The Wonder Of The Cerclage

By Meryl

My saga is a long one with many twists along the way, but a blessedly happy ending!

Pregnancy #1--

We became pregnant for the first time in April 1988.  Our happiness turned to fear with the first bleeding episode at 6 weeks.  Ultrasound confirmed that all was fine.  Progesterone was borderline low, so I took suppositories for that.  Two more first trimester bleeding episodes at 10 and 14 weeks.  The baby was always fine through all of this so the doctor felt that no concern was necessary.  At around 16-17 weeks, I began to notice cramping and heavy discharge.  All of my pregnancy books and well-meaning friends assured me that discharge was "normal" as pregnancy progressed.  This was a thick, rubber-cement type discharge and it concerned me, even with all of the reassurance.  Finally, at 18 weeks, I started to get really nervous about the cramping and discharge and insisted on being seen in between appointments.  I arrived that day 3-4 cm dilated with membranes funneling.  I was immediately rushed to the hospital, put head down in the Trendelenburg position, given Ritodrine for contractions, and scheduled for an emergency rescue cerclage the next morning.  IF they could get everything to "scoot" back and away from the cervix, and the uterus to quiet down.  I guess it worked because they came and prepped me for the cerclage the next morning.  I was given a general anesthesia and the first words I spoke when coming out of the drugs were "Is my baby OK?" I was assured that the baby was fine, but I was cramping severely, and I was scared.  I drifted in and out that whole day, praying for the cerclage to work.  The doctors were never overly optimistic as I recall, but I naively believed that NOW everything would be okay, and our precious, much wanted baby would be just fine.  I stayed in the hospital for one week.  Everything appeared to be stable.  The doctors told me to take it easy, OK'd my going back to work as long as I wasn't on my feet, so off I went.  The contractions never stopped.  I continued the Ritodrine, around the clock.  I had to set my alarm and wake up to take it in the middle of the night, but it just didn't seem to be working.  I also started having a lot of wetness, which I assumed was discharge.  I believe now it was leaking membranes, but I was so innocent and uninformed at that time, I simply didn't know it was cause for alarm.  I also had a lot of rectal pressure and what I thought was "constipation".  I know now that these are all ominous signs of preterm labor, but I simply didn't know it then.  If I had, I would have done things very differently.  I went back after 2 weeks for a cerclage check, and the doctor's face said it all.  He said "I'm afraid the cerclage has come out.  You are going to lose the baby."
I refused to believe this was happening.  I asked them to do whatever they could to help me.  They put me back in L&D, again with my head down, more Ritodrine (why if it wasn't working?) and there I laid throughout the day, again praying for my baby's life.  Another doctor checked things out later that day, and again said that he felt sure I was going to lose the baby.  He said the last ditch effort would be an IV with a different medication (I'm thinking it was probably Mag Sulfate but I didn't ask) that might be more effective, but he doubted it would prevent labor from progressing.  We wanted to try everything possible, so we said Yes.  I will never forget that night.  I was sick from the medication, not to mention the fear and anxiety.  The contractions continued all night long despite the meds, and by dawn, everyone knew the delivery was imminent.  My husband I cried many tears that night.  He was worried about my health as well.  Finally, the meds were stopped, I was offered an epidural which I accepted, and at around 8:00 a.m. our living, squirming healthy baby girl was expelled from my body.  She was alive for several minutes, and died in our arms shortly after birth.  I think the very hardest part about this (and IC in general, in my humble opinion) was knowing that a perfectly healthy, normal baby was being lost because of MY defective body.  That caused me so much mental anguish for a very long time, part of what we have to come to grips with when dealing with an IC loss and it's not easy.  We named our daughter Alexandra Rose.  She was perfect in every way, just too small to survive.

