M’C DONALD’S OPERATION

M’C DONALD’S OPERATION

It is known by different names like as tightening, cervical suture, cervical encirclage, nylon wiring.

Indication

1.     Incompetent cervical os.

2.     Prophylatically in cases with history of repeated second trimester abortions or history of premature labours with obvious case.

3.     Twin pregnancy to prevent preterm labour. Not scientifically proved.

      Time of operation

During pregnancy around 12-14 weeks is ideal time. It can be done as early as 10 weeks and is indicated cases up to as late as 32 weeks. Reasons for doing operation at 14 weeks

a.      After 14 weeks risk of abortion increases as the time passes.

b.     Before 14 weeks i.e in first trimester the abortion is commonly due to defect in the fertilized ovum or defect in the placenta.

c.      Even in proved cases there is very little risk of abortion before 14 weeks because only at the end of 12 weeks uterine cavity is completely filled up by the growing fetus so as to exert strain on the cervix at internal os.

Anaesthesia

It is performed under short GA ( IV/ pentothal). It can be performed in local anaesthesia and sedation. Pre anaesthetic medication in the form of Inj. Atropine 0.6 mg. Half an hour before operation is given.

Steps of operation

¨     Emptying of bladder. Lithotomy position. Painting and drapping.

¨     Anaesthesia is given. Per vaginal examination is done.

¨     Per speculum examination is done to see that there is no bleeding or leaking or herniation of membranes.

¨     Cervix is swabbed with dry sterile swabs.

¨     Anterior and posterior lips are held with swab holders. Instead 4 allis forceps are commonly used as they give better grip.

¨     Double strands of No.2 braided silk on round body half circle curved needle is used for suture. Persestring suture is taken as high as possible on the cervix without incising the epithelium. Suture is started anteriorly and minimum 4 bites are taken i.e at 1-2, 10-11, 7-8 and 4-5’O clock position anticlockwise. Bites should be deep in the cervical substance but avoiding endocervix.

¨     Post operative treatment: patient is kept in the hospital for 1 to 2 days. Antibiotics uterine relaxants and sedatives are given. P/S examination is done before discharge.

¨     Patient is adviced for weekly antenatal check up and should report immediately if she develops pains, bleeding p/v or leaking.

Removal of stitch

Suture is removed in 38^th week. But if the patient is not sure of her LMP it may be removed immediately after the onset of labour.

Long ends of the ligature are caught with an artery forceps and ligature is cut with the scissors beyond the knot close to the cervix and then pulled out.

Contraindications

Ø  Local infection

Ø  Bleeding p/v rupture of membrane

Ø  Irritable tissues

Ø  Cervical dilatation more than 3cm

Ø  Intrauterine fetal death

Ø  Fetal abnormalities

Ø  Suspected intrauterine infection

Complication

« Bleeding

« Accidental injury to membranes leading to rupture or ascending infection (amnionitis) or abortion

« During labour cervical dystocia (due to fibrosis)

« Cervical tears or rarely rupture uterus if stitch is not removed immediately after labour pains have started.