Treatment for premature birth/cervical incompetence

Most preterm babies arrive early without warning. However, some pregnancies are known to be at risk of ending in preterm birth.

Being told you are at risk of premature birth can be very worrying, but there are ways to manage the risk and to prolong your pregnancy. Preventing preterm birth is important because it gives your baby more time to develop in the womb so that they are fully ready for life outside the womb. On this page we have put treatment for premature birth together with treatment for cervical incompetence because these terms are often used to mean the same thing. 

Monitoring – also known as the ‘wait and see’ approach.

This may be used if you are at risk of premature birth and should involve monitoring via transvaginal ultrasound to check the cervix for shortening (in length) or funnelling (where the cervix begins to open from the top (baby end) down) every two weeks from 14-28 weeks to ensure there is no change. Funnelling and shortening are signs that you may need treatment to prolong your pregnancy.

This is an important part of caring for women at high risk of preterm birth. Regular contact with a consultant can provide important reassurance. If a problem does develop, it will be picked up early.


Progesterone is a hormone that is known to be important in preventing contractions and in supporting a pregnancy to full term. However, there is mixed evidence on the use of progesterone supplements to prevent cervical shortening but it may be recommended by your consultant as well as or instead of a cervical stitch. Progesterone is given as either daily pessaries or weekly injections. These can be started in the second trimester or earlier. Pessaries are more commnly used and can be inserted vaginally or rectally until around 34 to 36 weeks. You will need to visit your local hospital or GP practice if you have progesterone injections.

Arabin Pessary

Diagram showing placement of Arabin Pessary

The Arabin Pessary is gaining popularity in the UK. Doctors in the Netherlands and Spain have considerable experience with using it to reduce the chance of premature delivery. It is a soft silicon ring that is inserted into the vagina by your obstetrician and moved into place so that the cervix sits inside it (see pic). Research is being carried out currently by Tommy's to see how effective this pessary is at preventing preterm birth in the UK, and as yet is not used in all hospitals.

The transvaginal cervical stitch/cerclage (TVC)

If you have had one or more premature baby or late miscarriage/s, or have had cervical surgery in the past and your cervix is getting shorter in early pregnancy, you may be offered a cervical stitch (also known as a cerclage or cervical suture) with the aim of keeping your cervix closed during pregnancy. You may also be offered this if you have had a number of premature deliveries without cervical shortening.

There are two types of cervical stitch:

  • Transvaginal cerclage (TVC), also known as the vaginal stitch. It is inserted via the vagina during day surgery with spinal anaesthetic
  • Transabdominal cerclage (TAC), also known as the abdominal stitch (see below). It is inserted through the abdomen using keyhole surgery or open laparotomy.

A vaginal cervical stitch can be placed at the beginning of the second trimester (around 12-14 weeks), based on your previous pregnancy history (history-indicated stitch), or later in the second trimester in response to your cervix starting to shorten (an ultrasound indicated stitch). 
Current research has not clearly shown one approach is better than the other, therefore some women can avoid having unnecessary surgery if they have ultrasound monitoring and only have a stitch placed when their cervix starts to shorten.

If, on monitoring, your cervix is seen to be open and your membranes are coming down into the vagina, an emergency vaginal stitch may be attempted. It is not always possible to have a stitch placed in this situation, for example if there was evidence of infection or if you were having symptoms of labour. The benefits and risks would need to be discussed carefully with you in this situation.

There are two different types of vaginal stitch:

  • Low vaginal stitch (sometimes called a McDonald Cerclage)
  • High vaginal stitch (sometimes called a Shirodkar cerclage or TVCIC – Transvaginal cervicoisthmic cerclage)

There is no exact positioning for these stitches. They will vary depending on your consultant.

It is difficult to put vaginal stitches into categories as each consultant’s technique and method can vary greatly. The experience of the surgeon will affect exactly how high a stitch is placed. The higher the stitch is placed within the cervix, the lower the risk of preterm delivery . However, exactly which type of stitch is best often depends on your personal situation, for example whether you have had cervical surgery to remove some of the vaginal portion of your cervix. All of these details can be discussed with your consultant prior to stitch insertion.

