It's no secret that you need to prepare for childbirth. This preparation includes not only “raids” on stores with children’s things and a psycho-emotional mood. You also need to prepare for childbirth, in which your little one grows and develops for 9 months. In principle, nature itself made sure that all female organs “ripe” as much as possible before childbirth and do not fail at the right moment. However, not everything and does not always go according to plan.
Uterus unprepared for childbirth
The “house” of your belly is an elongated organ that consists of muscle and fibrous tissue - the uterus, which ends in the cervix in the lower part. As soon as labor occurs (researchers, by the way, still cannot figure out why labor occurs at one time or another), the uterus begins to contract, that is. During contractions (the first stage of labor - dilation), the baby should open completely and release the fetus. At this time, incredible events occur in the still pregnant body: the uterus, contracting, seems to “slide” from the fertilized egg, rising upward, and the fetus itself descends into the cervical canal. Full dilatation of the cervix is recorded when the baby’s head can “crawl” through it. As soon as this happens, the second stage of labor begins - expulsion and pushing, which ends with the birth of the baby.
To be born, the child has to go through a very difficult path, but the belly-dweller stops at nothing. For example, if the cervix does not allow it, it still climbs, and this results in ruptures, which are frequent accompaniments of childbirth. It is easy to guess why exactly this complication occurs - due to insufficient elasticity of the muscle tissue of the perineum. It is clear that there are other reasons for ruptures during childbirth, but nevertheless, the elasticity of the uterus is a prerequisite for successful childbirth.
It is interesting that during pregnancy the uterus independently prepares for the upcoming birth. In the last trimester of pregnancy, muscle tissue is very actively replaced by collagen fibers, which provide it with the ability to stretch. Doctors call this condition “maturity of the uterus and its cervix.” Typically, the attending physician determines this “maturity”, at which the length of the cervix should be up to 2 cm, its “consistency” should be soft, one transverse finger should pass beyond the area of the internal pharynx (this is the result of shortening of the cervix) and the cervix should be located in the center of the vagina.
Deviations from these norms (too long cervix, its dense consistency, closed cervical canal and external os) indicate immaturity of the cervix, that is, the body is not ready for childbirth and needs “recharge.” Doctors call an immature neck an “oak neck.” You should not hope that a uterus that is ready for childbirth will ensure that there are no ruptures, but its “maturity” will greatly reduce their likelihood. Therefore, you should not neglect preparation.
How to prepare the uterus for childbirth?
There are many ways to prepare the cervix for childbirth and help it ripen in time. When diagnosed with an “immature” cervix, doctors prescribe medications and procedures that should stimulate the process of cervical ripening. You may even be prescribed the use of prostaglandins, which are injected into the cervical canal and promote cervical ripening, or suppositories with kelp will be injected into the uterus, which stimulates the production of collagen, which makes the tissue more elastic.
Sometimes the cervix does not ripen due to strong muscle tension, so in the last weeks of pregnancy the doctor may prescribe antispasmodics (No-shpa, Papaverine) either intramuscularly or in the form of tablets or rectal suppositories.
Taking into account the characteristics of a particular pregnant body, the doctor may also prescribe cervical massage, or nipple stimulation, and perhaps even acupuncture. However, these procedures must be carried out according to indications and under the supervision of medical staff.
There are also other ways to prepare the cervix for childbirth, simpler ones, which can be carried out without prescriptions, but only in the absence of contraindications. For example, a widely known and simple method is systematic. Firstly, orgasm trains the muscles of the perineum and cervix. However, be extremely careful (especially if there is a threat), because this same orgasm is an excellent natural stimulant of labor. Secondly, male sperm helps the uterus to ripen (therefore you need to have sex without a condom), because it contains a huge amount of the natural hormone prostaglandin, which promotes the ripening of the cervix. Probably, it’s not worth even talking about the fact that the husband must be absolutely healthy, so as not to infect you with some kind of disease at such an important moment.
An excellent preparation for childbirth is the reception. It is often prescribed in capsule form (1 capsule per day half an hour before meals, washed down with plenty of water) a month before the upcoming birth. Primrose oil contains a huge amount of fatty acids that stimulate the production of prostaglandin. But do not take this medicine without consulting your doctor! It is safer to saturate the body with fatty acids by consuming fish and vegetable oil, for example.