Pregnancy #2--

I couldn't try to conceive again right away (although I wanted to) because I had a rubella shot shortly after losing Alexandra.  They did run some tests on me during this time, including a hysterosalpingogram, which showed that my uterus was "normal" (they suspected fibroids were possible, who knows why).  We started trying again in Nov-88 and were pregnant again by the following month.  I had switched to a new doctor (he's the one who ordered the HSG) and he was still unsure of what happened with my first pregnancy.  He recommended the "wait and see approach" with this one.  Check me closely for cervical changes and if anything occurred, it would be caught early and he could get the cerclage in.  This was all due to the fact that I had experienced a lot of contractions with my first loss.  Somehow that raised doubt about whether I had an incompetent cervix, or just an isolated bout of preterm labor.  I began bleeding at 9 weeks at which time I was put on total bedrest.  The baby was fine and I was not threatening to miscarry (looking back, knowing what I know now- I should have had the cerclage at that point in the pregnancy).  Things moved along and I stayed down into the second trimester.  The doctor did insist on doing weekly cervical exams in the office. (They didn't use ultrasound for measurements back then) I had a weekly check on Good Friday, late afternoon.  We went out for dinner on Easter Sunday, but other than that, I was on bedrest.  I woke up at 7:00 am on Tuesday morning to a distinct "popping" sound, which were my membranes rupturing.  I knew right away what had happened, even while the doctor and nurses tried to reassure me that it could have been my bladder, etc.  I was admitted to the hospital and the doctors continued to talk about the possibility of the membranes sealing back, but we knew deep down that it was over.  After two days, labor started and we lost a son, Michael, at 16 weeks.  They ran a chromosomal test on the baby and he too, like our first child, was a perfectly normal baby, lost to IC.  If a cerclage had been placed preventatively, we would have most likely not lost this baby.

Pregnancy #3--

Now I was finally getting aggressive.  I began to research everything I could on IC.  Keep in mind, the Internet didn't exist back then (1989) and material was extremely difficult to find.  The doctor's proposed a somewhat rare and fairly controversial approach.  Because my second loss was so sudden, they decided I should have a Shirodkar cerclage (placed higher and deeper in the cervix and allegedly more durable than the McDonald purse-string stitch) and have it placed PRIOR to pregnancy.  I tried to read up on the procedure but there was so little info available back then.  We decided to do it.  The stitch was placed in May, around 6 weeks after my second loss.  We immediately began trying to conceive and had no luck.  My first 2 pregnancies were achieved easily.  This time around month after month passed and nothing happened.  I was getting insane with the stitch already there, and not able to become pregnant.  The doctor finally decided to help things along and prescribed Clomid (a mild fertility drug).  This was after 6 months of trying on our own.  The second dose worked.  We found out we were pregnant once again and instantly I became a total WRECK.  I was really terrified of losing another baby.  When I was 8 weeks pregnant, we moved from South Texas to Atlanta, Georgia.  I started on complete bedrest at 12 weeks, although for the first time, I had no first trimester bleeding.  I took this as a good sign, but still felt like a walking time bomb.  My doctor this time around was very aggressive and compassionate.  He was sure that this pregnancy would result in a full-term baby.  I longed to have his enthusiasm, but couldn't get beyond "cautious optimism".  I continuously prayed to at least make it to "viability".  We made it to 24 weeks with no problems.  I stayed on bedrest and at 24 weeks, I was put on home uterine monitoring ("just in case") where I sent strips down the phone line to nurses who interpreted whether I was having contractions or not.  I stayed on pretty strict bedrest until around 30 weeks.  I started getting more confident at that point and got up more but still stayed quiet.  I didn't require any tocolytics with this pregnancy.  I had a scheduled c-section at 38 weeks because of the Shirodkar stitch.  It could stay in for future pregnancies since it was considered a 'permanent' stitch.  I went into labor exactly 9 days before the scheduled c-section and Nicholas was born at 37.3 weeks, weighing 7 lbs. 13 oz. 20.5" long.  A healthy, strong full-term baby BOY! My husband and I cried tears of joy in the delivery room.  I will never forget it as long as I live...the sound of that crying, squalling baby was the most incredible thing I'd ever heard!! I have goosebumps thinking about it right now and my big boy will be 9 years old very soon.  I love him so much.

