Rus Articles Journal

Rupture of a uterus on a hem: what it is necessary to know about a problem?

a Number of researches confirm that from 70 to 80% of women whose first labor ended with operation of Cesarean section can give birth to the second child in the natural way. In most cases natural childbirth after Caesarian is safer for mother and the child, than repeated operation. However, many women who are adjusted on natural childbirth after KS faced sharp criticism of such childbirth from obstetricians and doctors. Really, and now many physicians continue to consider that vaginal childbirth with a hem on a uterus is inadmissible as they seriously increase risk of a divergence of a hem. Let`s understand, whether so it actually?

Repeated childbirth with a hem on a uterus generally takes place

without special complications. Nevertheless, in of 1 - 2% from hundred such childbirth can end with a partial or full divergence of a seam. Other researches estimated probability of a rupture of a uterus at 0,5% provided that childbirth was not excited medicamentally. Also one of factors increasing risk of a gap, according to some information is the age of mother and too short interval between pregnancies.

a seam Divergence on a uterus at repeated childbirth - potentially dangerous state, both for mother, and for the child, also demands immediate surgical intervention. Fortunately, a rupture of a uterus if operation was made a horizontal section in its lower segment, the phenomenon rather rare which occurs less than at 1% of the women who are giving birth in the natural way after Caesarian. The majority of operations is performed in the lower uterine segment, the scar from it like operation is to a lesser extent subject to risk of a gap at the subsequent pregnancy, fights and childbirth. it is important to p to know

that the rupture of a uterus happens also at those women whom never operated. In this case the rupture of a uterus can be connected with weakening of uterine muscles after several pregnancies, excessive use of the stimulating preparations in labor, the previous surgeries on a uterus or with use of nippers.

the Rupture of a uterus at the time of delivery can be spontaneous and violent (a mistake of the doctor), also the gap happens full or partial. Some divide gaps into three categories: spontaneous, owing to injuries, and occurred on a hem. Most often the gap nevertheless occurs from - for insolvency of the hem on a uterus which remained from the previous operation of Cesarean section.

the Probability of a divergence of a hem in many respects depends also on type of a section which was made during operation. At a classical section which becomes vertically between a navel and a pubic bone the risk of a divergence of a hem is higher, than at horizontal.

the Classical vertical section in the top part of a uterus is now applied by

rather seldom and only in case of emergency. Such type of a seam is used in case of threat of life of a fruit, cross position of the child or in other emergencies when rescue of mother and child depends on speed of reaction. The risk of a rupture of a similar seam makes from 4 to 9%. At mothers with a classical seam on a uterus who have several children the risk of a divergence of a hem is higher.

the American board of obstetricians and gynecologists (ACOG), Society of obstetricians and gynecologists of Canada (SOGC) and Royal board of obstetricians and gynecologists of Britain (RCOG) recommend

to women with a classical section on a uterus at repeated pregnancies to carry out Cesarean section.

the Risk of a rupture of a uterus at vertical lower and horizontal lower cuts is approximately identical

, that is makes somewhere from 1 to 7%. The hem form on a uterus can vary and increase risk of its divergence. Sometimes do to women a section on a uterus similar to the Latin letter T or J, or even on the turned T (such type of a section meets very seldom). It is considered that from 4 to 9% T - similar scars can disperse.

What symptoms of a rupture of a uterus?

the Rupture of a uterus during pregnancy or childbirth - the hardest complication which can lead to death of mother and a fruit. Today insolvency of the hem which remained from the previous childbirth or other uterus medical operations is considered the main reason for a rupture of a uterus. The most important complexity of diagnostics of a rupture of a uterus consists that it is very difficult to predict a gap in advance. The gap can occur both during pregnancy, and in labor or even several days later after them. The risk of a rupture of a uterus increases after application of oxytocin, and also from - for a large number of childbirth at mother. The skilled doctor can determine by indirect signs a hem divergence during fights or attempts.

For prevention of a rupture of a uterus some researches suggest to measure hem thickness by ultrasound or to watch intensity of fights at the time of delivery. Nevertheless, the similar way of conducting childbirth with a hem on a uterus has under itself no serious evidential base which would allow to apply this method everywhere.

Distinguish the menacing, begun and made rupture of a uterus. There is a number of signs at which emergence it is possible to speak about the begun or occurred rupture of a uterus. At a clinical picture of the made rupture of a uterus deterioration in a condition of the woman in labor is observed, there are severe pains, development of vaginal bleeding is possible. Also can confirm a rupture of a uterus:

Unusual heartbeat of a fruit, various delays in a warm rhythm or bradycardia (low pulse) can be signs of a rupture of a hem. Happens that even after a hem divergence patrimonial activity does not stop, decrease in intensity of fights is also absent. Sometimes it happens that the gap occurred, and clinical symptoms are absent in whole or in part.

techniques of diagnostics of a rupture of a hem by means of the electronic device on supervision over a condition of a fruit Exist. Some obstetricians observe childbirth with a hem on a uterus by means of a fetoskop or by means of Doppler research, however efficiency of these methods is not proved. Various medical institutions recommend to carry out nevertheless similar childbirth with use of the device of electronic monitoring of a condition of a fruit.