Many women also resort to folk recipes, which also promote cervical ripening. For example, they drink a decoction of dried raspberry leaves (100 ml of decoction before meals), (200 g before breakfast on an empty stomach), hawthorn tincture (pharmacy version in drops) or strawberry decoction (strawberry compote with leaves). However, even with these infusions you need to be extremely careful. Remember about possible allergic reactions, and not every woman needs stimulation of cervical ripening, since the process occurs by itself without delay.
The whole body is prepared for childbirth and special exercises (train the vaginal muscles). There are special courses for expectant parents, where they are required to conduct gymnastics with pregnant mothers or tell them what exercises should be done. Squatting is very effective, but only if the fundus of the uterus is in a normal position. You need to exercise daily starting from week 35, first for 2 minutes, then the time of squats can gradually be increased to 15 minutes. However, gymnastics for pregnant women also has contraindications, so do not make any decisions on your own.
Finally, remember that the course of labor largely depends on a positive attitude. Believe in your strength from the very first days of pregnancy, and then your body will cope with this difficult, but most enjoyable task - easily give birth to a healthy and strong baby. Good luck to you!
Especially for- Tanya Kivezhdiy
Uterine prolapse is often called uterine prolapse. The most dangerous thing about this disease is that it proceeds almost unnoticed and does not manifest itself in any way. True, it is invisible until the time has come for the woman to give birth to a child. There is a medical term for this disease - genital prolapse.
Attention! Pregnancy is a provoking factor and can worsen the course of the disease. Therefore, knowing about the existence of this pathology, postpone conception until complete recovery, until the muscles return to normal tone.
This disease most often affects older women. According to statistics, in women of this age the disease occurs in forty percent of cases. Moreover, this process can last for several years, and the woman will not even know about it. There are cases when the uterus descends very quickly, then urgent surgical intervention is necessary.
Symptoms of the disease
The first signs of the disease include:
- discomfort in the pelvic area when walking or in a quiet position;
- pain;
- problems with urination;
- sexual intercourse becomes difficult;
- there is bleeding from the vagina;
- foreign body sensation.
Causes of the disease
The most common cause of the disease is intense physical activity. After childbirth, it also appears in the case of a difficult birth process and various postpartum complications. The disease is gaining momentum due to the fact that the muscles supporting the vagina and uterus weaken and cease to be elastic. These organs begin their downward movement, leaving the level of the vagina.
Attention! If you notice the first symptoms, you should immediately consult a doctor. Limit any physical activity and do not lift heavy objects.
Inattention to this disease or complete ignorance of it can lead to the fact that the prolapsed uterus is infringed, vaginal bedsores and purulent complications develop.
Impact on the bladder can lead to urinary incontinence and stagnation. As a consequence, ascending infection of the urinary tract and kidneys occurs.
Treatment methods
The number of women suffering from this pathology is surprising. Despite the prevalence of genital prolapse, there are treatments that can prevent the disease. You can do without surgery and use traditional medicine recipes. Most of these methods help to completely deal with the disease without resorting to medical treatment.
Without surgery
In the initial stages of the disease, manual reduction of the uterus in a horizontal position is possible. However, this method is not very effective, since the disease often progresses. Patients who have problems with uterine prolapse are prescribed a diet high in fiber. This will help avoid constipation and straining during bowel movements.
It is also important to avoid physical activity. Special gymnastics are effective, exercises of which can strengthen the pelvic floor muscles, abdominal muscles and prevent organ prolapse. The use of folk remedies is also practiced, which reduce pain and restore muscle tone. For example, tinctures of lemon balm, coltsfoot, and elecampane are effective.
Uterine prolapse in the elderly
Only a doctor can determine the method of treatment for older women. Initially, drug treatment is effective - for example, drugs containing the female hormone estrogen. It is important for patients to avoid physical activity, lead a healthy lifestyle, and engage in physical therapy. It is necessary to follow a diet and avoid constipation.
Doctors believe that the most effective way to treat uterine prolapse in the elderly is surgery. Sometimes this means complete removal of the uterus. If the operation is not possible, pessaries are used - special uterine rings.