How is the vaginal cervical stitch put in place?

Both of these stitches are put in under regional anaesthetic, such as a spinal block, which means you are awake but can't feel anything. Usually you go home the same day.

After the operation you may have some mild cramps similar to period pains, and you may have bleeding and spotting for a few days. Both of these should settle after two to three days.

You may or may not be given medication to stop contractions and calm your womb and/or antibiotics. There is no strong evidence to suggest these drugs reduce the chance of early delivery of your baby.

When should I not have a vaginal cervical stitch?

A stitch may not be the best thing for you if you have any of the following:

When is the vaginal cervical stitch removed?

If you have a vaginal stitch placed, it is usually removed at around 37 weeks so you can give birth naturally. It is rare to go into labour as soon as the stitch is removed and your pregnancy may continue for weeks afterwards. However, if you do go into labour before 37 weeks and it cannot be stopped, the stitch will be removed to prevent cervical tearing.

If you have any contraction-like pains with a stitch in place, you should go to your local maternity unit as soon as possible for checks.

How effective is the vaginal cervical stitch?

The research into how well a vaginal stitch stops preterm birth is still inconclusive, but so far it has shown that women who have a stitch carry their babies for longer than those who do not . It is thought to reduce the risk of early delivery by between 30-50% .

In a small number of women, however, the vaginal cerclage does not prevent the waters from breaking and in this case various options will be discussed with you. It may be necessary to remove your stitch to prevent an infection developing inside the womb, which may put your own health in danger, as well as that of your baby.

Diagram showing position of vaginal and abdominal cervical stitches (cerclage)

The transabdominal cervical stitch – TAC

This type of stitch involves abdominal surgery, which allows the stitch to be placed at the very top of the cervix. It is offered to women who have little to no cervix within the vagina to stitch or those who have previously been unable to carry a baby to a healthy point of pregnancy, even when they received a vaginal cervical stitch. Current experience suggests that many women who have previously lost a baby with a vaginal stitch in place were able to carry a normal full term pregnancy once an abdominal stitch was in place.

As this type of stitch is relatively new, it is only performed by a few obstetricians in the UK.

If you have had a failed transvaginal stitch, or know that you have very little cervical length to begin with, then ask to be referred to a transabdominal stitch specialist. A current list of specialists is available at the UK TAC Support group page on Facebook.

How is the abdominal cervical stitch placed?

The abdominal cervical stitch is preferably put in before you become pregnant but it can be placed during early pregnancy too. It is done either with a laparoscopy (where they make 3-4 small incisions in your abdomen and use a camera and long instruments to place the stitch) or an open laparotomy, which is a cut similar to a caesarean section cut.

If performed as an open procedure, this carries similar risks to a caesarean section.

Rare complications of the stitch can include infections or excessive bleeding . Ask your doctor to talk you through the risks.

Giving birth with a abdominal cervical stitch

If you have an abdominal stitch your baby will have to be delivered by caesarean section at around 38 weeks because the stitch cannot be safely removed during pregnancy to allow for a natural birth. It can however be left in place for further pregnancies as it does not prevent sperm getting into the womb or periods from happening as normal. IVF and IUI are also still possible.

What you can and cannot do during pregnancy with an abdominal cervical stitch.

This will very much depend on what treatment you have and the advice you’re given by your doctor. A very important part of monitoring during your pregnancy will be to reassure you that your pregnancy is progressing well. If the doctors or midwives have any concerns then, they will give you advice accordingly, this may be to reduce the amount you are working or to avoid certain activities. Your doctor may also advise you to refrain from sex if your cervix is short or your risk of early delivery has increased.

If at any point there is something you’re worried about then you should contact your doctor or midwife for advice.

The occlusion suture

An occlusion suture is sometimes used alongside a TVC or a TAC. It is placed at the very bottom of the cervix, at the tip, closing it completely. There is a theory that it could work to close the cervix completely to any bacteria and therefore prevents infection from getting into the womb, but an opposing viewpoint is that in itself it could create a breeding ground for infection. Research on the occlusion suture has not shown it to be effective.

