Published on April 5th, 2018 | by Caitlin Vestal0
The Uncertainty (or, Incompetence)
When my friend was 12 weeks pregnant, she called me to ask if she should get a cerclage (that is, a stitch to hold a woman’s cervix shut). One doctor had recommended it. Another doctor had told her she didn’t need to worry about it. She’d had a D&C and a LEEP before—both procedures that dilate or remove parts of the cervix; that opening and cutting are potential risk factors for incompetent cervix (and yes, that is the medical term), a condition that about 1% of pregnant women experience in which their cervices, not strong enough to hold in a growing fetus, begin to dilate with painless contractions or slight cramping. Most women don’t know their cervix is incompetent until their first baby is born prematurely and dies.
I told my friend that only she could decide if she needed the cerclage. I used to be a doula, so I’ve done lots of listening to women talk about their bodies and their doctors without telling them what to do. That’s a doula’s job: to listen to women, to help them make their own informed decisions. We talked for at least an hour, and when we hung up, she was still unsure what to do. A few weeks later, I asked her what she’d chosen, and she told me her Maternal Fetal Medicine Specialist (and yes, that’s the medical term) had said, simply, “Why would you not get it?” So she got it.
A cerclage is an outpatient procedure you get at 14 weeks pregnant. You get an epidural. Your MFM Specialist slips some stitches through your cervix. You wait for the anesthesia to wear off. You go home. You rest. You probably have some spotting or cramping or pain when urinating for a few days. You avoid sex for a week and use condoms after that. Some specialists will tell you to avoid sex for the next 26 weeks. Some specialists will tell you not to exercise strenuously for the next 26 weeks. Some specialists will tell you to go on full bed rest for the next 26 weeks.
No matter what else you do for the next 26 weeks, you spend them hoping that the cerclage holds. If it does, when you’re 37 weeks pregnant, your specialist will reach inside your vagina again and pull the stitches out, and then you start hoping instead that your cervix will not stay shut but will open wide.
If, on the other hand, the stitches don’t hold, you go into labor and your baby is born too soon.
I didn’t know during that conversation that my own cervix was incompetent, but a few months later, I went into labor (light cramping, bright red blood) at 20 weeks. That is, 15 weeks before my son was supposed to exist outside of my body. After my midwife put on her headlamp, looked inside my vagina, and swept out blood and mucus with giant q-tip swabs, I went to the hospital. The OB-GYN who saw me in triage told me that sometimes they did a “rescue cerclage,” (same stitch, but put in after the cervix has already started dilating) but that it usually didn’t work. The MFM Specialist I saw the next day told me it could work. The other OB I saw told me it was possible, but that she wasn’t optimistic. Then the same specialist told me it wasn’t going to work, after all. And few days later, after I’d left the hospital, a second MFM specialist told me there was no way it would work, not on my gaping cervix. That this was an inevitable loss. So finally, after five days of different opinions, my husband and I gave up. We went home to wait, and our son was born and died in our bed a few nights later.
After we told everyone on Facebook that we’d lost our baby, just weeks after we’d told everyone on Facebook that the baby was a boy, my friend who’d gotten the cerclage called me. Neither of us could believe the irony. She hadn’t spoken to a single other person about whether or not to get the cerclage. And it never occurred to me I might end up needing one when I got pregnant a few months after her. Of course, there’s no way to know if she did, in fact, need one at all. She might have chosen to forego the stitch and still have carried her baby all the way to full-term. She’d been aggressively offered the cerclage because of her D&C and her LEEP, and though I’d had a D&C myself, no one had ever mentioned it might make for cervical incompetence.
In fact, the second MFM Specialist I saw told me a D&C wasn’t even considered a risk factor anymore. If there had been complications with the procedure, perhaps. But a regular old Dilation & Cutterage? Nah.
“We used to think it was that,” he told us, “And then it turned out not to be. We also used to think it might be about Vitamin C, but it turned out not to be. We thought it might be genetic, but it’s not that either. The truth is, we don’t know what causes it. We just don’t know.”
This utter lack of certainty—of what we should do, of what caused the problem—is a regular part of most pregnancies. Some people don’t question the uncertainty. We assume our doctors know all there is to know and don’t ask further. But many of us find the information we need elsewhere—namely, from the Internet.
When people are told they need a cerclage (or a _______, or a ________), and we don’t happen to know a doula we can call up to discuss their diagnosis with, we take to the message boards (you know the ones): BabyCenter, JustMommies, BabyandBump, TheBabyCorner, etc. One of my friends warned me about the pregnancy message boards before I was even trying to get pregnant: “Just wait till you’re TTC,” she said. I had no idea what she was saying. “Trying to conceive,” she explained. “It’s a thing.”
It is, indeed, a thing. There’s a whole world of unsubstantiated information at pregnant people’s fingertips, should we be looking for it. I checked out the TTC boards when we started hoping to get pregnant, but I couldn’t stomach the stories or the lingo (DH = Dear Husband, BFN = Big Fat Negative on a pregnancy test, MC = miscarriage). I stopped looking at the forums after a few glances.
But then we were in the hospital. And no one would tell us what the right choice was. And I needed to know the actual success rate of a rescue cerclage at 20 weeks. And the life expectancy of a micro-preemie, which is a baby born before 28 weeks, when they’re much less likely to survive. I spent an entire night sobbing in the hospital bed, reading stories women had posted of their “miracle babies,” who were born at 24, 25, 26 weeks, and had made it through all those months in the NICU. And also stories of babies who hadn’t made it. Who had just been too tiny. Stories of people whose rescue cerclages had held or hadn’t.
In the end, none of those stories informed my decision. Lots of them, like the ones in which people were told a rescue cerclage wasn’t a good idea but demanded one anyway, still irked me, even in my desperation. I was as frustrated by these people and their willingness to pass off anecdotes as fact as I was by the doctors without answers for me. I couldn’t put my trust in stories that ended by wishing me baby dust.
But now, two years later, when I’m trying to get pregnant again, I find myself cruising these boards again. Searching: “pregnancy after incompetent cervix,” or “cerclage success rates,” or simply “pregnancy after loss.” Hoping that someone will tell me what to do, even as I digest the reality that there is nothing to do but wade through the uncertainty of it all. To know that each time my DH and I get a BFN, we can cry and hug each other, but also sigh, a little relieved that at least we don’t have to start worrying yet about how much we don’t and won’t and can’t know.