Anesthesia for Transvaginal Cervical Cerclage
Maria Borrelli, DO
Cecilia Uong, MD
Yunping Li, MD
Issue 3 | Volume 2 | August 2026
KEY TAKEAWAYS
- Spinal anesthesia is preferred over general anesthesia for transvaginal cervical cerclage in pregnant patients; reported failure rates range from <1% to 17%.
- A standardized institutional guideline for anesthetic and spinal medication dosing was developed to reduce variability and optimize safety.
- Intrathecal hyperbaric bupivacaine 0.75% (1–1.2 mL) with fentanyl 15–25 mcg is the recommended spinal regimen to achieve the sacral coverage cerclage requires.
- Left uterine displacement is required at ≥18 weeks gestation, and phenylephrine is recommended firstline for spinal-induced hypotension.
Background
Spinal anesthesia is the preferred anesthetic for transvaginal cervical cerclage due to risks associated with general anesthesia in the pregnant patient. The rate of spinal failure varies from <1% to as high as 17%1,2. This may be due to procedural experience, different medications/doses, as well as patient characteristics.3 While this is typically a scheduled ambulatory procedure, it may need to be performed more urgently (during off hours). At Beth Israel Deaconess Medical Center, cervical cerclage is performed in the main operating room and parturients may be managed by any anesthesia provider. Important to note, we found significant variability in the choice of anesthesia and spinal medication dosing for cerclages performed at our institution. We developed a comprehensive and standardized guideline for anesthetic management of cervical cerclage to help ensure patient safety, optimize clinical outcomes, and minimize complications associated with anesthesia administration.
Preoperative Assessment
A thorough preoperative assessment is essential before anesthetic management. This should include review of the pre-surgical evaluation as well as any obstetric and/or maternal-fetal medicine consultations. Patients should also be evaluated for factors that may complicate neuraxial anesthesia: history of spinal surgery, scoliosis, obesity, or previous difficult neuraxial placements. In addition, laboratory results and anticoagulation status should also be reviewed to ensure that neuraxial anesthesia can be performed safely.
Patient Preparation
Patient preparation includes obtaining standard informed consent and establishing intravenous access. Patients should be counseled on what to expect during the procedure, including the anesthetic plan, positioning, anticipated sensations, and postoperative recovery. Aspiration prophylaxis should be administered with a non-particulate antacid and/or famotidine to reduce the risk of aspiration. Midazolam is not contraindicated during pregnancy and may be administered in small doses (1–2 mg) for pre-procedure anxiolysis when clinically indicated. A pre-procedure fetal heart tracing (FHT) should be documented to establish fetal well-being before surgery. Intravenous acetaminophen (1 g) may also be administered as part of a multimodal analgesic strategy.
Intraoperative Anesthetic Management
In the operating room, standard ASA monitors should be applied before neuraxial placement, and laboratory results/anticoagulation status should be re-confirmed prior to procedure start. We recommend using the smallest feasible non-cutting (atraumatic) spinal needle (e.g., 25-gauge Sprotte needle) to reduce the risk of post-dural puncture headache. Intravenous fluid co-loading should also be initiated during spinal placement to help minimize spinal-induced hypotension. In cases of technical difficulty, neuraxial ultrasound may be utilized, and assistance should be requested early.
Cerclage surgery requires sacral coverage, so an intrathecal hyperbaric solution is the ideal choice — bupivacaine 0.75% in dextrose 8.25% (preservative-free), 1–1.2 mL. We also recommend intrathecal fentanyl 15–25 mcg for improved analgesia (particularly for visceral pain) and increased duration of block. Intrathecal chloroprocaine 2% (preservative-free) may also be considered, which may provide shorter block duration and potentially shorter PACU discharge time; however, there is less data on its safety and effectiveness intrathecally. After spinal administration, the patient should remain seated (approximately 2 minutes) to achieve an adequate saddle block.
Left uterine displacement is required if gestational age is >18 weeks (or the uterus is at the level of the umbilicus). It is important to maintain physiologic pregnancy homeostasis, specifically normotension, to preserve placental blood flow; we recommend phenylephrine as the first-line vasopressor for hypotension. If the patient requires sedation, midazolam or propofol may be administered in small doses with close monitoring of oxygenation, ventilation, and blood pressure. If a propofol infusion is required, we recommend a low-dose infusion (20–80 mcg/kg/ min), with priority given to avoiding deep sedation.
Postoperative Care
A postoperative fetal heart tracing (FHT) should be documented to establish fetal well-being after surgery. Patients usually have minimal pain but may benefit from acetaminophen (if not given pre-operatively).
| Category | Recommendation |
|---|---|
| Preparation | Apply ASA monitors; re-confirm labs and anticoagulation status before starting. |
| Needle and technique | Smallest atraumatic needle (e.g. 25 G Sprotte). Use ultrasound and call for help early if difficult. |
| Fluids | IV co-loading during spinal placement to limit hypotension. |
| Intrathecal drug | Bupivacaine 0.75% in dextrose 0.25% (PF), 1-1.2 mL, for sacral coverage. |
| Adjunct | Fentanyl 15-25 mcg for analgesia and longer block duration. |
| Alternative | Chloroprocaine 2% (PF): shorter block, faster PACU discharge, less safety data. |
| Positioning | Sit upright ~ 2 min for saddle block; left uterine displacement if GA > 18 weeks. |
| Hemodynamics | Maintain normotension for placental flow; phenylephrine first line. |
| Sedation | Small-dose midazolam/propofol with close monitoring; if infusion, 20-80 mcg/kg/min, avoid deep sedation. |
REFERENCES
- Harten JM, Boyne I, Hannah P, Varveris D, Brown A. Effects of a height and weight adjusted dose of local anaesthetic for spinal anaesthesia for elective Caesarean section. Anaesthesia. 2005 Apr;60(4):348-53.
- Levy JH, Islas JA, Ghia JN, Turnbull C. A retrospective study of the incidence and causes of failed spinal anesthetics in a university hospital. Anesth Analg. 1985 Jul;64(7):705-10.
- Fettes PD, Jansson JR, Wildsmith JA. Failed spinal anaesthesia: mechanisms, management, and prevention. Br J Anaesth. 2009 Jun;102(6):739-48.
- Li Y, Shainker SA. Cerclage. In: Hess PE, Li Y, Kowalczyk JJ, Stiles JK, eds. Obstetric Anesthesia Quick References & Practical Guides. New York: McGraw Hill; 2023:101-102.