Day #1—Consultation and Laminaria Placement

The morning appointment: The consultation

At your initial visit we will typically set aside a one-hour consultation in the morning. It’s important that you bring someone with you. Although no one is required to be there with you during your consultation we’ve found that another set of eyes and ears is often helpful. So hopefully you’ll be traveling with a trusted family member or close friend and you might feel comfortable having them accompany you through your initial consultation.

During your consultation I’ll review the medical information you’ve already provided. You will have already provided us with important and vital medical information so we’re not “starting from scratch.” After your consultation we’ll perform our own ultrasound examination and physical examination. This is always done by me since I’m the one who’ll be performing your surgery I won’t be relying on information from other reports or images from another technician. I often take measurements that are not “standard” ultrasound measurements—such as the thickness of your uterine walls specific and critical points. These measurement are important since they inform us precisely where we need to exercise great caution during your cervical preparation and surgical procedure.

Following your consultation and your ultrasound we’ll reassemble in my office and review your specific case and our particular approach for your surgery. This is very important. A textbook chapter or an article can provide generic information and “averages” but women want to know if their outcomes are expected to be “average,” “below average,” or “above average.” After we’ve reviewed your current information and findings I’ll be in a much better position to offer an opinion.

This is your time to ask all of your questions that haven’t been answered up to this point. Afterwards you’ll be asked to have a late breakfast or early lunch, if possible. You will be returning in the afternoon for our second appointment—preparing the cervix. I will ask you to not eat or drink for 4 hours before your afternoon appointment.

The afternoon appointment: Cervical Preparation and Laminaria Placement

You’ll be asked to return during the afternoon of first day— 2:30 PM appointments are typical. One of our staff will check your vital signs including a hematocrit (mini-“blood count”).

Although not everyone requires intravenous sedation for this part of the procedure most patients request it. If you would like to begin without it and see if you “need” it that’s okay—we often work with women who would like to avoid sedation, if possible. If you elect to have sedation we’ll insert an intravenous catheter and administer either fentanyl, midazolam or both (most women opt for both).

During this part of the procedure I will briefly repeat your ultrasound scan and insert a vaginal speculum. Following this an ultrasound probe is placed on your abdomen and the cervix is dilated and “stretches” the scar tissue that is often found in the lower portion of the uterus and upper reaches of the cervix. After dilation is accomplished—generally to 3 or 4 mm—a laminaria japonica–which is rolled up sea weed!—is inserted into the cervix and comes to rest just in the lower portion of the uterus. Once placed there the laminaria will absorb moisture over the next 12-24 hour and dilate your cervix to about 5-7 mm. This little bit of dilation is very important in most, but not all cases. Dilation is performed this way because it is slow and gentle on your cervix and prevents cervical tears during your surgery the following day. Here are some “highlights” about the “laminaria experience.”

  1. Most women find it uncomfortable and others find it painful—that’s why we offer intravenous sedation.
  2. The laminaria placement procedure takes 5 minutes.
  3. You will likely experience cramps if you are not receiving sedation.
  4. Those initial cramps last about 10-15 minutes.
  5. However, once those cramps disappear there will be other cramps that may begin 1-6 hour later as your cervix dilates.  
  6. Those secondary cramps can be mild to moderate—generally not severe.
  7. You will be given prescriptions for pain medication (as well as others) to manage those cramps.
  8. Take them.  Do not be “tough.”  Focus on getting sleep.
  9. That night will be the roughest part of your surgical ordeal in most cases.
  10. Do not eat solid food after midnight of the night prior to surgery if you have an 8:30 AM case.
  11. You may drink clear liquids up until 4 hours prior to your procedure.
  12. If your procedure is scheduled for 12:45 PM you may eat a light breakfast that ends before 8 AM.
  13. You should take your morning medications—especially if you have hypertension!
  14. If you feel that you need a medication to help you sleep the night prior to surgery don’t hesitate to ask!
  15. Try to arrive at our office—if possible—with a full bladder.  It will help you avoid catheterization.
Diagrams of Uterus prior to laminaria insertion and Uterus immediately following insertion of laminaria
Diagrams of Uterus prior just to laminaria removal (12 - 24 hours later) and Uterus immediately after laminaria removal