Pregnancy #4--

We started trying to conceive again when Nicholas was around 2 years old.  Again, nothing
happened.  Here I was again dealing with secondary infertility.  We tried Clomid again and this time it didn't work.  When Nicholas was about to turn 3, at a routine pap and exam, the doctor found the allegedly 'permanent' cerclage hanging out of my cervix.  He tugged and it came right out of there.  My body had rejected the "foreign body" and I had the c-section apparently for no reason.  I no longer had a cerclage.  And guess what?  Two months later I was pregnant.  I later found out that the stitch is a breeding ground for bacteria that was obviously preventing us from conceiving.  The 2 times I ever had trouble becoming pregnant was when I had a stitch in there.  This time I started the pregnancy without a stitch, so I was very stressed and nervous.  My new doctor felt that a normal McDonald stitch would do fine since my pregnancy with Nicholas was so uneventful.  The cerclage was placed as an outpatient procedure at 13 weeks, and everything went very well.  I went back to work 5 days later and everything was perfect until around 22 weeks, when contractions started.  Nothing dramatic, but I knew that my uterus was becoming irritable.  They put me out of work at the point and I stayed home on 'moderate' bedrest.  I had tons of contractions but no cervical change until around 30 weeks.  Things started to change at that point.  I was around 80% effaced, but somehow held on until the day I turned 35 weeks.  I started having more painful contractions that day and something didn't feel 'right'.  I called the doctor's office and reported the painful contractions.  They suggested that I go to L&D to be checked out.  I hung up the phone and told my husband that they said to go in and "POP" my water broke!!  I instantly went into 'hard' labor.  Contractions became more intense and were only around 2 minutes apart so we scurried into the hospital.  We arrived around 6:00 p.m. on 4/22/94.
My doctor was already there and he removed the cerclage right away.  I hadn't been dilated at all when I arrived.  Once the stitch came out, my cervix immediately dilated to around 2 cm.  Rebecca Rose was born at 9:44 p.m., 5 weeks early, but in great shape. 6 lbs. 6 oz 19 " long.  We were able to take her home the next day.  She did develop a pretty bad case of jaundice, but basically she was in perfect shape for a 35-weeker.

Pregnancy #5--

This time there was no cerclage and therefore, no fertility trouble.  In fact, we hit it on the first try which was a shocker after the last 2 difficult conceptions.  The pregnancy went along almost exactly as with Rebecca, EXCEPT with this one, I actually had to take oral Brethine tablets (Terbutaline) for contractions.  Again, the uterine irritability kicked in at around 22 weeks.  This time, I worked from home throughout my bedrest, which wasn't terribly strict.  I had limits placed on housework, shopping and anything that required me to be on my feet.  Once the cerclage was placed, I was restricted from sex with all three pregnancies.  I had 2 bouts of preterm labor with this one also, both times requiring short trips to the hospital.  Labor was stopped fairly easily both times, with the Terb shots and a dose of Mag sulfate.
I had my cerclage removed at exactly 36 weeks.  By that evening, I was feeling a lot of pressure and more regular contractions.  I tried to sleep but woke up several times wondering if this was "it" (when you live with contractions all the time, it's REALLY hard to discern the difference).  By dawn, I knew that labor was starting.  At around 8:00 am I felt that we should head for the hospital.  We took Rebecca with us and didn't call anyone to pick her up just yet.  Once we got into L&D, I asked my husband to call a friend to come for Rebecca.  I knew I couldn't concentrate any longer on her being there and that labor was active.  Imagine my surprise when the nurse said she couldn't FIND my cervix.  After much searching and contorting myself into a few odd positions (while in heavy labor!!) they found my cervix and proudly announced that it was nice and CLOSED. 100% effaced, but closed.  I was in shock considering the intensity of the contractions.  I was told to walk around for an hour and they would re-check then. (I refused to go home, which was their first suggestion) To make a long story short, Christofer was born before that hour was up.  Apparently with IC, the scar tissue that forms around the cerclage CAN be rather stubborn.  However, once it loosens up, the cervix will dilate rather quickly.  That's exactly what happened to me.  Once I started walking, labor intensified and I knew delivery was imminent.  The nurses certainly weren't convinced, considering that 30 minutes earlier I had no dilation.  I practically begged them to check again and when they did, things went into panic mode.  I delivered approximately 3 minutes after they frantically wheeled me to the L&D room. (I had been in the triage room all morning) Christofer was a healthy 6 lbs. 11 oz and 19 1/4 " long at 36.1 weeks.  He was in great shape, and had no complications.