Bed rest

Your doctor may recommend bed rest as part of your treatment. This has not been proven in research trials to be very effective but it is sometimes recommended as a safeguard. Bed rest can happen at home or in the hospital.

Warning signs of premature birth in pregnancy

Pregnancy for women at high-risk of premature birth can be a very anxious time. If you are worried about any signs or symptoms; then you should contact your midwife or hospital immediately. Here are some signs to look out for that could possibly indicate premature labour

  • an increase in pelvic pressure within the vagina or rectum
  • a change in your discharge, which may indicate a slow amniotic fluid leak or vaginal infection
  • bleeding or losing your mucus plug
  • period type pains in your abdomen or lower back. These may have a rhythm like contractions or be constant
  • your waters breaking (PPROM – preterm premature rupture of membranes)

What happens if the cervical stitch doesn’t work?

If you’re thought to be going into labour with a cervical stitch, there are a number of things that will need to be considered by your hospital. 
They may:

  • examine you to see if your cervix has shortened and dilated
  • perform a test called the fetal fibronectin test. This is a swab which checks for the presence of a protein within the vagina that has been found to be a predictor of labour. It is the glue that holds the amniotic sac to the walls of the womb. Finding it in the vagina is a good indicator of what is happening within the womb.

These two results will tell whether you are likely to go into labour within the next two weeks. Your doctor can then decide whether to administer steroids to help your baby’ lungs’ development if you’re far enough along in your pregnancy (minimum 23-24 weeks). Steroids are given over a 24 hours period in two injections. Timings are very important as they’re at their most effective if your baby is born within 24 hours to 7 days after administration of the second injection and multiple rounds are not advised .

If you’re at risk of imminent labour, you may be kept in hospital. You may have your bloods checked for signs of infection.

If you have a vaginal cervical stitch it will be removed to prevent cervical tearing. If you have an abdominal cervical stitch, you will need to have a caesarean section.

Read more about being at risk of premature birth

  • World Prematurity Day 2018

    The problem of premature birth in the UK needs to be addressed. Too many parents are currently enduring this anxious experience that can have a lasting impact.

  • Premature baby in hospital

    Causes of premature birth

    It's not always possible to explain the causes of preterm birth and why it happens. There are risk factors for being born early, such as infection, placental problems or genetic problems, but in many cases the cause is unknown.

  • Signs of premature labour

    Signs of premature labour

    The following symptoms before 37 weeks of pregnancy could indicate premature labour.

  • Premature baby in incubator.

    Gestational age and medical needs

    As soon as your premature baby is born, the healthcare team will decide what level of care they need.

  • Pregnant woman talking to midwife.

    Delaying a premature birth

    If it is established that you are in labour, your healthcare team will try to slow down labour or delay the birth until it is safe to continue.

  • Premature baby in incubator being touched by mother's hand.

    Giving birth to your premature baby

    Giving birth is one of the most life-changing experiences you'll ever have, but it doesn't always go as planned, especially when your baby is premature.

  • Healthy pregnant woman exercising.

    How you can reduce your risk of premature birth

    It's not easy for the healthcare team to discover why some babies are born prematurely, but there are steps that can be taken that can slightly reduce your risk of premature birth.

  • Pregnant woman talking to midwife.

    At risk of premature birth

    Being told you are at risk of premature birth can be shocking and distressing.

  • Premature baby.

    Premature birth - information and support

    A 'premature' or 'preterm' baby is one that is born before 37 weeks. If your baby is born early they may need special care as they may not be fully developed.

Read more about premature birth


  1. Conde-Agudelo A, Romero R, Nicolaides K et al. (2013) Vaginal Progesterone Versus Cervical Cerclage For The Prevention Of Preterm Birth In Women With A Sonographic Short Cervix, Singleton Gestation, And Previous Preterm Birth: A Systematic Review And Indirect Comparison Meta-Analysis. American journal of obstetrics and gynecology. 2013;208(1):42.e1-42.e18. doi:10.1016/j.ajog.2012.10.877.

