Births from A to Z
I give birth to myself? Natural delivery after cesarean section and other operations on the uterus
A few years ago it was believed that if a woman had previously had an operation on the uterus, then she will give birth only with the help of caesarean section. However, in the last ten years, more and more expectant mothers in such a situation have the opportunity to give birth naturally.
Ekaterina Svirskaya Obstetrician-gynecologist, Minsk
Even in the middle of the last century, cesarean section was an operation of desperation. Now - this is no longer a struggle for life, but a struggle to preserve the health of the mother and child. According to statistics, the cesarean section is 15% of all births in Russia. And the successes of gynecology allow conducting organ-saving operations for women with uterine myoma, with developmental defects of this organ and ectopic pregnancy. Naturally, the number of healthy women planning the next pregnancy after cesarean section and other operations on the uterus is increasing. But not always to a woman after cesarean section and other operations on the uterus, you can conduct births naturally. For this, it is necessary to take into account many factors, and first of all this is the type of surgical intervention, after which a scar on the uterus was formed.
Natural delivery after cesarean section
If the scar is formed after a caesarean section, it is important that the cut was made. For natural delivery it is necessary that the first operation be performed by a transverse incision. In this case, the muscle fibers are better fused and heal, such a scar is able to withstand the load of the next pregnancy and childbirth or, as doctors say, is "wealthy". Longitudinal incision on the uterus along the midline of the abdomen is currently used rarely, mainly if emergency delivery is needed. It is a contraindication for natural childbirth. The same applies to a situation where a woman has a scar after two or more operations on the uterus. After cesarean section, it is necessary to take into account those indications about which it was performed. It is clear that part of the testimony to the first Caesarean section will remain unchanged. This, for example, concerns the size and features of the structure of the pelvis of a woman or the presence of some chronic diseases (nearsightedness with changes on the fundus, heart defects, etc.). But some of the indications for operative delivery are not repeated in subsequent births. For example, it may be an incorrect position or hypoxia of the fetus, a weakness of labor. At the same time, natural births are planned only if the first child is healthy, and the present pregnancy proceeds without complications.
Natural labor after other operations on the uterus
If the scar on the uterus was formed as a result of removal of the nodes of myoma on the uterus (miomectomy) or reconstructive surgery for uterine defects (metaplasty), then the information about how the disease was going on and how it was treated will be decisive. Therefore, it is necessary to store a description of ultrasound before surgery, the course of the operation and the postoperative period.
Postoperative period of natural delivery
In addition to the type of operation, when planning for natural births, it is taken into account how the postoperative period progressed. So, after cesarean section there can be postpartum endometritis (inflammation of the inner shell of the uterus), insufficient uterine contraction after childbirth, delay of parts of the afterbirth in the uterine cavity with subsequent scraping. All this complicates the formation of a full-fledged scar. In order to after this give birth independently, the course of the postoperative period should be smooth, without signs of inflammation, in the scar area there should be no hematomas (blood accumulations), suppuration.
The condition of the scar on the uterus after natural delivery
For the course of pregnancy and the prognosis of the forthcoming delivery with a scar on the uterus, the character of the healing of the scar is of decisive importance. Depending on this, the scar can be considered full (or wealthy) and inferior (or insolvent). A rumen is considered worthy, in which there was a complete recovery of muscle fibers after surgery. This scar is able to stretch with the growth of the uterus during pregnancy, it is elastic and can contract during fights.
If the muscle tissue is replaced in the rumen by a connective tissue, then this scar will be considered insolvent, since the latter is not capable of stretching and contracting, like muscle. During pregnancy, the diagnosis of the condition of the scar is carried out using ultrasound.
Time to recover from natural labor in women with scars on the uterus
Complete restoration of functional full value of the muscular layer of the uterus after surgery occurs within 1-2 years after the operation. It is recommended to survive this interval, and if pregnancy occurs earlier, then a second cesarean section is planned.
Conditions necessary for natural delivery after operations on the uterus
Natural delivery in a woman with a scar on the uterus should be carried out in such conditions that in the event of a threat of rupture of the uterus or a rupture of the uterus along the scar, it was possible in time to provide surgical help in the next few minutes. Therefore, an obligatory condition is the availability of a prepared operating room and a sufficient number of qualified medical personnel. To solve the issue of the method of delivery to all pregnant women with a scar on the uterus, planned antenatal hospitalization at 37-38 weeks of pregnancy is shown for a full complex examination. It is necessary to use ultrasound, which helps to assess the consistency of the scar; the state of the fetus (natural birth plan only if the condition of the fetus does not cause fear); determine its position and presentation (necessarily longitudinal, head); calculate the estimated weight of the fetus - it should not exceed 3500 g, conduct a diagnosis of the placenta (there should not be multiple entrapment and visible nodes of the cord), etc.
How will natural birth take place in women with scars on the uterus?
Maintenance of the first period of labor
From the very beginning of childbirth, the future mother should be under the close supervision of doctors. To her immediately connect the sensors CTG for continuous monitoring of labor, measure blood pressure and pulse. Anesthesia in these patients is carried out according to generally accepted rules, including with the use of epidural anesthesia with good labor activity, which helps to relax the woman and smooth, gradual opening of the cervix. The most frequent complications of labor in women with a scar on the uterus are untimely outflow of amniotic fluid and weakness of labor. But the drug stimulation of labor in such cases is extremely rare, the appearance of weakness of labor is regarded as a threat of rupture of the uterus, which is an indication for the revision of the birth plan towards cesarean section. Emergency cesarean section is performed if there are any complications from the mother or baby. For example, if there are signs of fetal hypoxia, weakness of labor, bleeding, threatening rupture of the uterus. The main danger during labor is the rupture of the uterus along the scar. The problem is that this often occurs without severe symptoms. Therefore, during the birth, there is ongoing monitoring of the condition of the scar. Nausea, vomiting, dizziness, pain in the navel, weakening of the fights, spotting can be signs of the beginning of rupture of the rumen. If such symptoms are combined with changes in cardiac fetal activity and uterine activity on the CTG monitor - this is an indication for immediate surgery.
Maintenance of the second period of labor
Continuous monitor monitoring of the maternity and fetus status continues in the postpartum period of childbirth. Drugs are introduced to prevent bleeding after childbirth. It is prohibited to use obstetric aids such as obstetric forceps and pressure on the abdomen in order to speed up the progress of the baby. In order to ease the tardy period, a perineal incision is made (an episiotomy). Unfortunately, just as in the first stage of labor, there is a danger of a rupture of the uterus along the rumen, the only symptom of which will be signs of bleeding (spotting, falling blood pressure, increased heart rate, dizziness, weakness). Because of weakness, the separation of the offspring can also be delayed.
Immediately after childbirth, under intravenous anesthesia, a manual examination of the uterine cavity is performed to exclude the incomplete (not penetrating into the abdominal cavity) rupture of the uterus along the scar. In this case, the doctor enters his hand in a sterile glove into the uterine cavity, carefully probes its walls and the area of the postoperative scar. If a defect is found in the scar area, an urgent surgery is required to close the rupture to avoid intra-abdominal hemorrhage.
The woman continues to watch carefully for several days after delivery (very rarely the uterus rupture occurs after delivery). Before discharge from the hospital, a control ultrasound is performed to diagnose possible complications and scar condition. A number of studies confirm that up to 70% of women whose birth could have a cesarean section can naturally give birth to a second child. However, labor with the scar on the uterus is still a high-risk group, and therefore, when planning them, all carefully weigh and enlist the support of qualified personnel with the necessary modern equipment of the maternity hospital.