Many women of childbearing age who have a scar on the uterus are interested in several questions:
- How can this circumstance affect the course of pregnancy?
- Is it possible for a natural birth if there is a scar on the uterus or is the cesarean section inevitable?
- What is the outcome of labor with a scar on the uterus?
We will try to tell you about all the features of women who have such a defect.
The effect of the scar on the course of pregnancy and the upcoming birth
The degree of healing of the scar is of great importance, and depending on this circumstance, it is possible to build certain predictions:
- A solid (or full-fledged) scar is the one in which the complete restoration of muscle fibers occurred after the operation. Such a scar is elastic, able to stretch with increasing gestation and growth of the uterus, it is capable of contractions during labor.
- An inconsistent (or incomplete) scar is the one in which the connective tissue predominates, and it is unable to stretch and contract, like muscle tissue.
Because of what operation did the scar on the uterus appear?
Another aspect to consider is the type of surgical intervention, as a result of which operation a scar appeared on the uterus:
1. The scar after cesarean section can be of 2 kinds:>
- the transverse is done in the lower uterine segment, in the planned order with full term pregnancy, and it is able to withstand both pregnancy and childbirth, since the muscle fibers are located transversely, and therefore it is better to integrate and heal after surgery;
- longitudinal - performed in case of emergency surgery, bleeding, hypoxia (lack of oxygen) of the fetus or at the time of 28 weeks of pregnancy.
2. If the scar appeared due to conservative myomectomy (the removal of nodes of a benign tumor - myoma with preservation of the uterus), the degree of its restoration depends on the nature of the location of the removed nodes, access to surgical intervention (the size of the scar), the very fact of the opening of the uterus. Most often, small fibroids are located on the outside of the genital organ and are removed without opening the uterus, so the scar after this operation will be more well-formed than when the body cavity is opened, when the intermuscular nodules located between the fibers of the myometrium or the intermuscular are removed .
3. The scar as a result of perforation of the uterus after an artificial abortion is also considered taking into account whether the operation was limited only by suturing the perforation (puncture) or else there was a dissection of the uterus.
The course of the postoperative period and the occurrence of possible complications
How the process of restoring the uterus tissue after the operation will be affected by the course of the postoperative period, the presence of possible postoperative complications.
So, for example, after cesarean section, there may be:
- subinvaluation of the uterus - insufficient organ reduction after delivery;
- delay parts of the afterbirth in the uterine cavity, which will require scraping;
- Postpartum endometritis is the inflammation of the inner lining of the uterus.
Complications after a conservative myomectomy can be:
- formation of a hematoma (blood accumulation);
Abortions and curettage of the uterine cavity, performed after the surgery, injure the uterine cavity and do not contribute to the normal formation of the scar. Moreover, they increase the risk of forming an inferior rumen.
All these complications will complicate the healing process of the scar.
The term of pregnancy after a previous operation
Any tissue, including the uterine wall, after the surgical intervention has been completed, it takes time to recover. This determines the degree of healing of the scar. For the uterus to restore the full functioning of the muscle layer, it takes 1-2 years, so the optimal timing of pregnancy after surgery - no earlier than 1, 5 years, but not later than 4 years later. The reason is that the more time passes between births, the more connective tissue builds up in the scar area, and this reduces its elasticity.
That's why women who have undergone surgery on the uterus (whether it's myomectomy or caesarean section) are recommended 1-2 years to be protected from the onset of pregnancy. And even before the planned conception it is necessary to be examined for the consistency of the scar: based on the results it will be possible to predict the course of pregnancy and the birth itself.
Examination of the scar on the uterus
Follow the scar on the uterus after the surgery is carried out using:
- ultrasound. With the onset of pregnancy, this is the only possible type of research. Signs indicating inferiority of the scar - its irregularity, intermittence of the outer contour, the thickness of the scar is less than 3-3, 5 mm.
- Hysterosalpingography - X-ray examination of the uterus and fallopian tubes after the introduction of a contrast medium into the uterine cavity. For this procedure, a special substance is injected into the uterine cavity, and then a series of X-rays are taken, which allow to judge the condition of the internal surface of the postoperative scar, its position, the shape of the uterus body and its deviation (aside) from the midline. With the help of this method, it is possible to detect the inferiority of the scar, which manifests itself in a sharp displacement of the uterus, its deformation, fixation to the anterior wall, and also the unevenness of the contours and the niche of the scar. However, this study does not provide enough information, and therefore is rarely and often used today as a method of additional examination.
- Hysteroscopy - carried out with the help of a hyperfine optical device hysteroscope, which is introduced into the uterine cavity through the vagina (the procedure is performed on an outpatient basis under local anesthesia). This is the most informative method of examining the condition of the scar on the uterus, which is carried out 8-12 months after the operation, on the 4th-5th day of the menstrual cycle. The usefulness of the scar is indicated by its pink color, indicative of muscle tissue. Deformations and whitish inclusions in the rumen area indicate its inferiority.
How can the presence of a scar on the uterus affect the course of pregnancy and affect delivery?