After childbirth
Several methods are used to treat cervical prolapse after childbirth:
- special gymnastics – exercises aimed at strengthening the pelvic floor muscles;
- the use of ointments containing the female hormone - estrogen, to normalize hormonal levels and restore the tone of the uterine ligaments;
- special gynecological massage performed by a specialist;
- it is important to reduce the amount of physical activity;
- use of folk remedies.
Traditional medicine - to help
Treatment at home requires strict adherence to the recipe. It is important not to miss taking your medication and follow all accompanying instructions. There are many types of treatment for uterine prolapse:
- lying in baths;
- douching;
- internal use of folk remedies;
- use of tampons;
- physiotherapy.
An effective way is to make a decoction of gentian rhizomes. This herb is poured with 300 ml of boiling water. The decoction should sit for about an hour. After which it is filtered and taken chilled daily, a couple of times forty minutes before meals.
Dandelion
A dandelion bath is used in conjunction with this decoction. Grind 20 grams of dandelion leaves and pour a bucket of water into the bath. The herb and water should sit for ten minutes. Then everything is poured into the bathroom together.
Remember that the water temperature should not be higher than 38 degrees and lower than 30. It is enough to lie in such a bath for about twenty minutes.
Collection of herbs
Collecting plants affects the restoration of the position of the uterus. A collection of alder root, linden flowers, lemon balm and claret is poured with boiling water. Proportion: 200 grams of water per two tablespoons of herbs. Three times a day, drink half a glass of the decoction half an hour before meals. Treatment with this decoction is effective for three weeks. Then a break for a couple of weeks and again you need to repeat the three-week course.
Eggs
Egg shells help.
- It needs to be crushed and mixed with finely chopped lemons.
- 5 eggs and 9 lemons - this infusion should last for four days. It is necessary to stir it periodically.
- After four days, half a liter of vodka is poured into the mixture. After which you need to leave the infusion for five days.
- Next, the mixture is filtered and squeezed.
Treatment with infusion: a couple of times a day you need to take fifty grams of infusion until it runs out. Take a break for a month and make the infusion again. The procedure must be carried out three times, in which case it will be useful in treatment. Gynecologists do not consider this method effective.
Quince
Quince infusion allows you to restore tone to the muscles of the vagina and uterus. Quince is filled with water in a ratio of 1/10. The infusion is prepared in a steam bath and drunk like tea.
Lily
The infusion of white lily puts the uterus in order. We are talking about the roots of the plant. To make the infusion you need two tablespoons. They are poured with two glasses of boiling water and infused for twelve hours. The infusion is filtered and taken daily. You need to prepare it every day and take it three times a day an hour before meals.
Baths and douching
Douching is effectively done with a decoction made from oak bark. Take 70 grams of oak bark, grind it and pour two liters of cold water. The mixture is placed on fire and boiled for two hours. Usually this decoction is enough for three douchings. This procedure must be done every day for a month. Oak bark is sold at the pharmacy. The product can be used only after consulting a gynecologist.
Pine nuts in the size of one glass are poured with two liters of water, boiled in advance. The mixture is boiled over low heat for an hour and infused for about half an hour. The broth should be poured into the bath and lie in it for about fifteen minutes.
Remember that the temperature of the bath water should be about 38 degrees. This is the optimal regimen for effective treatment.
Folk remedies help and are effective only in combination with exercises. Make the famous “scissors” or “birch tree”. Cycling is also effective. A ride twice a week will be enough for good treatment. You can't lift anything heavy. You should be careful during sexual intercourse.
The treatment of any gynecological disease must be approached responsibly and always take care of yourself: women’s health is very fragile and difficult to recover.
When entering a maternity hospital, every woman experiences serious stress, especially when this happens for the first time. And this is connected not only with the change from the usual environment of her home to a hospital one, but also with the fear of what awaits her, of the unknown, and various terms from doctors, incomprehensible to the expectant mother, only intensify the state of stress and anxiety.
Perhaps the first frightening term for a woman when examined by a doctor in a maternity hospital is “cervical dilatation,” because it is this indicator that determines the body’s readiness for childbirth.
It is important to understand the meaning of medical terms and indicators, since understanding what the doctor is talking about will allow the woman to feel calm and comfortable.
