Premature

Cervical
Dilatation
Cer vical Insufficiency / Cer vical Incompetence

Section A Group 4

Abanilla, Charity
Duarte, Recel
Jumagdao, Jhyll Brynth
Pedres, Jenny
Premature Cervical Dilatation
Description of the Disease

Cervical insufficiency (Cervical incompetence)

is defined by American College of Obstetricians and
Gynecologists (ACOG) as the inability of the
uterine cervix to retain a pregnancy in the
second trimester in the absence of uterine
contractions.
- Occurs when weak cervical tissue causes or
contributes to premature birth or the loss of an
otherwise healthy pregnancy.
Prevalence and Statistics
- The incidence of cervical insufficiency is
estimated to be 1% of all pregnancies and
as many as 20% of midsecond
trimester spontaneous pregnancy losses.

- The incidence of incompetent cervix has

been reported to be 1 in 500 to 2000
pregnancies.
Anatomy and Physiology
Histologically, the cervix contains
fibrocollagenousstromal tissue.

-Internal os: the opening of the

cervix into the body of uterus.
External os – its size and shape
varies widely with age, hormonal
state, and whether the woman has
had a vaginal birth.
In nonparous women it appears as
a small, circular opening. Versus
being fish mouthed (meaning
wider, more slit-like and gaping) in
parous women.
In pregnancy, the normal cervical
length is 4 + 1cm.
Anatomy and Physiology
Continued...

Before parturition, the cervix is firm, composed

predominantly of collagen.
Any condition that degrades collagen enhances
cervical softening and pliability, which sets the
stage for dilatation.
This process involves several mediators,
including prostaglandins and cytokines; thus, it
is not surprising that inflammation is frequently
seen in the setting of preterm labor. The cervical
canal normally contains mucus with antibacterial
properties.
PATHOPHYSIOLOGY
When the fetus reaches its 20th week, it starts to
become heavy and gain fats.
The mother’s cervix is weak, and it could not hold
the fetus’ weight anymore as it slowly starts to
dilate.
This would cause the appearance of a show, a
pink-tinged vaginal discharge.
Then, the membranes would rupture and amniotic
fluid would be discharged.
Uterine contractions would start followed by a
short labor, then the birth of the fetus.

For most of pregnancy, the cervix must remain

strong and closed to keep the fetus in utero. Then
in a dramatic reversal of roles, at the end of
pregnancy, the cervix must be compliant enough
to dilate and allow for delivery of the fetus.
Risk Factors
The causes of incompetent cervix are somehow difficult to
explain, but it is believed to be associated with the following:
• Increased maternal age. The muscles around the cervix
start to slowly lose its elasticity because of increasing age,
and could contribute to the weakening of the cervix.
• Congenital structural defects. These are defects that
might contribute to the cervix’ incapability of holding in the
fetus.
• Trauma to the cervix. Any trauma experienced by the cervix
could weaken the muscles surrounding it, thus leading to its
premature dilation.
• Race. Black women seem to have a higher risk of
developing cervical insufficiency. It isn't clear why.
 ASSESSMENT
Signs and symptoms

Show. This is a pink-tinged vaginal fluid that is

discharged from the vaginal opening as a sign that
the cervix has dilated.
Increased pelvic pressure. The fetus is already
descending, causing a pressure felt by the mother
on her pelvis.
Cervical dilation. Upon inspection of the
physician, the cervix would show dilation.
Associated Findings
-History of cervical trauma
-History of repeated, spontaneous, second
trimester terminations
-Possibly spontaneous rupture of the membranes

