04.12 Incompetent Cervix

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Overview

  1. An incompetent cervix occurs when the cervix begins to thin and shorten too early in a pregnancy.
    1. Prior to 28 weeks

Nursing Points

General

  1. Dilation and effacement occur without contractions
    1. Dilation = widening
    2. Effacement = thinning
  2. Risk for miscarriage or preterm birth.

Assessment

  1. Vaginal bleeding or discharge (progressing from clear/white to pink/tan)
  2. Pelvic pressure
  3. Cramping
  4. Backache

Therapeutic Management

  1. Prevent contractions
    1. Bed rest, fluids, meds (tocolytics)
  2. Prepare for placement of a cervical cerclage (suture) if it appears that the pregnancy has been threatened
    1. May be monitored overnight for premature labor
    2. This reinforces the cervix, preventing further premature dilation
    3. Contraindications for cerclage
      1. Ruptured membranes
      2. Labor
      3. Intrauterine or vaginal infection
      4. Pregnancy beyond 28 weeks
      5. Fetus is too low in cervix

Nursing Concepts

  1. Reproduction
  2. Safety
  3. Patient Education

Patient Education

  1. Importance of bedrest and decreasing activity
  2. After cerclage – must educate on symptoms of infection, PROM, contractions
  3. Educate not to have sex or do much activity for a prescribed amount of time
  4. Educate to notify MD if contractions or bleeding

Reference Links

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Video Transcript

In this lesson I will explain about incompetent cervix, risk factors, treatment and your role in providing this care.

So what is an incompetent cervix? This is a cervix that can’t maintain the pregnancy. It starts to dilate and efface too early in the pregnancy. Dilation is widening of the cervix and effacement is the thinning. For a visual I want you to picture this donut. The circle in the middle is going to open up and get bigger or wider. That is the dilation. The flattening of the donut, so if you put it in your hand and squeezed it flat that is effacement. This patient is at risk for miscarriage or preterm birth if we don’t stop this from occurring.
Let’s talk about what your patient will look like that has an incompetent cervix. On assessment your patient will have vaginal bleeding or discharge. This could be clear or white discharge that progresses to pink spotting. The patient might complain of pelvic pressure. This pressure can sometimes make them feel like they are going to have a bowel movement. Cramping is another complain the patient might have. The uterus is irritating by what is occurring and causing cramping or contractions. Backaches can occur because of the uterine contractions and cramping that can radiate to the back.
Our management of this patient is going to involve preventing the cervix from making changes. So we want to prevent contractions. Contractions cause cervical change to happen. Imagine a water balloon. When you squeeze it the water is pushed down. With the uterus contractions it pushes the contents down. So it pushes the fetus and bag of water down which presses on the cervix and causes changes to occur like dilation and effacement. We can prevent contractions with bed rest, IV fluids, and tocolytic medication such as terbutaline. IV fluids help because if the patient is dehydrated it will cause the uterus to contract. The best way to manage this patient is with a cervical cerclage. As you can see in this picture there is a suture around the cervix keeping it closed. This is a stitch that goes through the cervix to keep it closed. Think of it as a reinforcement to prevent further dilation. When the patient receives a cerclage she may be monitored overnight for premature labor. This is great but there are some contraindications. If the patient has ruptured membranes, or is in true labor, or intrauterine infections. We don’t want to put a stitch that would keep the infection in. If the pregnancy has gone beyond 28 weeks then a cerclage wouldn’t be placed.
We need to educate on the importance of bedrest and/or decreasing activity. We want to keep the body calm to prevent contractions. If the patient has had a cerclage then she must be educated on symptoms to watch for. She needs to watch for signs of infection, rupture of membranes, and contractions. The patient might need to abstain from intercourse. Remember that this could cause oxytocin to be released which can cause contractions. She needs to also understand the importance of notifying the MD for contractions or bleeding.
Nursing concepts are reproduction, safety and patient Education. The patient has reproduced. We need to keep her fetus safe and the patient pregnant and there is a lot of education that revolves around having a cerclage and maintaining a pregnancy.
Let’s now review and look at our key points to remember. An incompetent cervix dilates and effaces and can not hold the pregnancy. So we can treat with a cerclage. The cerclage is a stitch that holds the cervix together and maintains the pregnancy. Contraindications are ruptured membranes or labor because that just means it is inevitable and delivery needs to happen. If there is an infection we do not want to cerclage because it is going to hold the infection in. If the patient is beyond 28 weeks they will usually not do a cerclage and just monitor until delivery. The patient will be taught signs to report. If she has signs of infection such a temperature she needs to report. If she has any leaking of fluid, bleedings or signs of labor she needs to notify the doctor.

Make sure you check out the resources attached to this lesson. Now, go out and be your best selves today. And, as always, happy nursing.

Read more

  • Question 1 of 7

A nurse is educating a client regarding placement of a cerclage for incompetent cervix. Which statement by the client shows understanding of teaching?

  • Question 2 of 7

A nurse is evaluating a group of pregnant clients with cervical shortening on ultrasound. Which of the following clients is likely to receive a cervical cerclage?

  • Question 3 of 7

A nurse is educating a pregnant client who has had a cerclage placed at 12 weeks about when to notify the provider. Which of the following should be included in the education? Select all that apply.

  • Question 4 of 7

A nurse is caring for a client who is 15-weeks pregnant. The ultrasound shows a shortening of her cervix on ultrasound. Which of the following diagnoses would the nurse anticipate?

  • Question 5 of 7

A nurse is counseling a pregnant client who has been diagnosed with an incompetent cervix. Which of the following statements by the nurse would be included as part of teaching?

  • Question 6 of 7

A woman who is 23 weeks pregnant is at risk for preterm birth and the provider decides to place a cerclage. Which information must the nurse tell this client as part of routine care with a cerclage?

  • Question 7 of 7

A nurse is caring for a 15 week pregnant patient with a shortened cervix on ultrasound. What management should the nurse expect at this time?

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