Rus Articles Journal

“The aggravating circumstance“. Childbirth with a hem on a uterus of

Now the hem on a uterus even more often becomes the satellite of pregnancy. How this circumstance can affect the course of pregnancy and the result of childbirth? Whether childbirth is possible in the natural way at the woman with a hem on a uterus or Cesarean section is inevitable?

the Hem on a uterus can be a consequence:

the hem Solvency on a uterus

with a hem on a uterus is important For the course of pregnancy and the forecast of the forthcoming childbirth nature of healing of a hem. Depending on extent of healing the hem can be considered full, or well-founded, and defective, or insolvent.

Well-founded the hem in which there was a complete recovery of muscle fibers after surgery is considered. Such hem is capable to stretch with increase in term of pregnancy and growth of a uterus, it is elastic and capable to reduction during fights. If in a hem the amount of connecting fabric prevails, then such hem will be considered defective as connecting fabric is not capable to stretch and be reduced as muscular tissue can do it.

So, the following factors exert impact to

on extent of restoration of a hem on a uterus:

  1. the Type of surgery after which this hem was created. If the hem is created after operation of Cesarean section, then the pregnant woman needs to know what section performed operation. Usually at the full-term term and operation in a planned order the section is made in the cross direction in the lower uterine segment. In that case conditions for formation of a full-fledged hem capable “to sustain pregnancy and childbirth“, are more favorable than if the section of a uterus was made it is longitudinal. It is connected with the fact that muscle fibers in the place of a section settle down cross and after a section grow together better and heal than if the section was made not on the course of a muscular layer. The longitudinal section on a uterus is generally carried out in need of the emergency rodorazresheniye (at bleeding, a sharp hypoxia of a fruit (a hypoxia - shortage of oxygen), and also at the Cesarean section which is carried out in term till 28 weeks.
    the Hem on a uterus can be a consequence not only Cesarean section, but also a conservative miomektomiya, an ushivaniye of perforation of a uterus, and also removal of a uterine tube.
    If the woman before pregnancy had a myoma of a uterus and she transferred a conservative miomektomiya (removal of knots of a benign tumor - myoma with preservation of a uterus), then character of an arrangement of remote knots, surgery access, the fact of opening of a cavity of a uterus matters. Usually the myomas of the small sizes located on the outer side of a uterus are removed without opening of a cavity of the last. The hem after such operation will be created by more well-founded, than when opening a cavity of a uterus for removal of the intermuscular miomatozny knots located mezhmyshechno or between fibers a miometriya. If the hem on a uterus is formed at perforation of a uterus after artificial abortion, then the obstetric forecast is more favorable in case operation was limited only to an ushivaniye of a punched opening without additional section of a wall of a uterus.
  2. the Term of approach of pregnancy after the undergone operation. Extent of healing of a hem on a uterus also depends on the period which passed from the moment of operation. Any fabric requires time for restoration. Also - and with a uterus wall. It is established that restoration of functional full value of a muscular layer after surgery happens within 1 - 2 years after operation. Therefore the most optimum approach of pregnancy in the range from 1 - 2 years after operation is considered, but not later than 4 years as the long interval between childbirth leads to increase of connecting fabric in the field of a hem that reduces its elasticity. Therefore to the women who underwent uterus operations whether it be Cesarean section or a conservative miomektomiya, obstetricians - gynecologists recommend protection in the next 1 - 2 years.
  3. Current of the postoperative period and possible complications. Uterus tissue restoration process after operation also depends on features of a current of the postoperative period and possible complications. So, can be complications of operation of Cesarean section a postnatal endometritis - the inflammation of an internal cover of a uterus, subinvolution of a uterus (insufficient reduction of a uterus after the delivery), a delay of parts of an afterbirth in a uterus cavity with the subsequent vyskablivaniye complicates formation of a full-fledged hem.

Diagnostics of a condition of a hem on a uterus

to the Woman with a hem on a uterus needs to be examined regarding a hem solvency even before pregnancy to have full information on the forecast of a course of pregnancy and childbirth. Out of pregnancy the patients who underwent the operations connected with risk of formation of a defective hem need to estimate a hem solvency on a uterus. To such operations treat a conservative miomektomiya with opening of a cavity of a uterus, the Cesarean section executed by a longitudinal section on a uterus, operation on an ushivaniye of a punched opening on a uterus after abortion with opening of a cavity of a uterus. Inspection of a hem on a uterus is possible by means of a gisterosalpingografiya, a gisterografiya and ultrasonography. If pregnancy already came, then diagnostics of a condition of a hem is possible only by means of dynamic OUSE - researches.

