p. 1063). (That’s encouraging…not!)

Unsatisfied with the limited data I found on the World Wide Web, I decided to collect my own data by polling the 600+ women in a Unicornuate Uterus support group on Facebook. I compiled the data in the chart below. This was a very informal poll with missing data and lacking context, but it was more than I could find online. Take aways, women with unicornuate uteruses who had to have a cerclage made it to 35 weeks on average. 43% were placed on bedrest. 83% of those who responded also were put on progesterone. I asked my doctor about this high frequency of progesterone use in addition to a cerclage, and she said that progesterone is used for a lot of different things, not just for incompetent cervix. This is one of those examples of how I don’t have adequate context to best interpret this data, so take it with a grain of salt!

Back to the cerclage surgery itself!

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Cerclage time

On Saturday, June 1, Cory and I arrived to hospital at 8 AM for my 10 AM surgery. We made our way to the third floor, labor and delivery. I checked in at the nurse’s station and was then led into a hospital room. The first 45 minutes were spent trying to get an IV started on my dehydrated veins, like once plump grapes that had shriveled into sad raisins in the hot summer sun.

Speaking of raisins, may I pose an unrelated question about dried fruit? Why do some fruits receive completely new names after they have been dried, but other fruits just become the dried version of their old name? For example, dried grapes become raisins. Dried plums become prunes. But dried bananas just become dried bananas and dried apricots just become dried apricots. I have found an inconsistency in fruit taxonomy! Do I win a prize?

Back to the IV debacle

In my previous six IVs this past year, the nurses have been able to get it on the first attempt. However, this was the only time in the past year that an IV was attempted on dehydrated veins. I was told to stop drinking and eating after midnight for my surgery.

Attempt 1 in right arm: major fail. “You’ll probably have a bruise from that,” my new grad nurse said. (See said bruise below. It gets worse as the days go on!) Attempt 2 in my left arm: fail. My nurse called in backup support from a slightly more seasoned nurse. Attempt 3 in my right arm: fail. Finally the most experienced nurse was called in. Attempt 4 in left arm: success! While I don’t love being repeatedly stabbed in my arm, I tolerate it just fine. So the four IV attempts, while just mildly annoying, didn’t throw off my mojo.

After the IV was in and fluids were started, it was a lot of waiting around and signing consents. Right before the surgery, a nurse practitioner came in and explained the cerclage surgery and did a quick ultrasound of baby boy to check out his heart. Everything looked great, so shortly after I was wheeled to the operating room. It was super bizarre - I was taken to right outside the operating room lying in the hospital bed, but then they had me get up and walk to the operating table and climb up aboard myself. I don’t know what felt so weird about that. Just knowing I was getting up on the table where soon I’d be receiving surgical intervention felt kind of morbid.

In the operating room

I sat on the operating table, my legs hanging off one side, as the anesthesiologist administered the spinal anesthesia. First, she injected a numbing agent into the skin on my back. This stung and then burned. I’ve never been stung by a bee, but I was told that’s what this numbing shot feels like. It wasn’t terrible, but it wasn’t fun either. Like I wouldn’t do it recreationally for funsies, but it wasn’t something I’d “write about in my diary,” said the anesthesiologist. It was over in just a few seconds, and I just breathed through it. After my skin was numb, she injected the anesthetic near my spinal cord. What a crazy sensation! As soon as she injected the anesthetic, I felt a rush of warmth from my legs down to my feet. The warmth was kind of nice because the operating room was so cold and I was naked minus a very thin hospital gown. Before my legs went completely numb, two nurses helped me lie back on the table and put my legs in some very attractive stirrups.

Over the next 5-10 minutes, my lower body slowly started to lose sensation. I tested out the anesthetic every few minutes, touching my thighs to make sure it was working. Slightly worried, I let the anesthesiologist know that I could still feel the touch of my hand on the skin of my legs after about 10 minutes, and she explained that skin is the last thing to lose sensation. She also said that if the surgery is painful even with my spinal, she could administer additional anesthetic through my IV and knock me out. Thankfully, I didn’t need that option. A couple minutes later, it was really weird to see my nurse give me an intramuscular shot of Toradol, a pain med, in my hip muscle and not feel a thing.