As often the rupture of a hem on a uterus occurs?

At women whom already operated the rupture of a uterus occurs in the field of a hem. Numerous researches prove that for women in labor who in the anamnesis had one Cesarean section in the lower segment of a uterus the risk of a gap makes from 0,5% to 1%. Women with multiple Caesarian to sections risk slightly more.

Here figures which show the quantity of the planned and carried out natural childbirth after Cesarean section in one of the American hospitals for the ten-year period.

Quantity of the previous KS Successful natural childbirth after KS hem divergence Percent Perinatal mortality
of 10 880 planned natures. childbirth after one KS of 83% 0. 6% 0. 018%
of 1 586 planned natures. childbirth after two KS of 76% 1. 8% 0. 063%
of 241 planned natures. childbirth after three KS of 79% 1. 2% 0

Source: Miller, D. A., F. G. Diaz, and R. H. Paul. 1994. Obster Gynecol 84 (2): of 255 - 258 V group of investigated entered women with buttock prelying, pregnant with twins, and also those whose childbirth took place with use of oxytocin.

At the independent beginning of childbirth at women with a hem on a uterus the risk of a rupture of a uterus makes less than one percent. It approximately as much or is even less than number of other complications which can arise in labor.

Physicians confirm that the risk of a divergence of a hem after one Cesarean section is not higher, than probability of emergence of any other unforeseen complication in labor (it is possible to carry a fruit distress, bleeding at mother to the last from - for a premature otsloyka of a placenta or loss of an umbilical cord).

Authoritative researches proved that the probability of carrying out the emergency Cesarean section among other complications makes about 2. 7% that honor in thirty times more, than risk of a uterine gap.

B 2000 from the registered 4 million childbirth which ended with the child`s birth, the American national center of statistics in the field of health care recorded a certain number of complications in labor. In the table below the comparative analysis of risk of a divergence of a hem is carried out in attempt of natural childbirth after one Cesarean section in the lower segment with risk of development of other not predicted complications in labor.

the Recorded complications in labor in the USA Quantity on 1000 childbirth
Loss of an umbilical cord 1,9
Pre-natal suffering of a fruit 39,2
of Otsloyk of a placenta 5,5

the Source: CDC: NCHS: Births: Final Data for 2000

the Rupture of a uterus at natural childbirth after Cesarean section Quantity on 1000 childbirth
a rupture of a uterus came From hundred women who are giving birth in the natural way after Caesarian on average in 0,09% - 0,8% of cases (the data based on a world systematic review of similar childbirth) 0. 9 - 8

Source: Enkin et all 2000. A Guide to Effective Care in Pregnancy and Childbirth

According to researches of the Vermont / Hempshirsky project on conducting natural childbirth after Caesarian, a divergence of a seam is possible somewhere at 5 women from 1000. At the second planned Cesarean section the similar outcome arises at 2 women in labor from 1000. Doctors of Royal college of obstetricians and gynecologists of Britain confirm that a rupture of a uterus - very rare complication, but the risk of its emergence increases at women who plan to give birth in the vaginal way after Caesarian (35 cases on 10 000 at natural childbirth with a hem on a uterus) in comparison with 12 cases on 10 000 childbirth at planned repeated Cesarean section.

When the seam on a uterus disperses...

the hem Divergence on a uterus in attempt of natural childbirth happens to

rather seldom, but if nevertheless it happens - the only rescue - carrying out urgent Cesarean section. The more time to the doctor it is required by

to p for establishment of the diagnosis, the probability that the child and/or a placenta will pass through a uterus wall in an abdominal cavity is higher. It seriously increases probability of extensive bleeding, and can cause neurologic violations and very seldom death in the child.

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Therefore at the begun or come true rupture of a uterus on a hem during pregnancy or in labor, the woman performs operation of Cesarean section during which take out the child and take in a gap. The gap on a hem is not always followed by emergence of symptoms of a classical rupture of a uterus as begins gradually.

Authors of “The guide on pregnancy and childbirth“, dear international edition, declare that any medical institution in which they deliver and which has the equipment for rendering the emergency medical care can deliver women with a hem on a uterus.

the American board of obstetricians and gynecologists recommends to provide

to the women who are giving birth independently later Caesarian, the doctor capable to perform the emergency operation, the anesthesiologist and other personnel which can be required in case of the emergency surgery. The community of obstetricians and gynecologists of Canada (SOGC) recommends continuous monitoring vaginal childbirth with a hem and an immediate laparotomy (a surgical section of an abdominal cavity) at suspicion for a hem divergence. “Immediate access to the operating room and blood transfusion on the place“ is also recommended.

Despite it, many clinics of the USA declare that they have no possibility of “immediate“ adequate reaction in case of a hem divergence therefore they freely refuse to the women seeking to give rise in the natural way after Caesarian.