Gisterosalpingografiya`s

is a x-ray inspection of a uterus and uterine tubes after introduction to a cavity of a uterus of contrast substance. At the same time the contrast substance (seen at x-ray inspection) is entered into a cavity of a uterus, then a number of x-ray pictures is carried out. By their result it is possible to judge a condition of an internal surface of a postoperative hem, to define situation, a shape of a cavity of a uterus and its deviation aside from the average line. At this method will point out sharply expressed uterus shift, its fixing to a forward wall, deformation inferiority of a hem, niches and roughness of contours of a hem. Owing to insufficient informational content this research is used rather seldom or as an additional method of research now.

by the Most informative tool method of research of a condition of a hem on a uterus is hysteroscopy - survey of a cavity of a uterus by means of the superthin optical device, the hysteroscope which is entered into a uterus cavity through a vagina.

hysteroscopy spend by

After operation in 8 - 12 months and on 4 - 5 - y day of a menstrual cycle. Now there are hysteroscopes of small diameter allowing to carry out this procedure in out-patient conditions and under local anesthesia. Pink color of a hem at hysteroscopy speaks about its full value and a solvency, he points to muscular tissue, and whitish inclusions, deformations in the field of a hem speak about its inferiority.

Complications after a conservative miomektomiya.

Also to adverse factors of formation of a postoperative hem are carried by the abortions and a scraping of a cavity of a uterus executed after earlier undergone operation, the uterus injuring a cavity. They considerably worsen the forecast of the forthcoming childbirth and increase risk of formation of a defective hem.

should Estimate a hem condition on a uterus usually during pregnancy by means of ultrasonography.

the Signs indicating inferiority of a hem are, for example, its roughness, intermittence of an external contour, thinning of a hem less than 3 - 3,5 mm.

of Feature of conducting childbirth

Several years ago many obstetricians - gynecologists for definition of tactics of childbirth were guided by the slogan:“ Cesarean section once - always Cesarean section“.

However now the opinion of experts changed. Cesarean section was and remains serious surgical manipulation after which there can be heavy complications. Despite the fulfilled techniques of an operational rodorazresheniye it is necessary to recognize that the risk of postoperative complications is much higher in comparison with the patients who gave rise in natural patrimonial ways. And process of restoration of an organism after vaginal childbirth takes place much quicker.

can be connected by

of Complication after operation both with actually surgical intervention, and with an anesthesia method. Danger of tromboembolichesky complications (during any operation there is a risk of formation of the blood clots capable to cause obstruction of vessels), heavy bleedings, damages of the next bodies and infectious complications is highest.

Considering it, in the last 10 years doctors make attempts to carry out childbirth at women with a hem on a uterus in natural patrimonial ways.

to

For the solution of a question of a rodorazresheniye method to all pregnant women with a hem on a uterus showed planned prenatal hospitalization in 37 - 38 weeks of pregnancy for carrying out full complex inspection. In a hospital the analysis of the obstetric anamnesis (quantity and the result of pregnancies), detection of associated diseases is carried out (for example, it is from outside warm - vascular, a bronchial tube - pulmonary system, etc.) OUSE - research, including an assessment of a postoperative hem is carried out, the fruit condition is estimated (a dopplerometriya - research of a blood-groove, a kardiotokografiya - research of warm activity of a fruit).

of the Indication to childbirth in natural patrimonial ways

Carrying out childbirth in the natural way perhaps at observance of the following conditions:

  1. the pregnant woman has only one well-founded hem on a uterus.
  2. the First operation was performed by
  3. according to “passing“ indications; so indications to operation which for the first time arose during the previous childbirth are called and optional can appear in the subsequent. Treat them:
    • a chronic pre-natal hypoxia of a fruit - insufficient intake of oxygen to a fruit during pregnancy. Such state can arise for various reasons, but not repeat at the following pregnancy;
    • weakness of patrimonial activity - insufficiently effective fights which do not lead to disclosure of a neck of a uterus;
    • pelvic prelying - the fruit is located the pelvic end to an exit from a uterus. Such provision of a fruit in itself is not the indication to operation, and serves as the reason for Cesarean section only in total with other indications and not necessarily repeats during the following pregnancy. Other wrong provisions of a fruit, for example cross situation (at the same time the child cannot spontaneously be born) can also not repeat during the following pregnancy;
    • large fruit (more than 4000 g);
    • premature birth (premature the childbirth happening earlier 36 - 37 - y weeks of pregnancy is considered);
    • the infectious diseases revealed in the previous pregnancy, in particular an exacerbation of a herpetic infection of genitals shortly before childbirth which served as the reason for Cesarean section at all not necessarily will arise before the following childbirth.
    At the woman in childbirth extract from maternity hospital the doctor is obliged to explain to the woman according to what indications Cesarean section was carried out. If indications to Cesarean section were connected only with features of the first pregnancy (an otsloyka or prelying of a placenta, clinically narrow basin, etc.) the second pregnancy quite can (and ideally - and has to) to end with natural childbirth.
  4. the First operation has to be made in the lower uterine segment by a cross-section. The postoperative period has to proceed without complications.
  5. the First child has to be healthy.
  6. This pregnancy has to proceed without complications.
  7. At the ultrasonic research conducted at the full-term pregnancy do not have signs of insolvency of a hem.
  8. . The estimated mass of a fruit should not exceed 3800 g