So there I was. Lower body numb. Feet in stirrups. Exposed for the whole world to witness. And there I waited for at least 20 minutes until my doctor came in. That was maybe one of the worst parts of the whole cerclage - waiting on the operating table with no sense of how long I would be waiting, cold (even shivering), numb, and ultra exposed (hello world!).

When my doc finally arrived, things got moving really quickly. She and the nurse practitioner got to work, requesting tools and prying me open with two big metal spatula-looking things (like the speculum’s bigger, badder brother). Even though I was being stretched to Canada in one direction and to Mexico in the other, I didn’t really feel much. After I realized that the spinal had done its job, I started to relax (well, as much as a person can relax with two people flocking around her vagina with sharp objects).

I looked to the right, and across the operating room I saw a door with a glass window. In the window, I could see a reflection of the operating room and the slightest angle of my doctor at work. I used this as my entertainment, watching the action as best as I could.

10 minutes into the procedure, my nurse came to my side and asked me how I was doing. “Feeling fine. Just watching the procedure in the window reflection over there,” I said as I nodded towards the door across the room.

The nurse was shocked, “Woah, really? You definitely don’t want to see what’s going on down there.”

“Actually,” I corrected her, “I really would want to see what’s going on! I’m destined to be a doctor in another lifetime.”

“Do you want me to take a picture?” she asked.

I immediately responded, “Yes!”

So that’s exactly what she did. Towards the end of the surgery, she told the doc that I wanted a pic. She took her nursing iPhone (the nurses at this hospital had iPhones for their work) and readied herself to snap a picture of my cerclage. Right before the picture, I felt playful and said, “Okay, I’m smiling!” In one of my most physically vulnerable moments, I was able to have one of my proudest moments, making the entire medical team laugh. That felt good.

I’ll spare you the picture, but I’ll just tell you that it didn’t look like much. I was hoping to be able to clearly see my donut-hole cervix opening with a nicely tied stitch like a Christmas bow, but it ended up looking like a blob of pink tissue with a few small black dots, the stitches, around it. At least I’ll always have a picture to document that moment. I’ll make sure to add it to the baby book (kidding!).

All in all, I was in the operating room for one hour. 10 minutes getting my spinal. 20 minutes waiting on the table for the doctor. 20 minutes of surgery. 10 minutes of getting me out of the stirrups and transferred back to the hospital bed. I gotta say - having numb legs was one of the weirdest things I’ve ever felt. Watching the nurses lift my legs out of the stirrups and down onto the table was so out-of-body. I saw it happen, but I felt nothing. Well, not exactly nothing. When they brought my legs back down to the table, it felt like my legs were still up in the stirrups. My anesthesiologist explained that this was because my brain remembered the last position my legs had sensation and froze that position in my mind. Wow!

Post-op and beyond

I was then taken to the post-op recovery area. My mom and Cory came to this area to keep me company. Immediately after the surgery, I had cramps across the lower part of my abdomen. Thankfully, my pain only reached a 3/10 on the pain scale. Like slightly irritating, more widespread period cramps. I was more concerned about how cold I was than the pain in my abdomen. Then, slowly but surely, sensation started to come return to my legs.

After an hour in post-op, I was taken back to my hospital room. The nurse told me that I only had to do three things before I could leave: walk, pee, and eat. Within two hours after my surgery, I had eaten a greasy, hospital burrito bowl, walked to the bathroom, and did my urination duties. After one more set of vitals and one more peak at baby boy (he was just fine!), I was discharged by 2:30 PM.

I spent the rest of Saturday, Sunday, Monday, and Tuesday resting. I had zero pain and zero bleeding Saturday night on. During those 3.5 days of rest, I didn’t do much other than showering, making simple meals, and going to the bathroom. I returned to work on Wednesday and felt about 90% back to normal!

A huge shout out to Cory and my mom who stayed by my side the entire day of the cerclage. They were supportive and loving and supplied me with flourless chocolate cake, all of the things a girl needs on a day like that. I am grateful for my supportive family and you all, who continue to amaze me in your consistent, never-ending Internet support! Thank you!

Resources

Maria & Tirnovanu, Mihaela Camelia & Grigore, M & Zanoschi, C. (2011). Cervical incompetence associated with congenital uterine malformations. Rev Med Chir Soc Med Nat Iasi. 116. 1063-8. Download full PDF here.