  2. Conde-Agudelo A, Romero R. (2016) Vaginal progesterone to prevent preterm birth in pregnant women with a sonographic short cervix: clinical and public health implications. Am J Obstet Gynecol. 2016 Feb;214(2):235-42. doi: 10.1016/j.ajog.2015.09.102. Epub 2015 Oct 9.

  3. Goya M1, Pratcorona L, Merced C et al (2012) Cervical pessary in pregnant women with a short cervix (PECEP): an open-label randomised controlled trial Lancet. 2012 May 12;379(9828):1800-6. doi: 10.1016/S0140-6736(12)60030-0. Epub 2012 Apr 3.

  4. Cook JR, Chatfield S, Chandiramani M, Kindinger L, Cacciatore S, Sykes L, et al. (2017) Cerclage position, cervical length and preterm delivery in women undergoing ultrasound indicated cervical cerclage: A retrospective cohort study. PLoS ONE 12(6): e0178072.

  5. RCOG (2011) Cervical Cerclage. Green-top Guideline No. 60. Royal College of Obstetricians and Gynaecologists 
    Cockwell HA, Smith GN (2005) Cervical incompetence and the role of emergency cerclage. J Obstet Gynaecol Can. 2005 Feb;27(2):123-9

  6. Liddiard A, Bhattacharya S (2011) Elective and emergency cerclage and immediate pregnancy outcomes: a retrospective observational study JRSM Short Rep. Nov 2011; 2(11): 91.

  7. Cochrane Database Syst Rev (2017) Cervical stitch (cerclage) for preventing preterm birth in singleton pregnancy. Jun 6;6:CD008991. doi: 10.1002/14651858.CD008991.pub3.

  8. Personal communication, Professor Andrew Shennan, Professor of Obstetrics at King's College London
  9. UpToDate, Transabdominal cervical cerclage [accessed 13/06/2017, updated Apr 2017]

  10. NICE (2007) Laparoscopic cerclage for prevention of recurrent pregnancy loss due to cervical incompetence, National Institute for Health and Care Excellence, London

  11. Brix N, Secher N, McCormack C et al (2013) Randomised trial of cervical cerclage, with and without occlusion, for the prevention of preterm birth in women suspected for cervical insufficiency. BJOG 2013;120:613–620.

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    Last reviewed on April 1st, 2017. Next review date April 1st, 2020.

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    Please note that these comments are monitored but not answered by Tommy’s. Please call your GP or maternity unit if you have concerns about your health or your baby’s health.
    • By ramneet (not verified) on 5 Jan 2020 - 08:35

      I am 17 weeks pregnant and my cervix got open on first day of 17th week. my sac is comes out whenever i walk and do anything. My baby has moved down the cervix and sitting very close to the vagina. Doctors have no hopes fro this baby's servival. they are sure that i will have miscarriage soon. But I am still keeping my baby with a hope to take this pregnancy to almost 25 weeks so that the doctors could save my baby.

    • By Hope (not verified) on 4 Jan 2020 - 15:08

      I has 6 recurring miscarriages. With my 4th one I discovered I had auto immune condition (lupas) and fibroids. They appeared at 19 to 21 weeks all of them .. I am afraid to even try again ... no child and married but no happiness in the house because we all longing to have a baby.

    • By anonymous (not verified) on 1 Jan 2020 - 05:05

      ive had 9 miscarriages all up ive never been able to carry past 12 weeks, over the time of 9 years ive now had 2 surgeries done on my uterus and had an endometriosis removal, i am now currently 31 weeks pregnant, we had a scare at 19 weeks and i had a cervical stitch put in, i was on strict bed rest for 2 weeks and off work for 6 weeks im now back at work but taking life very easy, booked in for a c section and removal of the stitch at 37 weeks. please ladys keep all hope

    • By My name is bilhah (not verified) on 11 Dec 2019 - 17:24

      Please I need advice of what to do to stop fluid discharge, I am 21 weeks pregnant and I started experiencing fluid right from 19 weeks, I have gone to hospitals and nothing could be done, so I need a specialist advice.