Pregnancy #6-- Benjamin’s Story the final chapter!

My little angel is here....Benjamin Arturo. Born at 37w3d (tying his big brother's record for my longest pregnancy!) at 7 lbs. even, 19 1/4 " at 1:10 pm on 3/8/00.

This pregnancy was probably the most stressful for me in many years. That's an ironic statement considering how smoothly it went in comparison to my others. I think it was mostly due to the pleasure of being labeled with a new risk factor along with IC with the lovely title of “advanced maternal age”. This had me very stressed from the beginning. There were other issues as well  I was taking medication for reflux, had severe tooth pain that required dental x-rays in the first trimester, my DH less than enthusiastic, etc. I had pretty bad morning sickness and found just coping with work and my children overwhelming.

I was also very concerned about my increased risk for Down's Syndrome, Trisomy, etc., and opted to go for a very new, and somewhat controversial (because of it's newness) "First Trimester Screening Test"  for Down's, and other chromosomal disorders. I did alot of research on it, and decided it was perfect for me because it was non-invasive, and because we'd get the results BEFORE the cerclage. Thank God the results were reassuring and it helped me to move on with a some peace of mind.

The cerclage was put in at 12w5d and went pretty smoothly.  I considered writing that it went “Without incident”, but that wouldn't be exactly true. The spinal anesthesia that was administered didn't work well and NO ONE believed me. The anesthetist thought I was a wacko and admonished me for not having had a sedative. It was pretty harrowing and I had to use some major mind control to get through the procedure.  I kept telling myself that it was almost over, and fortunately, it was over quickly.

My regular OB (the same one that I have had since I was pregnant with Rebecca) and the perinatologists agreed that I could continue working until there was some indication that I should slow down.  My initial cervical lengths were at around 4.5 cm, which was amazingly good for me. So I took 5days off after the cerclage was placed, and then went on with my life, taking it easy, but essentially keeping active.  I was restricted from exercise, sex, excessive time on my feet, etc.

Our level 2 ultrasound at 18 weeks revealed, by all accounts, a healthy baby. This was such a tremendous relief to me.  I finally started to let myself love this baby.  I'm still not sure exactly WHY but it took me a longtime to let myself “bond” to him. I was very much afraid of losing him, for a very long time.

We weren't able to see the gender until around 26 weeks. (although looking back, the tech at the peri's “thought” it was a boy at 14 weeks, but wouldn't swear by it) At 18 weeks, they couldn't tell, at 22 weeks another tech also said she was pretty sure it was a boy, and then at 26 weeks, it was clear that we had another son on the way!!  We were thrilled and over the moon!!

Time went by rather quickly as my life was very, very busy with 3 kids, a full-time job, all the kid's activities, etc.  I kept waiting for the bomb to drop, kept waiting for the bad news when I went in for my cervical checks, kept waiting for my uterus to get irritable...and time kept marching on.  I was actually starting to get perplexed at the incredibly EASY pregnancy I was experiencing.  I was extraordinarily grateful, but I was in shock. After 2 IC losses, and subsequent pregnancies with multiple complications, I felt like a “normal” pregnant woman.

The technician at the peri's office constantly teased me that I would be one of those women who went overdue when the cerclage was removed.  I couldn't imagine that to be true with my history of early deliveries, but I was beginning to wonder.  I wasn't even having Braxton Hicks contractions, let alone the “normal” PTL that I expected.

My cervix stayed between 3.8-4.5 cm with no funneling for the whole pregnancy. At 30 weeks my OB started to feel some changes that weren't necessarily ominous, but did (finally) cause enough concern to put me on more restrictions until 34 weeks.

My cerclage came out at 36w5d. It was a fairly difficult removal.  Dr. R had to dig around to find the knot, which had grown into the tissue.  It wasn't very pleasant, but it was a happy day for me.  I had “orders” from my DH  NOT to go into labor that weekend (stitch came out on a Friday morning) since he was scheduled to work outdoors all weekend long and was worried about being inaccessible. So here I was without a cerclage, ready for my baby to come, and taking it easy to honor his wishes!