The cervix is the lower part of this organ and is a kind of tube that connects the uterus to the vagina. The opening of the external pharynx of the cervix opens into the vagina, and the internal one into the uterus, forming the cervical canal between them.
During a normal pregnancy, the cervix should be tightly closed, holding the developing baby inside and protecting it from external threats. Before childbirth, the cervix begins to open, freeing the birth canal for the baby to be born.
As the duration of pregnancy increases, the cervix begins to change; natural physiological processes occur in it, in which muscle tissue is partially replaced by connective tissue.
In addition, the active formation of new collagen fibers begins, which makes the passage more elastic and increases the ability of tissue stretching.
The clinical manifestation of such changes is expressed in the shortening of the cervix and loosening of its structure, as well as the formation of a lumen.
Preparation for normal dilatation of the cervix during childbirth in the body begins at approximately 33 weeks, gradually softening and preparing for the release of the fetus, which at this time drops lower, creating additional pressure on the organ and facilitating the onset of dilatation.
In some cases, when the functioning of the organ is disrupted for various reasons, premature dilatation of the cervix may occur, which may begin at a later date or if the labor process began at a time when the fetus is not yet viable.
The opening begins from the side of the internal pharynx, where the baby’s head presses, while in women giving birth for the first time, the canal takes on a cone-shaped shape and the expansion of the external pharynx occurs gradually, as the fetus moves forward.
Sometimes the cervix does not dilate even at the beginning of active labor, which requires additional stimulation of the process.
In women who are giving birth not for the first time, dilation occurs not only easier, but also faster, since by the time the pregnancy ends, the external cervical os is usually already open by 1-2 cm.
Stages of cervical dilatation
Many young women expecting their first child, arriving at the maternity hospital with weak contractions, hearing from the doctor during an examination that there is no dilation yet, begin to worry and wonder why the cervix does not dilate during childbirth?
But the process of expanding the lumen is divided into 3 main stages, which are not always possible to recognize independently.
The first stage of disclosure The initial period is considered, sometimes called slow or latent. During this period, irregular and usually mild contractions may occur. There are usually no special sensations when the cervix dilates at this time, contractions are not painful.
The duration of the first period can vary and take from several hours to several days. You should not sit and count each contraction, concentrating your attention solely on this moment, since in this case the whole process of childbirth may seem endless. If you have mild, weak contractions, you should try to sleep, as you will soon need a lot of strength and energy.
Drug assistance is usually not required in the first period, but if the doctor sees that complications may arise, he can speed up the dilatation of the cervix to avoid possible problems.
Second period called medium or fast, as well as the active phase of opening. At this time, contractions begin to intensify, their intensity and duration increase, and the interval between them decreases. Dilation during this period can range from 4 to 8 cm.
At this time, the following rules should be observed:
- do not sit - this is what almost all doctors say; sitting during childbirth means sitting on the child’s head;
- lying down is also not recommended, since this often becomes the reason that the cervix does not open during childbirth or opens very slowly;
- It is best to walk at least around the ward during this period, this will stimulate faster opening and speed up the birth process;
- use special breathing exercises;
- if you have a strong desire to lie down, then you can, but you should find the most comfortable position.
In most women, the amniotic sac bursts in the second phase of cervical dilatation, but this can happen earlier or it can be punctured by a doctor.
Third stage is the complete dilatation of the cervix and the beginning of active labor. The transition from phase two to phase three can take varying periods of time and can sometimes be rapid, so it is important to have a doctor nearby to monitor the process.
Possible problems
From about 37 weeks, a woman’s body begins to actively prepare for the upcoming birth. Many pregnant women by this time, experiencing fear of the upcoming event, fall into panic.
Stress, nervous tension, and insufficient psychological readiness often lead to the fact that the production of hormones necessary for the beginning of the opening is inhibited, which is why the body is forced to delay the date of birth.
Many women wonder: what to do if the cervix does not open? First of all, don't be nervous. Secondly, you need to listen to the doctor and follow all his recommendations.
Often, cervical dilatation does not occur with severe polyhydramnios or oligohydramnios.
- With polyhydramnios, the uterus stretches too much, which significantly reduces its natural contractility and leads to weakness in labor as a whole.
