Again, an Allis clamp can be used for traction on the posterior mucosa, while the reflection of the Pouch of Douglas is created using blunt dissection. A similar incision is then made in the posterior cervical mucosa. This is continued until reaching the level of the internal cervical os. An Allis clamp can be used to elevate the bladder flap while the bladder is then mobilized cephalad using blunt or sharp dissection. Once the vesicocervical reflection has been identified, the mucosa of the anterior cervix is incised at this junction, similar to a vaginal hysterectomy. The Shirodkar technique begins with the patient positioned and prepared in the same manner. The suture is then tied down with a surgeon knot, either anterior or posterior. Just anterior to this junction, a nonabsorbable suture is inserted into the cervix in a purse-string manner, taking caution to avoid the paracervical vessels. The anterior lip of the cervix may be gently grasped using ring polyp forceps, and the vesicocervical junction should be identified. A speculum or right-angle retractors are used to adequately visualize the cervix. Under regional anesthesia, the patient is placed in the dorsal lithotomy position and prepped with a vaginal betadine solution. First applied in 1951, this procedure involves a simple purse-string suture at the cervicovaginal junction. The most common technique for performing transvaginal cervical cerclage is the McDonald method. Physical examination-indicated cerclage (also known as emergency or rescue cerclage) should be considered for patients with a singleton pregnancy at less than 24 weeks gestation with advanced cervical dilation in the absence of contractions, intraamniotic infection or placental abruption. It is important to note that this recommendation is invalidated without the history of preterm birth. According to the American College of Obstetricians and Gynecologists (ACOG), a history-indicated or prophylactic cerclage may be placed when there is a “history of one or more second-trimester pregnancy losses related to painless cervical dilation and in the absence of labor or abruptio placentae,” or if the woman had a prior cerclage placed due to cervical insufficiency in the second trimester.Īn ultrasound-indicated cerclage may be considered for women who have a history of spontaneous loss or preterm birth at less than 34 weeks gestation if the cervical length in a current singleton pregnancy is noted to be less than 25 mm before 24 weeks of gestation. There are three well-accepted indications for cervical cerclage placement.