Childbirth with a scar on the uterus

Authors of the article:

  • obstetrician-gynecologist (head) of the obstetric observational department of the 1st City Clinical Hospital Tereshko E.V., doctor of the highest category;
  • obstetrician-gynecologist of the obstetric observation department of the 1st City Clinical Hospital Veremeeva O.P., doctor of the first category;
  • intern doctor of the 1st City Clinical Hospital Pototskaya A.A. 

Childbirth with a uterine scar, or natural childbirth after surgical interventions (including after a previous cesarean section) is becoming increasingly important among obstetricians and gynecologists, and is increasingly in demand among women.

Today, in obstetrics, the previously so widespread firm rule “caesarean section once, cesarean section always” has been successfully refuted.

Currently, both around the world and in our country, considerable experience has been accumulated in managing childbirth with a uterine scar through the natural birth canal.

In women with spontaneous labor at full term, the favorable outcome of vaginal birth after a previous cesarean section is up to 75%.

However, when delivering vaginally to women with a uterine scar, it is necessary to evaluate both the benefits of independent childbirth for the mother and fetus, as well as the risk factors. Caesarean section, like any abdominal operation, has a certain risk of developing both intra- and postoperative complications and a longer recovery period.

The advantages of natural childbirth with a uterine scar are:

  • the ability to avoid repeated surgery,
  • lower risk of postpartum infectious, thromboembolic complications,
  • lower blood loss and lower risks of bleeding and blood transfusions,
  • lower risk of placentation disorders in subsequent pregnancies.

In addition, for a woman, such childbirth is an opportunity to experience maternal happiness from the process of natural childbirth and have a shorter recovery period.

The delivery plan, namely the possibility of a natural birth with a scar on the uterus, is discussed in as much detail as possible by an obstetrician-gynecologist individually with each woman (taking into account an assessment of her obstetric and gynecological history, concomitant diseases of the woman, the presence of certain conditions in the absence of absolute medical contraindications to physiological childbirth) , after which the optimal

Planning for vaginal delivery is possible under the following conditions:

  • the presence of one scar on the uterus in the lower segment or one scar in the body of the uterus after removal of the myomatous node without opening the uterine cavity

After a cesarean section, a scar is formed in the area of ​​the incision on the anterior wall of the uterus, and subsequently in the surgical suture, after 6-8 weeks.

Other reasons for the formation of a scar on the uterus may be conservative myomectomy, uterine perforation (abortion, hysteroscopy), a history of ectopic pregnancies, in the interstitial part of the fallopian tube, at the site of the rudimentary uterine horn, in the cervix after removal of a cervical pregnancy, reconstructive plastic surgery ( metroplasty, removal of the septum, rudimentary horn, etc.)

  • previous uterine surgery was performed at least 2 years ago

 It is believed that the most favorable interval for the next pregnancy after a previous operation is from 2 to 4 years, since it is during this period of time that the muscle tissue in the area of ​​the uterine scar is restored.

  • the postoperative period was without complications

In addition to the time factor, the morphological and functional consistency of the scar will also depend on the nature of healing. Infection of the uterine tissue interferes with the healing process and contributes to the formation of an inferior scar.

  • satisfactory condition of the mother and fetus, absence of other obstetric indications for surgery,
  • no signs of uterine scar failure,

The formation of a full-fledged scar on the uterus is influenced by the technique and duration of the operation, the quality of the suture material, the amount of blood loss, the presence of postoperative complications, incl. tissue infection, time from previous surgery.

To be able to give birth on your own, a mandatory condition is the presence of a wealthy (full) scar.

If there are signs of scar failure, the prognosis for natural childbirth is unfavorable: during pregnancy, the scar will become thinner, which will increase the risk of uterine rupture. In such a situation, delivery by elective caesarean section is indicated.

Criteria for failure (inferiority) of a uterine scar:

- clinical signs (pain in the area of ​​the postoperative scar, both during palpation of the anterior abdominal wall and during vaginal examination)

- ultrasound signs (thinning of the area of ​​the alleged scar less than 3 mm; heterogeneity of the tissue structure of the lower segment in the form of hyperechoic inclusions; crater-like thinning of the scar and sharp thinning of the lower segment of the uterus in the area of ​​the alleged scar, placentation directly in the area of ​​the scar).

During pregnancy, the optimal time to obtain information about the condition of the scar from ultrasound is 28–37 weeks of gestation. Ultrasound allows you to evaluate the shape, thickness of the lower uterine segment, the echostructure of the myometrium in this part of the uterus, and determine the localization of the placenta.

  • informing women

The mother's history of natural childbirth increases the likelihood of a successful natural birth after cesarean section.

In women with spontaneous labor at full term, a favorable outcome of vaginal birth after a previous cesarean section with a history of vaginal birth is up to 90%.

When is a caesarean section necessary?

  • With clinical symptoms of scar inferiority (failure),
  • If there are two or more scars (for example, 2 or more previous cesarean sections)
  • In the presence of one scar after cesarean section in combination with other conditions, aggravated by an obstetric history, myomectomy (with the exception of the submucosal location of the myomatous node and subserous on a thin base), a history of operations for uterine malformations
  • With a history of uterine rupture
  • If there is a scar in the body of the uterus (corporal cesarean section, or “anchor” incision on the uterus in the anamnesis)
  • When the placenta is located in the area of ​​the uterine scar;
  • If there are obstetric contraindications for vaginal delivery.
  • If the patient refuses to give birth through the birth canal.

Prenatal hospitalization to draw up a delivery plan is indicated at 38-39 weeks.

In the absence of conditions for vaginal delivery and (or) the presence of contraindications to them, delivery of women with a uterine scar by cesarean section is carried out as planned from 38 weeks.

Management of childbirth with a uterine scar

Vaginal birth in patients with a uterine scar is carried out in a qualified obstetrics facility. Childbirth in such women is carried out as physiological, observing the condition of the woman in labor and the fetus, the nature of labor, and the condition of the lower segment of the uterus.

However, in the event of abnormalities in labor (for example, weakness of labor), labor stimulation will not be performed (to avoid the risk of uterine rupture along the scar). Thus, the identification of deviations from the normal course of labor at any stage, as well as the occurrence of obstetric complications, are grounds for revising the birth plan in favor of a cesarean section.

The absence of obstetric aggression is a mandatory condition in the management of such births.

A history of cesarean section is also not a contraindication for the use of drug pain relief. In some cases, epidural anesthesia makes it possible to achieve a favorable psycho-emotional state of the woman in labor and better prepare the woman for natural childbirth.

In case of a favorable outcome of birth through the natural birth canal in the early postpartum period, it is necessary to perform a manual examination of the uterine cavity in order to exclude damage to its walls and assess the condition of the scar.

Repeated caesarean section: how will it happen?

The optimal time for planned delivery by cesarean section is 39 weeks of pregnancy.

If a woman gives birth again using a planned cesarean section, then, as with the first operation, she will be given a due date in advance, and may be advised to be hospitalized in the maternity hospital the day before in order to prepare for the operation. As a rule, the technique for performing a second operation will not differ from the first, although sometimes the operation itself may be more difficult and will take longer (for example, due to the fact that after a cesarean section (as after any abdominal operation) an adhesive process is often detected).

We welcome the conscious decision and desire of a woman to give birth on her own if she has a scar on the uterus and are ready to provide expectant mothers with qualified medical care. Our doctors will do everything possible to ensure that the birth of the long-awaited baby is physiological.

A healthy mother and child are the main value for obstetricians and gynecologists.

Successful birth and happy motherhood!