1ST CITY CLINICAL HOSPITAL

Natural birth after caesarean section - myth or reality?

The article was prepared by:

Assistant of the Department of Obstetrics and Gynecology BSMU Sushch E.L., doctor of the first category

Obstetrician-gynecologist (head) of the obstetric observation department of the 1st City Clinical Hospital Tereshko E.V., doctor of the highest category

Childbirth with a scar on the uterus, or natural childbirth after surgery, is a phenomenon that is becoming increasingly important among specialists and is increasingly in demand among modern women. Just 10 years ago, there was a firm rule in medicine: once a caesarean section, always a caesarean section. Fortunately, today doctors, using modern advances in medicine, can give a woman the happiness of natural motherhood by giving birth to children through the natural birth canal.

It should be remembered that not every birth after a cesarean section can be natural. The decision is always made individually, based on a thorough analysis of the obstetric-gynecological and general somatic situation, assessment of risk factors, subject to certain conditions and the absence of absolute medical contraindications to physiological childbirth, as well as the presence of advantages of independent birth of a child for the mother and fetus.

If you already have a child born by caesarean section, and you are planning to become a mother again, you should think about whether you are ready and want to give birth to a baby on your own. In some cases this is quite possible and safe. During a consultation with an obstetrician-gynecologist, you can always discuss in as much detail as possible all the possibilities of natural childbirth for you, evaluate the information received and, together with the doctor, make the best decision.

Caesarean section, like any surgical procedure, has a high risk of complications and adverse consequences for women's health and life. Natural childbirth with a uterine scar is often a real opportunity to avoid these risks, as well as to live independently with the child every second of his birth, which is sometimes especially valuable for mothers who have never experienced this.

If you have already undergone surgical childbirth twice or more times, do not risk your health and the well-being of your family, be extremely attentive to pregnancy planning, only after an expert assessment of the condition of the uterus and scars, and when a long-awaited pregnancy occurs, be sure to be under the close attention of experienced doctors. A healthy mother is the main value for her children and the whole family.

Let's discuss the need for certain conditions to fulfill the dream of having a child through the natural birth canal:

1-body of the uterus, 2-lower segment, 3-contraction ring, 4-vagina.

As a rule, a scar on the uterus forms after a cesarean section . To help the baby be born, surgeons make an incision on the front wall of the uterus. After the baby is born, a surgical suture is placed on the incision, and after about 6 to 8 months it turns into a scar. Other reasons for the formation of a scar on the uterus may be a consequence of surgery on the uterus (removal of fibroids, for example).

You should not plan a new pregnancy if 2 years have not yet passed since the caesarean section. In such a short period of time, a full-fledged scar, as a rule, does not have time to form.

It is not recommended to delay planning for more than 5 years after surgical birth. The more time passes, the more muscle fibers in the rumen atrophy, which prevents it from stretching elastically under the load of the fetus. The nature of the healing of dissected tissue and the formation of a full-fledged scar on the uterus are also influenced by the technique and duration of the operation, the quality of the suture material, the amount of blood loss, etc.

The complete healing of the uterine wall is the basis for determining delivery tactics for subsequent pregnancies and childbirth. It is possible to suspect incomplete tissue regeneration during previous operations on the uterus with a careful history taking. The indications for the first cesarean section and the presence of extragenital pathology are important. A defective scar is formed in the presence of preeclampsia, placenta previa, premature placental abruption, obesity, anemia, and chronic infectious diseases. Overstretching of the lower uterine segment with clinical discrepancy, incorrect insertion of the fetal head, incoordination of labor, and cesarean section performed with full dilatation of the uterine pharynx are also unfavorable. It is necessary to know whether the caesarean section was performed planned (when the woman is fully examined and prepared for surgery) or emergency, how long the woman in labor was in labor (infection with an increase in the anhydrous interval and repeated vaginal examinations). It is important to know that a defective scar is formed during a minor caesarean section and during a corporal incision on the uterus.

The nature of the healing of dissected tissue and the formation of a full-fledged scar on the uterus are also influenced by the technique and duration of the operation, the quality of the suture material, and the amount of blood loss.

Assessment of criteria for the consistency of a uterine scar:

Clinical criteria (Pain in the lower abdomen, lower back, throughout the abdomen, in the area of ​​the scar on the anterior abdominal wall, of unclear localization should be interpreted as failure of the scar on the uterus and the threat of its rupture).

During pregnancy, the most reliable information about the condition of the uterine scar can be obtained by ultrasound. The optimal period for this is 28–37 weeks of gestation. Ultrasound allows you to evaluate the shape, thickness of the lower uterine segment, and the echostructure of the myometrium in this part of the uterus. It is important to determine the localization of the placenta using ultrasound, since its location in the area of ​​the scar on the anterior wall makes it potentially defective.

Ultrasound signs of scar failure:

Thinning of the area of ​​the suspected scar is less than 3 mm;

Heterogeneity of the tissues 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 suspected scar, placentation in the area of ​​the scar

Absolute contraindications to vaginal delivery:

• previous corporal cesarean section or “anchor” incision on the uterus;
• history of uterine rupture;
• location of the placenta in the area of ​​the uterine scar;
• 2 or more scars on the uterus (we strongly recommend that women with two scars on the uterus be very careful when planning their next pregnancy and contact experienced obstetricians-gynecologists to monitor the condition of the scar and the condition of the uterus);
• patient refusal;
• the presence of obstetric contraindications for vaginal delivery.

Physiological childbirth with one scar on the uterus is now ready to be accepted in almost every maternity hospital in the capital. But since such a birth is associated with certain risks, the woman in labor will receive special attention from doctors.

If you have a scar on the uterus at 38-39 weeks of pregnancy, your doctor at the antenatal clinic will refer you to hospitalization to draw up a delivery plan.

The obstetric departments of the 1st City Clinical Hospital in Minsk have all the necessary medical and technological resources to provide the mother and fetus with emergency, including high-tech medical care if complications arise during natural childbirth after surgery.

Anesthesia and the absence of obstetric aggression are prerequisites in the management of such childbirth.

In our practice, there are frequent cases when patients come to us with one scar on the uterus, as well as those who have already undergone two, and sometimes three operations, and have the intention of giving birth on their own. In the first case, we carefully evaluate all risk factors, indications and contraindications for natural childbirth; in all others, spontaneous childbirth is contraindicated, because the risk is unreasonably high and in this situation we openly tell the woman that her already born children need a living and healthy mother.

Over the past two years (2020/2021), 83 children were born through the vaginal birth canal from mothers with a uterine scar in the maternity wards of the 1st City Clinical Hospital in Minsk.

We welcome a woman's informed decision to give birth herself, as long as it meets the safety standards for mother and child.