Cerclage at 19wks

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Ok, so I have a question.

We have this new doc on our unit, fresh out of residency, who does some strange things. For instance, she puts "preeclamptic" pt's with 130/70 bp's, trace proteinuria, normal reflexes, no visual disturbances, no HA, etc on Mag, has them wear SCD's and gives them bathroom priveliges. ???

She calls up to our unit from the ED 2 nights ago and says that she has a 19wk pt down there with a cerclage who is experiencing cramping. Now, our rule is that pt's do not come to us unless they are 20 wks or greater, otherwise they recieve their care in the ED. Anyways, she says that she wants to send the pt up to us and have us get her on the monitor to see if she is in active labor. She then says that she wants us to set up in the OR so she can clip the cerclage because she can't have her tearing her cervix since she is cramping.

Now, I'm still kinda new at this, so I just want to know: at 19 wks, we're not going to get anything on the monitor, right??? And I don't know why she placed the cerclage in the first place (don't know at how many weeks it was placed) if they weren't going to try to get her to viability. What does it take from the uterus to tear the cervix from the stitch anyway? Does this make sense to you guys? End result, the pt does come to us, she does clip the stitch and when we left, membranes were bulging in the lady parts.

Any thoughts?

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Specializes in Maternal - Child Health.
Ok, so I have a question.

We have this new doc on our unit, fresh out of residency, who does some strange things. For instance, she puts "preeclamptic" pt's with 130/70 bp's, trace proteinuria, normal reflexes, no visual disturbances, no HA, etc on Mag, has them wear SCD's and gives them bathroom priveliges. ???

She calls up to our unit from the ED 2 nights ago and says that she has a 19wk pt down there with a cerclage who is experiencing cramping. Now, our rule is that pt's do not come to us unless they are 20 wks or greater, otherwise they recieve their care in the ED. Anyways, she says that she wants to send the pt up to us and have us get her on the monitor to see if she is in active labor. She then says that she wants us to set up in the OR so she can clip the cerclage because she can't have her tearing her cervix since she is cramping.

Now, I'm still kinda new at this, so I just want to know: at 19 wks, we're not going to get anything on the monitor, right??? And I don't know why she placed the cerclage in the first place (don't know at how many weeks it was placed) if they weren't going to try to get her to viability. What does it take from the uterus to tear the cervix from the stitch anyway? Does this make sense to you guys? End result, the pt does come to us, she does clip the stitch and when we left, membranes were bulging in the lady parts.

Any thoughts?

I'm puzzled as well.

Monitoring at 19 weeks would definitely be difficult, but having experienced PTL at 16 weeks, I was able to feel and report my contractions. My fundus, which was still well below the umbilical level, bunched up and felt just like a tennis ball. I wonder if it would have been possible (with 1:1 care) to have assessed her contractions by hand.

I understand the risk of cervical tearing, but it seems to me that the OB would have at least tried to stop her contractions with terbutaline or MgSO4 prior to making the decision to remove the cerclage. With bulging membranes at 19 weeks, does she plan to keep this patient on bedrest, or just write her off?

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We routinely placed cerclages in pts with hx of incompetent cervix as early as 15 weeks. We also had the rule of 20 weeks or less not on our floor. But there are plenty of exceptions and this is definetly one of them. Cerclage placement pts need to be monitored closely for bleeding and contractions following placement. Also they should be monitored on a L&D floor if contractions are present due to likelyhood of cervical tearing and/or delivery. I wonder were the membranes bulging prior to her cutting the cerclage? Bulging membranes are not a good sign at 19 weeks. ROM is extremely likely once the membranes are exposed to bacteria present in the lady parts. By the way, if you have a very skinny pt you can sometimes get toco monitoring to work at 19 weeks. Other than that is palpation and pt reports of UCs. I'm sorry for your patient. I hope she has a good support system.:o

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Specializes in Ante-Intra-Postpartum, Post Gyne.

You know how you can tell a first time mother just by the way she is with her baby...maybe this woman Dr is just being extra pre-cautious while she is new...

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That's why I was baffled too - I couldn't see why she would not give her some Terb at least to see if it would quit the cramping. She really seemed like she was writing the pt off to me, that's why I was upset by the whole thing. I just thought maybe the pt should be obs'ed longer and then a decision made about the cerclage.

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We had a pt brought to our floor the other day... 14weeks who had just had a cerclage...

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That's why I was baffled too - I couldn't see why she would not give her some Terb at least to see if it would quit the cramping. She really seemed like she was writing the pt off to me, that's why I was upset by the whole thing. I just thought maybe the pt should be obs'ed longer and then a decision made about the cerclage.

You could monitor with the toco at least, at 19 weeks, unless Mom is "fluffy". I could see her removing the cerclage if her cervix was starting to change even with it, or if the membranes were coming through then. Terb or Mag might have helped if the membranes weren't already bulging, but to be honest, I don't know if we would have used either tocolytic so many weeks before viability either.

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