Congenital structural defects of the lower genital tract can cause cervical incompetence, depending on the nature and location of the defect. Such defects are more frequent in women who were exposed to diethylstilbestrol (DES) in utero, a hormone given in the 1950s and 1960s to prevent spontaneous abortion. Another important cause of incompetent cervix is previous cervical trauma such as excessive mechanical dilation during previous obstetric procedures, removal of tissue during previous cervical biopsy, and improperly healed lacerations from previous deliveries. Hormonal factors can also contribute to cervical incompetence, particularly excessive levels of relaxin, which may cause loss of normal cervical resistance to dilation. Relaxin levels may be higher than usual during some multiple gestations, increasing the risk of cervical incompetence in these pregnancies.
Nursing care plan physical assessment and examination
Obtain a detailed obstetric and medical history. Ask about the date of the last menstrual period to determine the gestational age of the fetus. Inquire about risk factors that are related to cervical incompetence. Women experiencing cervical dilation because of cervical incompetence may have symptoms that range from feelings of low pelvic pressure or cramping to vaginal bleeding, loss of amniotic fluid, and spontaneous passage of the fetus and placenta. Patients who experience cervical incompetence frequently report a history of previous secondtrimester pregnancy loss, induced abortion, dilation and curettage, cervical biopsy, or prenatal exposure to DES. A history of fertility problems may also be reported.
Inspect the perineum for bleeding and fluid. Patients frequently have pink or dark red spotting, increased vaginal discharge, passage of the mucous plug, or leakage of amniotic fluid. Cervical incompetence can be predicted by examining the cervical length with transvaginal ultrasound. A cervical length of less than 25 mm between 16 and 24 weeks’ gestation indicates potential cervical incompetence and a risk of preterm birth. A cervical length greater than 35 mm between 18 and 24 weeks’ gestation is correlated with preterm birth in 4% of patients. Thus, a shortened cervical length is an excellent predictor of cervical incompetence and eventual preterm birth, especially in high-risk women. Perform a sterile vaginal examination. The cervix is effaced and dilated, with progression in the absence of painful uterine contractions. A bulging amniotic sac or the fetal presenting part may be palpated through the cervix during the vaginal examination.
The patient who experiences pregnancy loss because of an incompetent cervix is in a state of psychological crisis. If this is a first episode, the patient is likely to be bewildered because of the rapid progress of dilation and the unexpectedness of the loss. In patients who have experienced infertility or previous fetal loss, psychosocial reactions may be complicated by unresolved feelings or cumulative effects of grief experiences. Anger, fear, numbness, guilt, severe grief, and feelings of loss of control are common in both the pregnant woman and her significant others.
Nursing care plan primary nursing diagnosis: Anticipatory grieving related to an unexpected pregnancy outcome.
Nursing care plan intervention and treatment
Medical management depends on the degree of cervical dilation that has occurred at the time the patient is examined. If dilation is progressing rapidly or is complete, preparation is made for delivery of the fetus and placenta. As with any spontaneous abortion, careful evaluation of bleeding is required to detect hemorrhage. Dilation and curettage may be necessary to control bleeding if placental fragments are retained in the uterus.
In less advanced dilation, particularly if the membranes are not ruptured, the patient may be maintained on bedrest in Trendelenburg’s position in an attempt to prolong the pregnancy. Usually, if the woman is no more than 23 weeks’ gestation, cervical dilation is no greater than 3 cm, the membranes are intact, and bleeding and cramping are not present, a cerclage may be used. In this surgical procedure, a purse-string suture is placed in the cervix at the level of the internal os and tightened to prevent dilation by mechanically closing the os. Either the Shirodkar or the McDonald technique can be used to create the cerclage. Prior to placement of the cerclage, an ultrasound is done to confirm a live fetus and to rule out gross fetal anomalies. In any future pregnancies of women with a history of cervical incompetence, a cerclage may be placed prophylactically at 14 to 18 weeks’ gestation. Prophylactic cerclages have an 85% to 90% success rate of reducing preterm births. Local anesthesia is usually used during cerclage placement, although regional or light general anesthesia may occasionally be chosen. After a cerclage has been placed, assessment for signs of labor, rupture of membranes, maternal infection, and fetal well-being continues for the remainder of the pregnancy. The cerclage is removed at or near term, with vaginal delivery typically following shortly thereafter. Bleeding, uterine contractions, chorioamnionitis, and ruptured membranes are all contraindications to placement of a cerclage. A third type of cerclage, transabdominal cerclage, is done via laparotomy and is used for severe anatomical cervical defects or if the other two cerclage techniques failed in previous pregnancies.
Pharmacologic management of cervical incompetence is not indicated, until after the loss of the fetus and placenta have occurred.
Nursing care for patients with cervical incompetence centers on teaching, psychological support, and prevention of injury to the mother and fetus. If a transvaginal ultrasound is going to be done to measure cervical length, be sure the patient has an empty bladder. Teach the woman about her condition and alert her to the potential for injury of the cervix if labor proceeds with a cerclage in place. Symptoms of labor, rupture of the membranes, and infection should be explained to the woman, with emphasis on the need to report such symptoms promptly if they occur. Consider the patient’s support systems and coping mechanisms if the pregnancy is continuing. Determine if the patient has the social and financial resources to manage a difficult pregnancy, and make appropriate referrals if they are needed.
Nursing care plan discharge and home health care guidelines
Be sure that the patient understands the importance of immediately reporting any signs of labor or infection. If vaginal rest has been prescribed, teach the patient to avoid vaginal intercourse, orgasm, douching, or tampon use. The patient should also avoid breast stimulation (causes uterine contractions), heavy lifting, and heavy housework. If antibiotics are prescribed, teach the patient to finish the prescription, even though she feels well. If bedrest has been prescribed, assist the patient and family to develop strategies for maintaining bedrest at home. Ensure that the patient understands and can carry out plans for follow-up surveillance and care. Alert the patient of the signs and symptoms of preterm labor.
Be sure that the woman understands the likelihood of repeated cervical incompetence and the possibility of prophylactic cerclage placement in future pregnancies.
Teach the patient to report signs of infection or hemorrhage. Be sure that the patient understands the need for pelvic rest until the follow-up gynecologic appointment. Provide the patient and family with resources to support grieving, including anticipatory guidance, reading lists or materials, contact information for support groups, and referral to counseling, if desired.