The shirodkar stitch or Mc Donald Circlage is a ‘purse-string’ stitch put into the cervix (mouth of the womb) to keep it tightly closed during pregnancy.
This procedure helps to prevent a miscarriage or premature birth when the cervix has been weakened. Calling it an “incompetent cervix” in medical terms is not very complimentary for this mighty little valve that's been weakened by unforeseen circumstances.
Assessing the strength of the cervix to take the pregnancy to term can only be done at 21 weeks of the pregnancy by sonar. The means that women who are considered to be “at risk” should be screened early in her pregnancy because it’s safest to insert the shirodkar stitch between 10 and 14 weeks. Women who have had multiple miscarriages or a very premature baby want to be spared repeated trauma – and costs. The benefits of having the shirodkar stitch far outweigh the possible risks of scarring the cervix, the need for caesarean births and uncomfortable sex because of the “stitch”.
Who is at risk?
Bacterial infections (particularly syphilis) and viral infections (especially the Human Papillomavirus or HPV) are fast becoming the primary cause of cervical damage to women worldwide. The domino effect is that tissue damaged by viral infections can become cancerous. Removing cancerous cells either by a cone biopsy or a LLETZ procedure at a depth that exceeds 10 mm into the cervix can damage these valves irreparably.
Another alarming risk factor (that nobody talks about) is second trimester surgical abortions. Women whose mothers were prescribed diethylstilbestrol (DES) for breast cancer during her pregnancy may have a congenitally weakened cervix.
Birth trauma that damages the cervix includes tearing caused by a previous precipitous labour (giving birth within two hours after the first contraction) pushing a baby through an undilated (not fully opened) cervix, difficult breach birth or a traumatic forceps delivery.
Understanding the cervix
During a pregnancy, the cervix has to do two things. Firstly it has to stay tightly closed while the baby grows in the body of the womb. At the end of the pregnancy, hormones soften the cervix while the baby’s descending head gently coaxes it into opening a full ten centimetres while she is in labour. The cervix is made up of rigid connective tissue and this determines how far it can stretch. When tissue is damaged and then heals, it becomes scarred tissue that’s never quite the same.
What to do if you need to have a shirodkar stitch
There are two ways a shirodkar stitch can be inserted. When the condition is mild and even prophylactic (when there is an anticipated risk) the procedure is done vaginally. The stitch is removed at about 38 weeks of the pregnancy or earlier if the mother shows signs of going into labour. Her baby can be delivered vaginally, but she will need to have a shirodkar stitch with each subsequent pregnancy.
In severe cases, or when the cervix is very short, the shirodkar stitch may have to be inserted abdominally – which means surgically. The stitch will be left in place even after the delivery (which will be a caesar) so that she can fall pregnant again.
Even though this is a relatively simply procedure, it is not without risks. Ideally the mother should stay in hospital and at bed-rest (which means no getting up) for at least 24 hours. After that she should rest for several days and when she is quite sure that her womb is not contracting in reaction to the procedure, and then she can gradually increase her activities.
While the cervix is healing, she should minimise the risks of infection and avoid sexual intercourse. Her partner will need to understand that sex may be uncomfortable (and even painful) while the stitch is in place, so they should experiment and use alternative positions or even less invasive sexual activities.