- With oligohydramnios, the amniotic sac cannot exert the necessary pressure on the cervix for its proper full dilatation, and this also causes weakness in labor.
Also, problems with disclosure also occur in women over 35 years of age. In this case, difficulties are associated with a decrease in the elasticity of the tissues of the cervix and vagina.
In addition, difficulties during childbirth due to the fact that the cervix does not open often occur in women with various diseases of the endocrine system, for example, obesity or diabetes, as well as diseases of the genitals.
It often happens that when visiting a doctor before giving birth, a woman hears that the cervix is not yet ready and does not have the required maturity, although the day of birth is already close. This problem is serious in cases where the pregnancy is already full term and exceeds 40 weeks, since during this period the placenta can no longer perform the necessary functions of providing the fetus with nutrition and oxygen, resulting in pregnancy loss.
Stimulation of labor and the onset of dilatation can be carried out using both medicinal and non-medicinal methods.
At the same time, medicinal stimulation using tablets and drugs to dilate the cervix is carried out only in a hospital setting, since such actions can cause rapid labor.
One of the most dangerous complications of childbirth is uterine rupture (ruptura uteri), which at the end of the last century gave 100% maternal and child mortality, i.e. all women with uterine rupture died.
The cause of death of a woman in labor due to uterine rupture is bleeding from ruptured vessels of the uterus, rapid and sudden bleeding and shock. The larger the caliber of damaged vessels, the stronger the bleeding and the faster anemia occurs. Shock develops as a result of trauma with extremely strong irritation of the nerve endings of the uterus itself, especially its peritoneal covering, as well as as a result of irritation of other abdominal organs by the contents of the uterus, which enter the abdominal cavity after its rupture. Even today, with the modern organization of obstetric care, with the presence of a blood transfusion service and modern anesthesiology, uterine ruptures often end in the death of a woman.
What are the causes of uterine rupture and how to avoid them? For a long time it was believed that the causes of spontaneous uterine rupture during childbirth were a clinical discrepancy between the size of the presenting part of the fetus and the inlet into the pelvis. A similar discrepancy occurs with a narrow pelvis, with a giant fetus, extensor insertions of the fetal head, hydrocephalus, and advanced transverse position of the fetus. The mechanism of such a rupture is that in the presence of an obstacle to the advancement of the fetus, excessively strong labor develops, the consequence of which is overstretching of the lower segment of the uterus due to the continued movement (retraction) of layers of muscle fibers upward into the body of the uterus. As a result, the lower segment of the uterus becomes thinner and ruptures. This mechanical theory of uterine rupture was proposed by Bandle in 1875, and therefore uterine rupture, which occurred as a result of hyperextension of the lower segment of the uterus, is sometimes called a Bandle rupture today.
Subsequently, as pathological changes in the uterine wall at the site of rupture were studied, it was proven that spontaneous uterine rupture is always preceded by changes in the myometrium, as a result of which rupture occurs. For the first time, the idea that the main cause of uterine rupture is the fragility of its pathologically altered tissues was expressed at the beginning of the 20th century by the Russian obstetrician N. Z. Ivanov. Another Russian doctor, Ya. F. Verbov, developed this idea in 1913 and with his research proved that a healthy uterus does not rupture spontaneously, and that rupture occurs due to the inferiority of the myometrium.
It has now been established that the main cause of uterine rupture is pathological changes in its wall. Less often, rupture occurs only as a result of hyperextension of the lower segment of the uterus, but most often spontaneous uterine rupture occurs due to a combination of reasons - the existence of a defective uterine wall and the phenomena of clinical inconsistency.
Inferiority of the uterine wall occurs after damage to it during an abortion, which remained unrecognized at the time of curettage, after previous operations on the uterus - cesarean section, conservative enucleation of one or more fibroid nodes. The incidence of uterine rupture after previous operations depends mainly on three factors: the location of the incision, the direction of the incision and the healing characteristics of the postoperative wound of the uterus.
It is known, for example, that a transverse dissection of the uterus in the area of the lower segment during a cesarean section reduces the risk of rupture during subsequent births by 10 times, since the most intensively contracting part of the uterus, its body, is not damaged by such a cut.