Spontaneous childbirth at pregnant women with a hem on a uterus has to take place in an obstetric hospital where the round-the-clock highly skilled surgical help is possible, there are anesteziologichesky and neonatal services. Childbirth is carried out at continuous cardiomonitoring. It means that directly in families of the pregnant woman special sensors connect. One of them registers sokratitelny activity of a uterus, fight, and another writes down fruit heart rate. Such control allows to find out a condition of the child at the time of delivery, and also force of fights. Natural childbirth at the woman with a hem on a uterus has to be carried out in such conditions that in case of threat of a rupture of a uterus or at a rupture of a uterus on a hem there was opportunity in due time, within the next minutes, to give surgical help.

during pregnancy the patient has to be hospitalized by

At suspicion on inferiority of a hem long before childbirth, in 34 - 35 weeks of pregnancy.

If any signs indicate

of the Indication to operation by

inferiority of a hem on a uterus, childbirth has to be quick - it is necessary to determine rodorazresheniye only terms depending on a condition of a fruit and mother.

Indications to repeated Cesarean section are:

  1. the Hem on a uterus after korporalny Cesarean section, or the operation executed by a longitudinal section on a uterus (in this case it has very high risk to be insolvent).
  2. the Hem after two and more operations.
  3. the Insolvency of a hem determined by the shown symptoms and data of ultrasonography.
  4. a placenta Arrangement in the field of a hem on a uterus. If the placenta settles down in the field of a postoperative hem, then its elements deeply take root into a muscular layer of a uterus that increases risk of a rupture of a uterus at its reduction and stretching.

If the woman with a hem on a uterus gave birth in natural patrimonial ways, obligatory action after the delivery is manual inspection of walls of a postnatal uterus for an exception of an incomplete rupture of a uterus on a hem. This operation is performed under an intravenous anesthesia. At the same time the doctor enters a hand in a sterile glove into a uterus cavity, carefully feels walls of a uterus and it is obligatory - area of a postoperative hem on a uterus. At detection of defect in the field of a hem if it partially or completely dispersed, in order to avoid intra belly bleeding urgent operation for an ushivaniye of area of a gap is required, life-endangering swear.

Possible complications

the Hem on a uterus can cause some complications during pregnancy. Most often there is a threat of interruption of pregnancy in different terms (occurs at every third pregnant woman with a hem on a uterus) and placentary insufficiency (i.e. receipt of insufficient amount of oxygen and nutrients through a placenta). Often such pathology arises at a placenta attachment in the field of a postoperative hem and develops owing to a placenta attachment not in the field of full-fledged muscular tissue, and in the field of the changed cicatricial fabric.

However the main danger threatens with

to the woman at the time of delivery and consists in a rupture of a uterus on a hem. The problem is that ruptures of a uterus in the presence rubtsand often proceed without the expressed symptoms.

by

Therefore at the time of delivery conduct a constant control of a condition of a hem. Experts determine it by a palpation method through a forward belly wall, that is probing of area of a hem. Despite fights, it has to remain equal, with a clear boundary and almost painless. Nature of bloody allocations in labor (them has to be a little) and complaints of the woman in labor to pains is important. Nausea, vomiting, pains in a navel, weakening of fights can be signs of the beginning of a rupture of a hem. For an objective assessment of a condition of a hem in labor use OUSE - research. And at the arising signs of its inferiority which first of all weakness of patrimonial activity or any other complications at the time of delivery is pass to a rodorazresheniye by operation of Cesarean section.

Thus, at the woman with a hem on a uterus spontaneous childbirth is admissible only at a hem solvency, a normal state of mother and a fruit, they have to be carried out in the large specialized centers where at any time will be able to give to the woman in labor highly skilled help.