    • By Midwife @Tommys on 16 Dec 2019 - 14:25

      It is quite normal to have increased vaginal discharge in pregnancy and is usually clear or milky but without a smell. This page may help

    • By kanayo (not verified) on 23 Nov 2019 - 06:14

      we have lost 4babies, the first 2 were early during 13th n 14th week and the remaining 2 we lost both of them at 24weeks, one was on 3apr18 and the last one on 17nov19. Water bag burst open and we have taken TVC in both pregnancies and infact during the 4th pregancy first tehy gave lower macdonald stitch and after 15days of bedrest they saw funneling is happening , so again they gave higher mac donald stitch then after 2 months of bed rest now in nov19, water bag burst open and premature delivery happened. her cervical length which was 1cm in Aug19, in oct it was 3.7cm and now in nov they found it to be 4.7cm. Dr is suggesting to take TAC before becoming pregnant next time , although we are not sure if we want to go through this trauma again. I want to know how successful is TAC and what are the chances of having a full term baby?

    • By Petro (not verified) on 26 Nov 2019 - 00:46

      Sorry for your loss. I’ve had two losses, 1st PPROM, 2nd McDonald Cerclage placed at 14wks then reenforce at 18wks which failed at 19wks.
      Got TAC placed 3/19 got pregnant with Twins (we were all shock) 7/19 now I’m 20wks funnel through the TAC and cervix shortening. Not sure if the TAC wasn’t placed properly or my cervix is just a mess.
      I suggest join Abbyloppers TAC group on Facebook they’re are great success with TAC

    • By Nonto Sithole (not verified) on 19 Oct 2019 - 02:57

      I had 2 second trimester miscariages the 1st one was at 16 weeks 2018 n this 2nd at 18 weeks Aug 2019 with a cervix stitch that was done on 13 weeks my water just broke in both miscarriages worse on the last one i had the stitch i really want to try again bt im scared what other options do i still hv after stitch has failed thank you

    • By Samantha (not verified) on 23 Jul 2019 - 12:36

      I had PCOS but I had my first miscarriage at 6 weeks , my second one at 8 week it’s ectopic pregnancy they remove my left tube. Luckily after a year I got my third pregnancy 18weeks , last week I lost my baby. I was devastated. Now I lost my hope also .

    • By Sally (not verified) on 18 Sep 2019 - 18:46

      I'm so sorry for your losses. For some who have recurrent early miscarriages it's because of an incorrect immune response and can be treated with steriods or other medications. This article might be helpful:
      It is also worth inquiring about incompetent cervix, though, considering the second trimester loss. But that is unlikely to be what caused the other two earlier losses.

    • By Millyvonie (not verified) on 9 Jul 2019 - 18:46

      I had 3 miscarriages before but last year i had vaginal stitch and it was a success it was removed at about 38 weeks and given birth normaly. This year was was pregnant again with twins and i had viganal stitch on wednesday on sunday i miscarried. Does this means the stitch does not work in multiple pregnancy. Please help

    • By Affy (not verified) on 6 Jul 2019 - 16:39

      I had my first miscarriage at 17weeks, secoind at 19weeks with a tvc, third at 19weeks 3day with a tvc, and the fourth pregnancy was IVf with a Tvc at 13 weeks, and I started taking Makena progesterone at 18 weeks once a week and at 20weeks 3days on the day for my third Makena shot my water broke. My due date was Nov17,2019. That has been the longest I have ever carry my baby. Is it that my uterus cannot stretch to enable me carry my baby to term? If so, what test can I undergo to help me determine the cause? Though my next appointment is on July 11. Help pls.