Any dissected tissue heals better the less lymphatic and blood vessels and nerves are damaged in it. In different parts of the uterus, the course of the main arterial and lymphatic vessels, as well as nerve fibers, has a different direction. For better healing, uterine incisions should be made parallel to the course of the vessels and nerves. In the area of the isthmus, the direction of the vessels and nerves is horizontal, therefore, during a caesarean section, a transverse incision of the uterus in the lower segment is the most anatomically justified.
As for the healing of a postoperative wound of the uterus, if a rough connective tissue fibrous scar has formed at the site of the incision, when the uterus is stretched by subsequent pregnancy, especially during childbirth, the wall of the uterus at the site of the scar may become incompetent and easily rupture.
Inferiority of the uterine wall can be caused by past endomyometritis of various etiologies, prolonged labor, during which there was prolonged compression of the uterine wall between the fetal head and the woman’s pelvic bones with symptoms of tissue malnutrition, as well as underdevelopment of the uterus and various anomalies of its development, in which place of congenital functional weakness of the myometrium.
All of these factors are the main predisposing causes of spontaneous uterine rupture, which most often occurs during the expulsion period, but can also occur in the first stage of labor and even during pregnancy.
In addition to spontaneous ruptures, there are also violent ruptures. These ruptures occur during obstetric surgery or care. In all cases, a violent rupture is a consequence of either inept and crude execution of the surgical technique, or the operation being carried out in the absence of the necessary conditions, or in the presence of contraindications.
Most often, violent rupture of the uterus is caused by turning the fetus on its leg in the absence of its mobility in the uterine cavity, i.e., in a neglected transverse position; extraction of a large fetus or a fetus with unrecognized hydrocephalus by the pelvic end; the use of obstetric forceps in the absence of conditions (highly located head, lack of full dilation), etc.
No obstetric operation should be complicated by uterine rupture. Therefore, by correctly assessing the conditions for performing a particular operation, as well as paying attention to the presence of contraindications, we can and must eliminate the group of forced uterine ruptures.
Each spontaneous uterine rupture is preceded by a picture of a threatening rupture, the symptoms of which are sometimes well expressed and sometimes erased. A particularly striking clinical picture is the threatening uterine rupture due to a mechanical obstacle to the expulsion of the fetus. It is characterized by the following symptoms:
1. Excessively intense or violent labor. Contractions of the uterus follow one after another almost without pauses; convulsive labor may be observed when there is no relaxation of the uterine muscles.
2. Premature attempts that appear when the head is pressed against the entrance to the pelvis or fixed by a small segment.
3. The uterus is tense, especially in the area of the lower segment, which is sharply stretched, thin and painful on palpation.
4. Stretching of the lower segment of the uterus, which contains almost the entire fetus expelled from the uterine cavity, leads to the fact that the uterus changes its shape. It takes on a shape reminiscent of an hourglass (Fig. 23). The upper part is the dense contracted body of the uterus, and the lower part is the stretched and tense lower segment. The border between them is the so-called retraction ring, located at the level of the navel or above it and running in an oblique direction.
23. A woman’s abdomen with threatening uterine rupture.
5. Due to tetanic contractions of the uterus, sharply tense round uterine ligaments are palpated.
6. Severe compression of the urethra and the lower part of the bladder between the fetal head and the pubic bones leads to difficulty urinating. The woman in labor either cannot urinate at all, or she urinates frequently, but only a few drops at a time. The symptom of urinary disorder is one of the first alarming symptoms; it appears several hours before the development of a picture of a threatening uterine rupture. Therefore, every woman during childbirth must pay special attention to the function of urination.
7. Violent labor and premature attempts lead to swelling of the external genitalia.
8. The behavior of the woman in labor is restless, she rushes about, screams, and complains of severe pain.
9. Continuously following contractions or attempts without relaxation of the uterus between them lead to a deterioration in the uteroplacental circulation and the occurrence of intrauterine asphyxia of the fetus. Tension and pain in the abdomen make it impossible to listen to the fetal heartbeat.