On Monday, it was no holds barred!  I had an appointment that morning with a CNM- I REALLY felt like a normal pregnant woman, seeing a midwife! (my regular OB was on vacation) She said my cervix was thin (70-80%) but closed. She felt that labor was close, but couldn't promise. She recommended the “normal” stuff like sex, herbs, walking, etc. to get things going if I was anxious to.  At that point, I was still pretty peaceful about being pregnant and not overly anxious.

I went shopping at Target and started taking some of the herbs she recommended. I heard they could help “tone” the uterus for the work of labor, so what the heck. They were actually pretty gross tasting and made me nauseous so I slacked off fairly quickly. (I do think, in retrospect that they did get things started) Looking back, it seems like labor actually started Tuesday evening. I felt alot of intense pressure (vaginal & rectal) throughout the day and I went off to Nicholas' soccer practice thinking the activity might help.

It did- that evening, we picked up take-out fajitas for dinner and the contrax were coming pretty regularly. By the time I sat down for the evening, I felt a bit of an adrenaline rush that this “might” be it. I even ran and took a shower and got “ready” in case I had to go into L& D. I knew my cervix was closed and 70-80% effaced at the appointment the day before.so I didn't think I'd be in a big hurry, although I did have a precipitous labor last time, with Christofer, and I had that in the back of my mind.

I decided to lie down and try to sleep, knowing if it was true labor I'd be up again soon. I slept soundly til around 3:00 am and got up for my “normal” bathroom trip. I didn't feel any contrax so I thought "oh well, another false alarm" and went back to sleep in the recliner. I was feeling “crampy”at that point, like a period coming on- but that was happening alot in these last weeks, so it wasn't a big sign to me.

I woke up and got online around 7:00 am. I was disappointed that nothing was really happening and that I'd slept so well all night. While I was posting and writing e-mails, the contrax started up again fairly regularly at around 6-7 minutes apart. I got hopeful again, but still just puttered around the house, normal routine...told DH that it might be “real” and he was sort of like “yeah right” but I could tell he wasn't really believing me. LOL :-) In fact, his biggest concern at that point was the appointment we had for the mobile glass repair that was coming to replace the windshield on our van. I called the company and told them I “might” be in labor and would they come to the hospital to do the work??  It was pretty funny, they said they would, and actually did it in the hospital parking lot, by the way

At around 8:30, after several trips to the bathroom and contrax that continued to feel uncomfortable, I decided I was going into L & D- it was just a matter of “when”. I wasn't feeling a sense of urgency, yet I was worried about labor advancing rapidly. I decided to get ready...we took our three kids with us (decided to skip school that day) , thinking we'd call our friend to pick up the little ones when we knew for sure what was going on, because I STILL wasn't convinced that I was in labor.

We got to the hospital around 10:00. I went to triage to be monitored for around 45 minutes before they even checked my cervix. Contrax were still coming every 6 minutes or so and very manageable. My two previous labors started and ended with extremely intense, long contrax that gave me very little break in between, so this was very cool...and I was doing well. They finally checked my cervix and said I was 5 cm dilated!! WOO HOO!!! You can't imagine how happy I felt at that moment...I was halfway there, and not really suffering yet. I was pretty sure I'd be able to manage without medication at that point. I called Jane and she came promptly to pick up my younger kids. Nicholas stayed to participate in the birth.

The BIG problem was my blood pressure. Now, I have to say that I have NEVER ONCE during 6 pregnancies (4 full-term) had a high bp reading. It was registering 200/100 when I got to L & D on Tuesday. They re-took it several times, on different parts of my arm, with different cuffs, moving me here and there, on my side, turn to the other side...you name it. It wasn't budging. I was pretty scared for a moment, thinking about eclampsia,seizures, etc. The nurse and midwife were sort of hemming and hawing about what to do about my bp, and it was suggested that one of the LEAST interventive things to do was to get an epidural. By this point, my labor was progressing and even though I really hoped to have an unmedicated delivery, I figured a “light” or “walking” epidural was better than being put on mag sulfate, (which slows the contrax) and end up with a c-section. So I agreed to do the epidural, and it worked wonders. In fact, my bp went down to 60/40 (TOO LOW) after only a few minutes with the epi. The odd part is (and actually this is the part I am happiest about) that this epi didn't ever really work as far as “numbing” me. I did have some pain relief on my left side, but it did notwork at all on the right side....so I was able to lower my bp, but still have the birth experience I wanted...which was to essentially be an active participant and not “numb” all over. This was important to me after the “natural” birth experience I'd had with Christofer.

