Natural childbirth after cesarean section

The main question that interests women who gave birth to their first child by uterine incision and extraction of the child through this incision is whether natural childbirth is possible after a cesarean section?

Obstetricians cannot answer this question right away: they need to know for what specific reasons a woman's previous births required surgical intervention. That is, only on the basis of complete information regarding the patient's "reproductive parameters" and her obstetric history can doctors give an approximate estimate of the chances of a successful natural birth after a cesarean section.

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Reasons for the impossibility of natural childbirth after cesarean section

According to the World Health Organization, the normal rate of cesarean section is within 10% of all births, including both emergency and planned surgeries. Although in the United States, at least 29% of women give birth by cesarean section.

Let us recall that the need for emergency extraction of the child from the mother's womb with the help of surgical intervention is most often associated with unforeseen complications that arise during labor that has already begun. Among such complications, obstetricians note: abnormalities of labor (including its insufficient activity or sudden complete cessation of contractions); too early placental abruption; the threat of uterine rupture; intrauterine hypoxia of the fetus.

In cases of emergency cesarean section, a vertical midline laparotomy of the anterior abdominal wall is performed (an incision from the suprapubic fold to the periumbilical area), but access to the uterus is through a horizontal incision in its lower segment (except in the presence of twins or abnormal fixation of the placenta). In this case, the risk of uterine rupture during subsequent physiological births is estimated at 6-12%. In planned cesarean section, the incision is only horizontal, which significantly reduces the risk of uterine rupture during future pregnancy and childbirth.

Obstetricians and gynecologists consider vaginal, that is, natural childbirth after a cesarean section, impossible for the following reasons:

• anatomical features (too narrow pelvis or vagina);
• abnormal presentation of the fetus (oblique, breech, foot);
• the placenta is located in the lower segment of the uterus;
• large fruit or multiple fruit;
• premature birth or post-term pregnancy;
• the need to induce labor;
• fetal distress;
• the mother has cardiovascular disease, hypertension, diabetes, renal failure, severe myopia and retinal detachment;
• cervical cyst;
• active herpes virus was detected in the genital area;
• obesity in pregnant women;
• pregnancy after 40 years;
• less than two years have passed since the surgical delivery.

Natural childbirth after cesarean section is successful if the woman has had at least one physiological birth or has already had such birth after cesarean section; if the underlying reasons for this operation are not repeated in the current pregnancy; the woman does not have major medical problems; the size of the fetus and its position are normal.

Preparing for a natural birth after a cesarean section

When anticipating or planning the possibility of having children after surgical intervention during childbirth, a woman needs to know that preparation for natural childbirth after a cesarean section includes determining the condition of the scar on the uterus before a new pregnancy - a maximum of 1-1.5 years after abdominal delivery.

For this purpose, hysterography (X-ray of the uterus with a radiopaque substance) is prescribed, as well as hysteroscopy (endoscopic examination of the scar). This is especially important if the cesarean section was corporal (i.e. with a longitudinal dissection of the peritoneum and uterus).

When deciding to give birth naturally after a cesarean section, a woman should be aware that observation by a gynecologist - with all examinations and tests - is mandatory and involves medical support of pregnancy literally from its first days. And prenatal care will be the same as with any other healthy pregnancy. And the body of a pregnant woman prepares for the appearance of the child in advance: under the influence of the hormone relaxin, the elasticity of muscle fibers increases, the ligaments of the symphysis (pubic articulation) gradually relax, the pelvic bones diverge slightly, etc.

Doctors can make a final conclusion starting from the 36th week of gestation – after an ultrasound, which is designed to determine the size of the fetus, its position in the uterus, the condition of the placenta and the scar on the uterus.

Peculiarities of natural childbirth after cesarean section

The main features of natural childbirth after a cesarean section are that the medical staff pays increased attention to the process, and the surgeon and anesthesiologist – in case of unforeseen complications – must be ready to perform a cesarean section at any time.

Leading obstetricians emphasize the importance of allowing labor to proceed naturally, despite the possibly longer process of natural dilation of the birth canal during contractions, and warn of the dangers of stimulating them.

However, most often such births are stimulated. First, an amniotomy is performed, that is, the amniotic sac is artificially opened. Such a procedure is supposed to promote the activation of labor due to increased irritation of the uterine receptors after the fetus's head comes into contact with them.

Next, to increase uterine contractions, uterotonic drugs can be used: Oxytocin, Ergometrine (Methylergometrine), Dinoprostone (Dinoprost, Misoprostol).

Studies conducted by Western obstetricians have shown that prostaglandin-based uterine stimulants (Dinoprostone, etc.) should not be used during vaginal births after cesarean section, as this is fraught with an increased risk of uterine rupture by 1-1.9%. Experts from the American College of Obstetricians and Gynecologists (ACOG) believe that in case of weak labor in the active phase of labor, it is permissible to use Oxytocin, although, of course, this can lead to undesirable consequences.

The biggest concern for women who had a cesarean section in their last birth is the threat that during a vaginal birth the uterus may not withstand the force of contractions of the muscular layer and "rupture along the seam." Indeed, such a risk exists, and, according to ACOG, if the section was transverse and low, the probability of uterine rupture in physiological birth is 0.2-1.5% (approximately one chance in five hundred).

According to WHO statistics, natural childbirth after a cesarean section is successful in 7-9 cases out of 10.

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