How the Shirodkar or McDonald stitch is put in?

The term cerclage can also be used to describe the procedure. It aptly describes the method whereby a stitch is placed around the cervix, making it much like a tobacco pouch where the strings have been pulled tight. In the same way, the stitch pulls the cervix tight. This famous technique, as mentioned earlier, is named after one of its main proponents. Professor Shirodkar. His was just one technique and, as it is quite a lengthy procedure, it is often not done quite as he described it. Other doctors lent their names to similar techniques, such as the Macdonald or lash procedures. They are all modifications of the same idea, trying the strings or tape in different ways. The tape can even be tied through a button to prevent it from loosening and rolling down the cervix.

A most important point to bear in mind is that the stitch should be put in early. It used to be said that it could not be placed before about the 14th week of pregnancy. But that late date was dictated by the fact that, prior to the use of ultrasound, neither the doctor nor the patient would have heard the fetal heartbeat, or felt movement, until that time. Now, sonography can tell us if the fetus is alive from 6weeks or even earlier. Obviously, one would not want to put in a stitch if there was not a live pregnancy in the uterus.

I often recommend putting in the stitch around 9 to 10 weeks. The earlier the stitch is in, the longer it may hold the pregnancy. One of the reason is that while the cervix is still as long as it is going to be, it gives the doctor more to work with. And the stitch is placed as high up in the cervix as possible. Throughout pregnancy, the cervix normally contracts because it contains muscle tissue. This may cause the stitch to dislodge, and so it must be put in high and firmly.

If there are any overwhelming high-risk factors, and you are unsure of the health of the fetus, you can have a chorionic villus sampling (CVS) test between 6th and 9th week, which is a very early method of providing the information usually discovered by amniocentesis. The CVS can precede putting in the stitch, which will be done once normal results are obtained.

Generally, the stitch should not be put in if you are actively bleeding or contracting, as the procedure may mask what is going to be an inevitable miscarriage.

A stitch can even be placed in the cervix before you undertake a pregnancy. Usually this is only done where there is virtually no cervix present, making it technically very difficult or impossible to insert one once the patient has become pregnant and the the cervix has already begun to shorten. It is quite rare to do this, because putting a stitch in between pregnancies might interfere with fertility, and the technique used would almost inevitably mean a C-section delivery. As the type of cerclage technique will vary from patient to patient, you must rely on your doctor’s advice.
 
When your physician has decided that a stitch is needed, it will be done in the hospital. Prior to putting in the stitch, an ultrasound scan will be done to ensure that the fetus is alive (its heart is beating) and there are no other problems. You will be admitted into the hospital either on the day of the procedure or possibly the night before. Some anesthesia will be necessary as it is a little too painful otherwise. An epidural anesthetic, which is often used during labor, is a commen choice. The procedure is done in the operating room. Your legs are placed in stirrups, and the technique usually takes about fifteen to thirty minutes. Following the procedure you may be discharged home on the same day or kept in overnight. The fetal heartbeat can be checked afterward by ultrasound or possibly with a fetone.

Treatment and care after surgery
Once a stitch is put in, the doctor keeps a close eye on the patient, as accidents can happen to the stitch itself: the knot may come loose, or the stitch can roll down the cervix and loosen. It is very important to see the doctor regularly, even once a week initially, until the fetus is viable at round 30to 32 weeks.

You will probably have to be examined vaginally at each visit, as your doctor will want to know how secure the stitch is. If it has rolled down or if the cervix is beginning to open, your doctor may even decide to put in another stitch.

He may advise some bed rest after the procedure, because gravity can put pressure on the cervix.

As the stitch is a foreign body, it could be a site for infection. So, as a preventive measure, one week out of every month I may prescribe an antibiotic, either by mouth or vaginally, to prevent infection. This is not always done and depends on the particular patient’s history.

I have always believed in seeing patients with a history of miscarriage often and in giving a lot of reassurance. I believe this has a physically beneficial effect.
What if you have contractions even with the stitch in place.

One common fear among women needing a cervical stitch is whether intercourse is safe, even after a stitch, or whether it will set off contractions. If you feel comfortable about the idea and your doctor feels there is no inherent danger, then he may tell you it is safe to resume intercourse. But you will probably be asked to use a condom to avoid the possible effects or the prostaglandins from semen, which just might stimulate uterine contractions, and to minimize infection.

If premature labor dose begin, ritodrine may be given as treatment. As I mentioned earlier, ritodrine is only approved for use from the 20th week. However, even with no signs of premature labor, if a patient is very high-risk and anxious, I sometimes give her ritodrine from 220weeks. A side effect, as mentioned earlier, is that it will make your heart beat faster, but it dose not have adverse fetal effects.

When is the stitch removed?

The stitch can be taken out in the doctor’s office and dose not usually require hopitalization or an anesthetic. Removal is not painful. We aim for two weeks before due date, or the 38th week. Once this stage is reached the baby is fully mature and the stitch can be removed.

You would not want to go into labor with the stitch in because this could lead to a frantic rush to get it out in time, and delivery with the stitch in place could lead to bad tearing the cervix. You also need a few days to allow any infection from the stitch site to leave your body. These are the reasons why we always try to remove the stitch before labor begins.

After the stitch is removed, it is common to have minimal bright bleeding from the stitch site. Labor itself usually starts within hours or one to two days, especially if the cervix is very weak. However, labor may even be delayed beyond term in some cases, possibly because of scarring from the stitch site!