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Hidalgo, Louella C.

BSN4-1 PREMATURE CERVICAL DILATION Premature cervical dilation previously termed an incompetent cervix is a condition in which the cervix begins to open (dilate) and thin (efface) before a pregnancy has reached term. In a woman with cervical incompetence, dilation and effacement of the cervix occur without pain or uterine contractions. Instead of happening in response to uterine contractions, as in a normal pregnancy, these events occur because of a weakness in the cervix, which opens under the growing pressure of the uterus as pregnancy progresses. If the changes are not halted, rupture of the membranes and birth of a premature baby can result. Risk Factors: Cervical incompetence is relatively rare, occurring in only 1 to 2 percent of all pregnancies. It is thought to cause as many as 20 to 25 percent of miscarriages in the second trimester. It may have any of several possible causes, such as: * A previous operation on the cervix (D&C or biopsy) * Damage to the cervix during a prior difficult delivery * A malformation in the cervix due to a birth defect (such as in DES-exposed women). These risk factors make it more likely for the problem to recur in another pregnancy. Other women at risk for this problem include those who are pregnant with more than one fetus and those who have an excess of amniotic fluid (a condition called hydramnios) in the current pregnancy. For these women, cervical incompetence is less likely to recur in a subsequent pregnancy. Clinical Manifestations: * Spotting or bleeding * A vaginal discharge that is bloody or thick and mucus-like (the latter may be the passing of the mucus plug from the cervix) * A sensation of pressure in the lower abdomen

Diagnosis: The diagnosis of cervical insufficiency is either based on historic factors or, preferably, by a combination of historic factors and transvaginal ultrasound (TVU) measurement of cervical length. *Using historic factors alone, cervical insufficiency is defined as painless cervical dilatation leading to recurrent second trimester pregnancy losses/births. This definition precludes diagnosis of cervical insufficiency until at least two pregnancy losses/births before 28 weeks of gestation have occurred. *A preferable definition allows the diagnosis of cervical insufficiency to be made in primigravidas or in multigravidas without multiple prior pregnancy losses. Using this definition, cervical insufficiency is defined by TVU cervical length <25 mm and/or advanced cervical changes on physical examination before 24 weeks of gestation in women with either: - One or more prior pregnancy losses or preterm births at 14 to 36 weeks, and/or - Other significant risk factors for cervical insufficiency Treatment: Cervical cerclage - is the placement of stitches in the cervix to hold it closed. In select cases, this procedure is used to keep a weak cervix (incompetent cervix) from opening early. When a cervix opens early, it may cause preterm labor and delivery. Cervical cerclage involves stitching shut the cervix, which is the outlet of the uterus. Cerclage can be done preventively at 12 to 14 weeks before the cervix thins out, or as an emergency measure after the cervix has thinned. It is rarely used after 24 weeks. Cerclage is performed using either general anesthesia or regional anesthesia (such as spinal injection). Usually cerclage is done through the vagina. A speculum, an instrument with paddles shaped like spoons, is inserted into the pregnant woman's vagina to spread the vaginal walls apart for the surgery. The surgery can be done in different ways: *Stitches can be placed around the outside of the cervix. *A special tape can be tied around the cervix and stitched in place. *A small incision can be made in the cervix. A special tape is then tied through the cervix to close it.

The cerclages fall into 3 types - McDonald - a pursestring stitch around the cervix to cinch it together, Shirodkar - a pursestring stitch around the cervix underneath the skin of the cervix to help cinch it together, and an abdominal cerclage - a stitch around the lower part of the uterus through an abdominal incision to cinch the lower part of the uterus and upper cervix together. Nursing Responsibility * Obtain a complete history of the events of current and past pregnancies * Observe for signs of impending delivery such as ruptured membranes, active bleeding, and regular painful uterine contractions. * Provide emotional support. * Explain the plan of care and all the procedures to the client and family.