The midwife came in and checked me after the epi and said my cervix was basically “whatever she wanted it to be”. She felt it as 7-8cm but it was so “stretchy” she said it could be more very easily. At this point, she broke my water without my permission, and pronounced that it was clear. I think it would have been appropriate to ask me about rupturing my membranes, but oh well...this is the way things go in the hospital. I was still handling the contrax very well but they got very close together and then the pressure started to build....I told the nurse that I was getting close to pushing and she said I had only an anterior lip left and she'd call the MW in right away.Suddenly, all hell broke loose and I started pushing, whether they liked it or not!! (they didn't) The MW was literally yelling at me not to push while she got ready, which actually made me angry!! The baby was coming fast and I wasn't about to “pant” through the pain while she got ready...so it was a fairly chaotic scene! It only took around 2 pushes for his head to pop out, I couldn't see anything but I heard the MW “talking” to the baby as she suctioned him out...and then the rest of him slid out out with the next push. And for the first time ever, after 6 pregnancies and 4 close-to-term births, I got to actually SEE my baby with all of the vernix and blood...they even put him up on my chest for a moment- This may sound routine to most, but with Nicholas it was a c-section and they whisked him away, and then Rebecca & Christofer were considered “preterm” and also had to be taken away and checked by the neonatal team before I got a look. That was one of the best parts of this birth to me-he was considered “term” and I got to see and hold him, fresh from the womb.

As I mentioned earlier, I had so many fears throughout this pregnancy,mostly related to my age and the decision NOT to have an amnio. My first trimester screening and Level II ultrasound results were reassuring but I never completely lost my worries about Down's Syndrome, especially. So it was important to me to see for myself that we had been blessed with another healthy child. For that, I am extremely grateful.

The rest of the story was fairly routine. I had a large tear & laceration that required 10 stitches. And the MW thought since I had the epidural I didn't require lidocaine for the stitching..WRONG! That was agonizing to say the least. I told her from the start that I could feel it, but by the time I was screaming for her to numb it, she only had 3 stitches left and said it would require 4-5 shots to numb it. That was NO fun, believe me.

It's also worth a mention here that my almost 10 year son, Nicholas was there with us, and it was amazing how well he handled everything. He was by my side the whole time, didn't get squeamish at all and the MW took the time to show him the placenta, the sac, the cord vessels...and she explained what each one of those things did for the baby. It was really cool...he even cut the cord since Dad said “no thanks”...LOL! When all was said and done he pronounced the whole experience “not gross at all, just really interesting”...and he's very much in-love with his baby brother.

I am feeling very content and satisfied with how everything went, and mostly I am so very, very thankful that through the miracle of cerclage, I have been able to realize my dream of motherhood. I am still in awe of the whole thing.

This pregnancy and birth were a lovely ending to the most miraculous ride of my life.

So that's my long and drawn out tale.  I hope it helps you in some way.  I hope it also answers some of the questions you may have about IC.  I felt that my ability to finally have children came after developing the attitude that I would do whatever it took to have a close-to-term pregnancy.  I quit work, I stayed on bedrest for 6 months...I didn't care.  Whatever it took.  To me, it was a short-term investment in a long-term benefit!! This also included finding the right doctors.  For me that meant doctors who considered me a partner in my care and who trusted my instincts as much as their own.  I did find such a doctor and I believe that was part of the confidence that I gained with each subsequent pregnancy.  I have been blessed with an incredibly beautiful family.  I am aware of this fact every single day and I enjoy being able to share some of the knowledge and experience I have gained throughout the years.

-Meryl