The ‘Wait-and-See’ Approach

The “Wait-and-See” Approach means bi-weekly monitoring to check for cervical changes.  If any are detected, they will place an emergency vaginal cerclage.  In addition to the frequent cervical monitoring, progesterone pessaries or P17 shots are often given as a preventive for uterine irritability.  These don’t cause any harm, so aren’t a problem.  However, they still don’t keep the cervix actually closed and, therefore, don’t address the physics of disallowing baby to fall out.

Other considerations with the ‘wait and see’ approach:

  • Accuracy of Frequent Monitoring:  The cervix is so dynamic that bi-weekly (or even weekly) monitoring may not catch cervical changes in time to place a cerclage.  The problem with this is that the success rates for emergency cerclages is drastically lower than a preventive one.  The cervix is already changing; the pregnancy is already compromised.  These emergency cerclages are, in fact, called “rescue cerclages.”  You hope the rescue is successful to at least viability.  This is not like waiting at the railroad crossing to see if any trains are coming.   This is like you seeing there is a train coming and hoping, hoping, hoping, hoping that you make it over the train tracks without getting hit.  Do you see the difference in urgency and potential consequence?
  • Actual Cerclage Placement: If changes are caught, there may not be enough of a cervix to place a cerclage.  What doctors won’t tell you is that they aren’t just looking for change – they’re looking for your cervix to shorten below 2.5cm.  So, now, they have a less than optimal length to try and place a vaginal cerclage.  Also, placing a rescue cerclage on a shortened cervix is not without risk.  Amniotic rupture IS a risk of having an emergency cerclage placed.  And this does happen.  Also, ask your doctor what the latest gestation is that he would place a rescue cerclage – many will not place one after 22/23 weeks.  That means that you might not make it to viability. Or, you might deliver at 24/25/26 weeks.
  • Strict Bedrest: Placing an emergency cerclage needs to mean that you also get in bed and stay there until 34 weeks.  I do not mean that you ‘take it easy’ with this cerclage – go to the movies, ride the electric scooter around Target, avoid running the vacuum.  I mean that you stay reclined with your butt above your head to alleviate any pressure off the cervix.  You definitely don’t take baths, though doctors will allow you quick showers.  If it were me, I’d do sponge baths only because I wouldn’t be getting up.  But I’ve watched a lot of babies die, so that’s why I’d stay down.  To be honest, I’d personally use a bed pan.  Again, that’s because of what I’ve seen.  Strict bedrest is absolutely necessary if an emergency cerclage is placed.  This can be a huge financial strain on families, but also emotional.  It’s difficult to just lie in bed for weeks upon weeks.  What if you have a toddler you need to care for?  Certainly you do what you have to do for your family, but it needs to be said that this is a consideration in this approach.
  • Steroids for Baby: If you go with a ‘wait and see’ option, you need to familiarize yourself with giving steroids for lung development.  Know the pros/cons. Many doctors won’t give steroids unless delivery is eminent, but if it’s eminent, then you may not have the time to allow the steroids to work.  Plus, you need to get two doses in for baby.  (guidelines for viability are changing constantly, but you want to know what the latest standards are nationally and at the top children’s hospitals)
  • Micropreemie Care: There is a definite possibility that you may deliver very early (23-28 weeks) and now you have a micropreemie on your hands and a long nicu stay ahead of you.  Hopefully, a long nicu stay.  I hate to share that I’ve read of many many mamas whose micropreemies die in the nicu – either from immaturity or from NEC.  Another part of this is for you to also find out what level care NICU your delivering hospital has.  If it is not at least a true Level III, they are not equipped to care for a micropreemie and your baby will be transferred to another hospital.  Hopefully, this is in the same town as you, but, often, it’s not.  You may find yourself in the situation of being in one hospital recovering and your baby fighting for life in another.  This is especially rough on dads.  (I’d like to add here that if you do have a preemie, you can request donor breast milk for him rather than formula.  Breast milk’s connection to infection prevention – like NEC – is invaluable.)
  • Failure: Finally, I hate to share this, but I’ve seen this approach get women to 21/22 weeks, have an emergency cerclage placed and that lasts 5-7 days and baby is born at 22.5 weeks.  Baby doesn’t survive.  Also, ask your doctor to explain to you what to watch out for with a failing cerclage.  Women have reported feeling a lot of pressure down below to feeling like a large tampon is inside of them.  If the cervix does not close back up, then the amniotic sac can actually bulge through the stitch.  Further, baby can actually deliver through the stitch and then the stitch rips right out of the cervix.   This doesn’t always happen at a hospital, either.
    • Funneling: the TVC is placed at the BOTTOM of the cervix.  That means the weight of baby and fluids still rest on the top of the cervix.  Sometimes the cervix just gives out and crumples under the weight and actually funnels – the top (the internal os) opens up, though the bottom (the external os) has not dilated or perhaps has dilated but is being held closed by the stitch.  Either way, the baby can slip into that funnel.  This causes two problems: 1) the pressure of the funnel can cause the waters to rupture  and 2) the baby is now much closer in proximity to good vaginal bacteria that is bad uterine/amniotic sac/undeveloped baby bacteria.
    • Infection: the TVC is placed at the BOTTOM of the cervix – close to the vaginal vault.  Good, normal, healthy vaginal bacteria can actually be wicked up by the stitch material and introduced into the cervix and beyond.  That good vaginal bacteria is very very bad uterine bacteria.  If you have a vaginal infection – like bacterial vaginosis (very common) – then that could also go up and cause problems.  Either way, bacteria in the vagina needs to stay out of the uterus.  An incompetent cervix doesn’t allow this, so one would expect the stitch to handle it.  Sadly, that stitch material can – and does at times – suck that infection right up.