Diagnostic Tests. There are few diagnostic tests that

could detect an incompetent cervix before it usually
happens. It is usually diagnosed after the pregnancy
has already been lost.
Ultrasound. This is the only test that the physician
could order if an incompetent cervix is already
suspected.
MANAGEMENT
Progesterone supplementation. If there is a
history of premature birth, the doctor might suggest
weekly shots of a form of the hormone progesterone
called hydroxyprogesterone caproate (Makena) during
the second and third trimester. However, further
research is needed to determine the best use of
progesterone in cervical insufficiency.
Medical management by the physician would
not include any medications that could hinder
the dilation of the cervix. Surgical procedures
are immediately enforced to prevent
compromising the pregnancy.
Surgical Management
There are two types of surgical
management for incompetent cervix.
• McDonald’s Cervical Cerclage. Nylon
sutures are placed horizontally and
vertically across the cervix. They are
pulled back together until the cervical
canal is only a few millimeters in
diameter.
• Shirodkar Cervical Cerclage. Sterile
tape is used for this technique, where it
is threaded in a purse-string manner
under the submucous layer of the
cervix. Then, it is sutured in place so it
would close the cervix. These sutures
are removed on the 37th or 38th week
of pregnancy for the fetus to be born
vaginally.
 Nursing Management
1. Provide client and family teaching. Describe problems
that must be reported immediately (ie, pink-tinged
vaginal discharge, increased pelvic pressure, and
rupture of the membranes).
2. Maintain an environment to preserve the integrity of the
pregnancy.
a) Prepare for cervical cerclage, if appropriate.
b) Maintain activity restrictions as prescribed.
c) Discuss the need for vaginal rest (ie, no intercourse
or orgasm)
3. Prepare for the birth if membranes are ruptured.
4. Address emotional and psychosocial needs.
Nursing Process
NURSING ASSESSMENT
Objective Data:
Subjective Data: Light vaginal bleeding or
• Pelvic spotting
pressure • Ask the woman who is
reporting for painless
• Abdominal bleeding if she is feeling an
intense pressure on her
cramping pelvis.
(premenstrual- • Inspect and save pads used
like) by the woman during
bleeding to determine any
• Backache clots or tissues that already
passed out.
• Change in • Determine if the woman is
vaginal experiencing true
discharge contractions to prepare for
the birth of the fetus.
Nursing Diagnosis

Anxiety related to impending loss of

pregnancy as evidenced by
premature dilation of the cervix.
Nursing Plan

To maintain viable pregnancy: avoid

preterm delivery or miscarriage

To reduce anxiety.
 Nursing Interventions
• Determine any factors that further contribute to the
anxiety of the woman so it could be avoided.
• Monitor vital signs to determine any physical
responses of the patient that could affect her
condition.
• Convey empathy and establish a therapeutic
relationship to encourage client to express her
feelings.
• Provide accurate information about the situation to
help client back into reality.
• Administer analgesics as ordered by the doctor.
Evaluation
• Patient would appear relaxed and
report that anxiety has been reduced.
• Verbalize awareness of feelings of
anxiety.
• Enumerate ways to deal with anxiety.
• Use resources or support system
effectively.
References
Mayo Clinic. “Incompetent Cervix”. Accessed January 20, 2020.
https://www.mayoclinic.org/diseases-conditions/incompetent-cervix/symptoms-
causes/syc-20373836

Diagnostic Gynecologic and Obstetric Pathology. (2018) “Cervical

Incompetence”. Accessed January 20, 2020.
https://www.sciencedirect.com/topics/medicine-and-dentistry/cervical-
incompetence?fbclid=IwAR23f9ZRnTUmdeYf7g__LKD_sReER78O2aXr22Iow
Cw43cMIk4UNC4VTwO8

Belleza, Marianne RN. (2016) Nurse Labs. “Maternal and Newborn Nursing
Care Plan: Premature Dilation of the Cervix”. Accessed January 20, 2020.
https://nurseslabs.com/incompetent-cervix/

RN Pedia. “Incompetent Cervix Nursing Care Plan & Management”. Accessed

January 20, 2020. https://www.rnpedia.com/nursing-notes/maternal-and-child-
nursing-notes/incompetent-cervix/
Let’s Do Quiz!
1. The best time to treat premature cervical dilatation or
incompetent cervix is between ___ and ____ weeks of pregnancy
before the dilatation occurs. 2 points
A 12, 18
B 10,12
C 2, 3
D 18, 25

2. When does premature cervical dilatation occurs?

A. first trimester
B. second trimester
C. third trimester
D. during active labor
3. Check all that apply to incompetent cervix:
(Select all that apply) 2 points
A occurs in 2nd trimester
B dilatation is sometimes painless
C shortened cervical length
D minimal symptoms

4. Risk factors of incompetent cervix: (Select all

that apply) 2 points
A history of incompetent cervix
B anatomic abnormalities
C black woman
D damaged cervix
5. Restriction of activities and cervical cerclage are the
treatments for __________ .
A Abruptio Placenta
B Placenta Previa
C Incompetent Cervix
D H-mole

6. Which of the following is described as premature

separation of a normally implanted placenta during the
second half of pregnancy, usually with severe hemorrhage?
A Placenta previa
B Ectopic pregnancy
C Incompetent cervix
D Abruptio placentae

7. True or False. Premature cervical dilatation is also termed

as Incompetent cervix and/or cervical insufficiency.