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Rupture of the uterus. Are you at risk?
Thanks to the achievements of modern medicine, such a serious complication, like rupture of the uterus, occurs during labor is extremely rare. Nevertheless, such a probability should be kept in mind - both supporters of home births and women, wary of any surgical interventions and, contrary to medical indications, insisting that their baby is born through natural birth canals. Unfortunately, there are situations when only a timely operation can save the life of the mother and child. It is to such situations that the threat of rupture of the uterus.
Olga Ovchinnikova obstetrician-gynecologist doctor
Rupture of the uterus can occur in different situations. The most common of these are:
- discrepancy in the size of the fetus (most often it is the head that passes through the birth canals first) and the pelvis (in women with a narrow pelvis, transverse position of the fetus);
- extensor insertions of the fetal head (if the fetal head is normally born of the occiput - in this position it passes through its pelvic bones through its smallest size, then when the head is extended, for example, the face or forehead, the head movement along the birth canal is difficult) in combination with a large fetus, tumors small pelvis, preventing natural delivery;
- pathological changes in the uterine wall due to inflammatory processes, as well as a scar after cesarean section or surgery to remove nodes of uterine fibroids (meaning conservative myomectomy - an operation in which only the myomatous nodes are removed, and the uterus itself remains).
The risk of this serious complication is:
- in pregnant women with a history of obstetric anamnesis (these include women who gave birth 3 times or more or who had several abortions);
- in parturient women who are threatened by a mismatch between the fetal head and the pelvis of the mother (this may be with a large fetus, narrow pelvis, incorrect insertions of the fetal head, fetal hydrocephalus - hydrocephalus of the brain);
- in pregnant women with multiplicity, polyhydramnios, transverse position of the fetus;
- in parturient women with a weak or, on the contrary, an extremely strong labor activity;
- in pregnant women with scars on the uterus after a previous cesarean section, conservative myomectomy, perforation (disruption of the integrity) of the uterus during an induced abortion.
The peculiarities of uterine ruptures at the present stage include a decrease in the frequency of spontaneous uterine ruptures due to mechanical causes (gross trauma, illiterate obstetric intervention, inappropriate use of rhodostimulating agents). However, the role of uterine ruptures caused by scars on its wall has increased. This is associated with an increase in the frequency of cesarean section, a large number of abortions, often complicated by uterine perforation or the inflammatory process of the uterus, as well as an increase in the number of conservative-plastic operations in myoma (benign uterine tumor) in young women. With regard to the tactics of giving birth in pregnant women with a scar on the uterus after the previous cesarean section, it has long been believed that if a cesarean section was used at least once during labor, it should be used for all subsequent births. At present, obstetricians have abandoned this theory. The new approach is that natural births after cesarean section should become the norm. Practice shows that 50-80% of women who underwent this operation can subsequently give birth in a natural way. Even women who had more than one cesarean section, as well as those who wait for the twins, have a good chance of giving birth through the natural birth canal.
Whether a woman with a scar on the uterus can give birth herself depends on many factors. The location and consistency (strength) of the scar on the uterus is important. Thus, in the presence of a scar in the lower uterine segment after cesarean section and its consistency, in the absence of other contraindications to labor through natural birth canals, the chances of giving birth through natural birth canals are large enough. True, in this situation, childbirth is conducted under close monitoring control over the condition of the parturient woman and the fetus. If the scar on the uterus is corporal (ie, vertical) or if it is not well-founded, a second cesarean section is necessary. Also of great importance is the reason why the cesarean section was previously performed. If the probability of the occurrence of the causes that led to the previous operation is small, then the delivery through the natural birth can be permissible. For such reasons include acute hypoxia - cessation of oxygen to the fetus, premature placental abruption, placenta previa (the placenta is located directly above the exit from the uterine cavity). If the causes were chronic diseases (diabetes mellitus, arterial hypertension - increased blood pressure, heart disease), then, most likely, do not repeat cesarean section.
In any case, it is necessary to clarify the reason for the cesarean section in advance.
Distinguish the menacing, started and completed rupture of the uterus. These three components are consecutive links of one chain.
The threatening gap can proceed in different ways, depending on its mechanism. With a spatial discrepancy between the size of the fetus and the pelvis against the background of turbulent labor after the outflow of amniotic fluid, signs of overstretch of the lower uterine segment appear: the uterus extends in length, the contraction ring-the place of the transition of the cervix to the uterine body-is high (at the navel) and oblique; if you look at the belly, the contours of the uterus resemble an hourglass. When palpation (probing) of the lower uterine segment, tension and soreness are determined. The fruit is almost entirely located in the overstretched lower segment of the uterus. The lying-in woman is restless, rushes, screams, tries to push with the highly positioned part of the fetus. In this state, intrauterine asphyxia (lack of oxygen) of the fetus quickly occurs.
The threatening rupture of the uterus, caused by pathological changes in the uterine wall (inflammatory and others), is diagnosed more difficult. Generic activity in this case is weak, contractions are painful, despite the absence of regular labor. Despite the fact that the head of the fetus is still high, attempts begin. For a threatening rupture of the uterus, the scar is characterized by the thinning and soreness of the scar in the area of the emerging rupture. Of great importance for diagnosis is the presence of inflammatory complications after the previous operation.
The beginning of the rupture of the uterus is characterized by symptoms of a threatening rupture with the addition of signs indicating an obstruction of the uterine wall: the appearance of bloody discharge from the vagina, an admixture of blood in the urine, fetal asphyxia.
A ruptured uterus usually does not cause difficulties in diagnosis. At the moment of rupture, the maternity patient feels severe pain in the abdomen, labor activity stops, signs of shock appear. The fetus quickly dies in utero (if it is still possible to save a baby with a threatening and beginning rupture of the uterus, then this does not seem to be realistic with a broken rupture), flatulence (bloating), blood is released from the vagina. When the fetus passes into the abdominal cavity, the abdomen becomes irregular in shape, the small parts of the fetus are clearly palpable through the anterior abdominal wall.
In case of threatening and started rupture of the uterus, the labor activity is immediately stopped with the help of deep anesthesia. Then the operation is performed. At the same time, measures are being taken to combat shock; for this, the woman is intravenously injected with blood and blood substitutes, medicines. The extent of surgical intervention depends on the duration of the rupture, signs of infection, the condition of the torn uterine tissue, and the localization of the rupture. Depending on the place of rupture and the degree of its severity, the integrity of the uterus is restored or the uterus is removed. If the gap was diagnosed in a timely manner, when signs of only a threatening rupture appeared, then it is possible to preserve the organ, and in the future the woman will be able to take the baby out again. In this case, the fetus, as a rule, does not die, but to save his life may need resuscitation. If the rupture of the uterus has occurred and there was a severe bleeding, the uterus must be removed.
In order to prevent such a serious complication as rupture of the uterus, all women with a history of obstetrical anamnesis (caesarean section, removal of myomatous nodes, perforation of the uterus during the abortion), as well as pregnant women with a narrow pelvis, improper fetal position, large fetuses other pathologies, dangerous in relation to the rupture of the uterus, in women's consultations take on a special account and are hospitalized 2 weeks before the birth.