The presence of a scar on the uterus can affect the course of pregnancy, provoking some complications:
- the threat of termination of pregnancy at different times;
- placental insufficiency (lack of supply of fetus with oxygen and nutrients), it occurs when the placenta is attached to the rumen not to the full muscle tissue, but to the scar tissue.
But the main danger - rupture of the uterus on the scar - threatens a woman during childbirth. The problem is that the rupture of the uterus in the presence of a scar often occurs without significant symptoms, and therefore, during the delivery, continuous monitoring of the scar's condition is necessary. This is determined by the method of palpation (probing) of the scar area through the anterior abdominal wall. Even during fights, he should remain flat, with clear boundaries and almost painless. At the same time pay special attention to spotting during labor (there should be a little) and complaints of the mother in pain on pain.
Weakening fights, pain in the navel, nausea and vomiting - this may be a sign of the beginning of a rupture of the scar. Objectively assess the condition of the scar at the time of delivery will help ultrasound. If there are signs of inferiority (and first of all it is a weak labor activity, then any complications during childbirth), the delivery is performed by a cesarean section.
Births in women with a scar on the uterus
Still some 10 years ago, all the women who once gave birth by Caesarean section, in subsequent births were automatically sent to cesarean. This is a serious surgical procedure, after which serious complications may occur, and the recovery of a woman after surgery is much slower than after a natural (vaginal) birth.
Complications after cesarean section could arise both because of the most surgical intervention, and be a consequence of the chosen method of anesthesia. Among them:
- thromboembolism - the formation of thrombi, which can cause blockage of blood vessels;
- severe bleeding;
- damage to neighboring organs;
- infectious complications.
However, medicine does not stand still, and in recent years, women with a scar on the uterus after a planned prenatal hospitalization at 37-38 weeks of pregnancy and conducting a comprehensive examination (in the absence of contraindications) are trying to send for delivery through natural ways.
The examination implies:
- obstetric history: the number and outcomes of pregnancies that preceded the present;
- identification of concomitant diseases (special attention is paid to the cardiovascular, bronchopulmonary system);
- Ultrasound examination with evaluation of postoperative cicatrix;
- evaluation of the fetus - the study of its blood flow (dopplerometry), cardiac activity (cardiotocography).
Births through natural birthmarks
Conducting births naturally is possible if the following conditions are met:
1. There is only one well-founded scar on the uterus.
2. The first operation was carried out according to the relative indications (indications that may not appear in the given births), which must be reported at the discharge from the hospital:
- chronic intrauterine fetal hypoxia;
- weak generic activity;
- the pelvic or transverse position of the fetus;
- a large fruit (more than 4 kg);
- premature birth (earlier 36-37 weeks of pregnancy);
- Infectious diseases in a previous pregnancy, which were identified or aggravated shortly before birth (eg, genital herpes). / ul>
- longitudinal scar after cesarean section or surgery on the uterus;
- scar after 2 or more surgeries;
- the location of the placenta in the area of ??the scar on the uterus (this increases the risk of rupture of the uterus as it stretches and contracts).
If the indications for cesarean section were exclusively related to the characteristics of a previous pregnancy (for example, a clinically narrow pelvis, abruption or placenta previa), then the current pregnancy may (and should) end in a natural birth.
3. The first operation was performed in the lower uterine segment with a transverse incision, with a postoperative period without complications.
4. The first child is healthy.
5. This pregnancy was without complications.
6. According to the results of an ultrasound study conducted with a full-term pregnancy, there are no signs of a rumen insolvency.
7. Fetus is healthy with an estimated weight not exceeding 3, 8. kg
In pregnant women with a scar on the uterus spontaneous delivery should take place in the hospital, because there is possible, round the clock surgical care; constant cardio monitoring is performed (special devices with sensors that control the contractile activity of the uterus, the frequency of contractions, the heart rate of the fetus are connected to the pregnant woman), which makes it possible to monitor the force of contractions and the state of the child during childbirth; there is an anesthesia service and a neonatologist.
In a word, the natural delivery of women with a scar on the uterus should take place in such conditions that in the event of rupture of the scar or the emergence of a threat of rupture of the uterus in the next 15 minutes was provided with surgical care.
If suspected of rancidity, the patient is hospitalized at 34-35 weeks of gestation.
After the completion of natural labor, the walls of the postpartum uterus must be manually examined (under intravenous anesthesia) to exclude incomplete rupture of the uterus along the scar. In this case, the doctor inserts a hand in a sterile glove into the uterine cavity and carefully probes the walls of the organ (especially the area of ??the postoperative scar).
If during the examination a defect in the rumen area is found (he could partially or completely disperse), an urgent operation is performed to avoid intraabdominal bleeding that threatens the mother's life - the area of ??the rupture is sutured.
Indications for surgery
Births should be performed promptly if the study of the scar on the uterus indicates its inconsistency:
In this case, it remains only to determine the duration of the operation, which depends on the condition of the fetus and the mother.
Thus, in a woman with a scar on the uterus, births through natural birth can only be tolerated with the consistency of the scar, the normal state of the mother and the fetus. Labor should be carried out in specialized centers, where at any time the woman in labor can provide highly qualified assistance.