    • By Adu (not verified) on 29 Jun 2019 - 21:57

      I had preterm delivery in 5 month, lost baby, suddenly labour pain happens, membrane rupture, n in withhin 2 n half hour this thing suddenly happen before 2 days in morning... My cervix length was 4•2 then, what is the reason that this thing happened... N when should I try for next pregnancy n what precaution should be taken in next pregnancy

    • By Joyce (not verified) on 22 May 2019 - 08:01

      I have had 4 second trimester loses. The recent one was at 19weeks. I have had a tvc but still lost the pregnancy. I am currently 10weeks pregnancy and I'm confused whether or not to have a stitch. I need some advice please.

    • By Chidinma (not verified) on 16 May 2019 - 18:44

      I have had miscarriage twice this year. One in January 2019 and the other this may 2019. Am worried and confused. I was given progesterone yet it did not stop it. Pls advice me on what to do

    • By Shawn Garnett-W... (not verified) on 9 May 2019 - 14:49

      My daughter received the Arabian Pessary at 17 weeks. Her appt. yesterday was given news that her cervix lining is paper thin at 19 weeks. I'm curious as what can be done next to keep her twins in longer. She's due in September.

    • By Lily (not verified) on 4 May 2019 - 07:36

      I had a punch biopsy 4 weeks before I got pregnant . I’m having scan of my cervix at 20 weeks, I am worried that is too late to pick up if I have a weakened cervix from the bioosy? I am a very anxious person and this is making me worry a lot. Thank you

    • By Shannon Stewart (not verified) on 28 Apr 2019 - 02:53

      I had my first miscarriage at 16 weeks and my second and third at 18 weeks. I’m pregnant and received my TVC at 14 weeks. I started taking Makena Progesterone Auto injector at 17 weeks every week. I also take Bayer 81mg aspirin,Vitamins D 5,000 unit and my Prenatal Vitamins once a day. I’m currently 27 weeks pregnant and I must say it was the best decision my doctor’s and I made. I’m having a boy and he is 2 lbs and 6 ounces. The doctor’s say he is very healthy. I’m praying my pregnancy continues until 37 weeks when the doctor take out my stitch. I’m here to encourage women to consult with your doctor the pros and cons of getting TVC. TVC has worked for me no bedrest but I put myself on it. I’m a Home Health Aide and I stopped working full time at 14 weeks after TVC to Part time. I don’t do any heavy lifting, pulling or pushing. My son is due July 28th 2019.

    • By Evelyn Romero (not verified) on 5 Jul 2019 - 10:40

      I just want to thank you for sharing your story it gave me hope being able to carry baby at 27 weeks. I’ll be praying for you and hope you have a healthy baby. I’m almost at 19 weeks and I’m terrified of losing my baby, but I’m doing my best and staying positive.

    • By SHELEKA B (not verified) on 9 Oct 2019 - 20:54

      Thank you for sharing your story. It was very encouraging. I pray that I will be able to carry to term as well.

    • By Maha (not verified) on 3 Jan 2020 - 08:57

      Plz i also done my 19 week that time my lenath 2 but till my 22 week 5 day 1.8 what to do

    • By Ally (not verified) on 25 Apr 2019 - 18:15

      I'm 22 weeks pregnant got stitch a week now I'm really concerned can you give me some advice I'm having some cramps in the lower abdomen

    • By Louise (not verified) on 27 Aug 2019 - 12:00

      Hi, Ally, just saw this and I’m waiting to find out if I can get the stitch as I have bulging membrane and baby is working his way out. How did your experience go?

    • By Vanessa chin (not verified) on 31 Jan 2019 - 06:23

      I have multiple miscarriages I had to vaginal stitch And I still lose the baby the longer I ever carry a baby for a 15 weeks

    • By Midwife @Tommys on 31 Jan 2019 - 10:35

      Dear Vanessa - I'm so sorry to learn of your pregnancy losses. If you would like any support or advice, please feel free to contact us on our pregnancy helpline 08000147800 or email us at [email protected]
      Best Wishes
      Tommy's Midwife

    • By Anonymous (not verified) on 28 Apr 2016 - 10:34

      Very good,and informative.

    • By Anonymous (not verified) on 11 Nov 2017 - 09:21

      Very informative, thanks

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