Supporters of natural childbirth with a hem on a uterus insist

on improvement of approach to quality of the provided medical care to women after Caesarian. They consider that to support women who want to give rise after the first Cesarean section more correctly, than to dissuade them, printing stories about unsuccessful attempts of vaginal childbirth with a hem.

Doctor Bruce L. Flamm, the famous researcher in the field of natural childbirth with a hem on a uterus, warns the American physicians against hasty conclusions and advises to support natural childbirth at women with the previous KS in the anamnesis. In his opinion, unwillingness of doctors to support desire of the woman to give rise most and the politician “the second Caesarian after the first“ will promote “to carrying out additional 100 000 operations in a year.“ It is unlikely such large number of operations will be carried out without any serious complications, including without maternal death“, - Flamm considers.

a hem Divergence, than it threatens mother and the child?

Most of the researchers studying seam divergence cases at repeated natural childbirth agree in opinion that continuous monitoring of similar childbirth, timely diagnostics of a divergence of a hem and in time the performed emergency operation heavy complications minimize. One of the conducted researches in large Californian clinic proves that consequences for children considerably more encouraging if adequate measures were taken the first 18 minutes or less after the begun rupture of a uterus.

an Opportunity to make emergency Caesarian seriously reduces risk of death of a fruit from - for seam divergences. During studying of data on child mortality at a divergence of a hem the following was established:

Other Raget`s
Number of the women who were giving birth with a hem on a uterus the Number of the children who died owing to a rupture of a uterus Doctors
17 613 5 , 2000
10000 3 Other Rosen, 1991
5022 0 Other Flamm, 1994

Representatives Vermont / New - the Hempshirsky center for support of natural childbirth with a hem on a uterus came to a conclusion that the limit risk of child mortality in attempt to give rise naturally makes somewhere 6 children on 10 000 whereas can lose the child at planned Cesarean section 3 women on 10 000.

of the Woman who are carefully observed during pregnancy and who in labor are conducted by skilled doctors in the maternity hospital equipped for rendering the emergency help usually give birth without serious consequences for themselves and the child.

Those women who want to give birth houses after Caesarian have to remember

that risk of a divergence of a hem not the myth. House childbirth with a hem on a uterus is not recommended in such countries as the USA, Canada, Great Britain.

of the Woman, collecting to give birth in the vaginal way after Caesarian in non-state medical institutions have to take an interest whether is in this to clinic the emergency resuscitation resources and a possibility of carrying out immediate operation in case of unforeseen complications. whether

the risk of a divergence of a seam Can be minimized by

?

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In spite of the fact that it is almost impossible to foresee precisely what of the women who are giving birth after Caesarian will have a seam divergence, nevertheless, it is possible to determine those factors which can increase risk a rupture of a uterus. Treat the last:

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According to data of the American board of obstetricians and gynecologists, for initiation of patrimonial activity at women after KS it is not recommended to use prostaglandins. The board declares that use of a mizoprostol in labor seriously increases risk of a rupture of a uterus, this medicine should not be used at childbirth with a hem.

the Informed choice - the informed refusal

By the existing American legislation, the woman who gave birth to the first child through operation KS has the right to try to give rise independently or to choose repeated Cesarean section.

In Russia according to the law on “Protection of public health“ (the section VI. The rights of citizens when rendering the physician - the social help, Art. 30) each person at the request for any medical care has the right on:

  1. the valid and humane relation from medical and service personnel;
  2. the choice of the doctor, including family and attending physician, taking into account his consent, and also the choice lechebno - preventive establishment according to contracts of obligatory and voluntary medical insurance;
  3. inspection, treatment and maintenance in the conditions corresponding sanitarno - to hygienic requirements;
  4. carrying out at its request of a consultation and consultations of other experts;
  5. pain relief, connected with a disease and (or) medical intervention, available ways and means;
  6. preservation in secret information on the fact of the request for medical care, on a state of health, the diagnosis and other data received at its inspection and treatment
  7. the informed voluntary consent to medical intervention according to article of 32 real Bases;
  8. refusal of medical intervention according to article of 33 real Bases;
  9. obtaining information on the rights and duties and a condition of the health according to article of 31 real Bases, and also at choice of persons to which for the benefit of the patient information on a state of his health can be transferred;
  10. receiving medical and other services within programs of voluntary medical insurance;
  11. compensation of damage according to article of 68 real Bases in case of infliction of harm to its health at delivery of health care;
  12. the admission to it of the lawyer or other lawful representative for protection of his rights;
  13. the admission to it of the priest, and in medical institution on granting conditions for departure of religious practices, including on granting the certain room if it does not violate the internal schedule of medical institution.

in case of violation of the rights of the patient it can address with the complaint directly the head or other official lechebno - preventive establishment in which medical care, in the relevant professional medical associations and the license commissions or in court is provided to it.

Remember that in independence of your financial position and the social status, each woman has the right to ask questions, to obtain full information on possible consequences, to discuss the forthcoming childbirth with the doctor, and on the basis of it to make the conscious choice - to give birth naturally after KS or to choose repeated operation.