After reading all of this, you may wonder why anybody would choose the ‘wait-and-see’ approach.  It’s often employed if women are unsure of an IC diagnosis.  Or if doctors are hesitant to diagnose IC after “only” one loss.  “Wait-and-see” is attractive because there is no unnecessary intervention (though if you are on this page reading about IC options, I highly doubt that any intervention is ‘unnecessary.’).

Do women sometimes have no changes? Absolutely.  That’s the crapshoot of IC – who knows when it will show up.  Do women sometimes have successful rescue cerclages placed?  Absolutely.  Do some women go to term?  Yes!   There ARE successes with waiting and seeing and with rescue cerclages.  What you need to understand is that you will not know if you’ll be one of the successes until either you are or you aren’t.  So, the risk is baby.  And, despite your doctor’s confident demeanor, that risk is high.

Please spend considerable time in prayer begging the Lord to show you the way He intends for you to go.  He may, in fact, call you to a wait-and-see approach.  And choosing that because of prayer is awesome.  I am for that.  I don’t understand it, but I am for anything that points to Christ as Redeemer and Savior.

I am not trying to scare anybody.  I simply want to offer a sobering view of what I’ve witnessed over the past few years.

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7 responses to “The ‘Wait-and-See’ Approach

  1. Thank you so much for this info! Drs don’t want to do much for me. 1st pregnancy..but I’m 37. Begged for progesterone since a tiny spotting episode wk 10. No dice. Didnt get suppositories till i spotted again at 18 and discovered 2.9 cervix that has shrunk every week since. Already changed docs for 2nd opinion. They will do rescue at 24 weeks if I keep shrinking like I have over past 4 weeks. Last visit I was 1.7 – 2.3. I’m a nurse and believe bedrest is also right despite the michigan study. Its worked this far-moderate bedrest for 3 weeks now. Last week doc told me to get out of the house and more activity to avoid deconditioning and dvt prevention. Ill do my leg excercizes in bed thank you. I plan to hang in there till I get the rescue cerclage at wk 24 and keep my fingers crossed (and uterus up in the air) with my 50/50 chance. Thanks so much for your information. It helped me put the puzzle together!

  2. I’m currently 22 weeks and 2 days. I had a rescue cerclage placed at 20 weeks and 6 days, 12 hours after an ultrasound tech saw that I was 3 cm dilated during the anatomy scan. I was already at an MFN clinic because of high risk pregnancy (pre-existing diabetes). I was in the hospital for 4 days after the surgery then sent home on modified bed rest (I get up to use the bathroom). Just hoping and praying all goes well. Joined abbyloopers today, but since the focus is on those who’ve already had losses and getting the transabdominal cerclage, it doesn’t seem like the best place at this moment, when I’d like to save this pregnancy, God willing. I have an appointment with my OB on Monday. I hope and pray everything is holding up. It’s hard to get a sense of what the statistics are.

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