10. Vaginal examination often reveals pinching of the edematous anterior lip of the cervix. If the cervix is pinched between the impacted head and the pelvic bones and is unable to move upward, then the stretching of the lower segment of the uterus above the place of pinching occurs especially intensely. In case of signs of threatening uterine rupture, under no circumstances should the pinched lip of the cervix be refilled. The slightest violence can transform the state of a threatening rupture into an accomplished one.
Consequently, with careful monitoring of the woman in labor during childbirth, it is possible to promptly recognize the threat of the so-called Bundle uterine rupture and prevent the onset of a catastrophe.
The clinical picture of threatening uterine rupture due to pathological changes in its wall is expressed completely differently. In these cases, due to the incompetence and fragility of the myometrium, the uterine wall appears to spread in the most altered area. Therefore, sometimes the scarred wall of the uterus spreads during pregnancy, unable to withstand even its gradual stretching by the growing fetus. The location of the rupture can be different and depends on which part of the uterus there is pathologically altered tissue.
Rupture of the pathologically altered uterine wall more often occurs during childbirth in multiparous women. A distinctive feature of these ruptures is the absence of vigorous labor. The altered myometrium is not able to produce intense contractions. The wall of the uterus begins to creep apart with frequent, but weak, unproductive and painful contractions. Weak but painful contractions in a multiparous woman after the rupture of amniotic fluid with a high-standing head should be especially alarming.
The next symptom indicating a threat of uterine rupture is thinning of the uterus in the area of the scar and pain in this area when palpated. It is quite natural that cicatricial changes in the posterior wall of the uterus are not accessible to the palpation method of examination. All other symptoms of impending uterine rupture, described earlier, may occur with a spreading rupture mechanism, but they are much less pronounced.
If help is not immediately provided in a state of threatening uterine rupture, then it will inevitably happen soon. The process of uterine rupture itself occurs very quickly after the symptoms of its threat reach their climax. Therefore, a midwife who is independently conducting childbirth should, if she suspects a threatening uterine rupture, immediately stop or weaken labor and call a doctor, be sure to tell him the reason for the call. To stop labor, mask ether anesthesia is used.
Diagnosis of a completed uterine rupture during childbirth is not very difficult, since the clinical picture observed in this case is very characteristic. Suddenly the painful contractions that were causing the woman in labor to scream and thrash around stop. Following the rupture, the general condition of the woman in labor quickly changes due to the development of traumatic shock and increasing anemia: the face turns pale, the pupils dilate, the pulse becomes frequent and weak, blood pressure decreases, breathing becomes rapid and shallow, dizziness appears, the skin becomes cold to the touch, becomes covered in sweat, sometimes uterine rupture is accompanied by nausea and vomiting.
With a complete rupture of the uterus, when all layers of the uterine wall are broken, the fetus, completely or partially, and sometimes together with the separated placenta, enters the abdominal cavity. In this case, parts of the fetus can be very easily palpated just under the abdominal wall. The presenting part of the fetus, which was previously fixed at the entrance to the pelvis, becomes mobile, and sometimes is determined from the side. If the entire fetus was born into the abdominal cavity, then next to the deviated presenting part of it, the contracted body of the uterus is determined.
With complete rupture of the uterus, due to the entry of blood and amniotic fluid into the abdominal cavity, the phenomena of irritation of the peritoneum quickly increase - nausea, vomiting, diffuse pain throughout the abdomen, a positive Shchetkin-Blumberg sign, tension in the anterior abdominal wall, flatulence.
If an incomplete uterine rupture (non-penetrating) occurs, in which the mucous membrane and muscular layer of the uterine wall are torn, but the serous layer remains intact, then the blood and contents of the uterus do not enter the abdominal cavity. In such cases, retroperitoneal hematomas are formed. The size of the hematoma depends on the location and size of the rupture, which vessels are damaged and how intense the bleeding is (Fig. 24). With a large hematoma formed between the leaves of the broad ligament, the uterus deviates to the side, and a rapidly enlarging, tense and painful formation begins to appear on the side of the uterus. In these cases, the woman in labor complains of persistent pain in the lower abdomen, sometimes in the sacrum and lumbar region, radiating to the lower limb.
24. Uterine rupture.
a - complete, b - incomplete.
External bleeding during uterine rupture appears from the moment it begins; as a rule, it is not very strong, since most of the blood enters either the abdominal cavity or the retroperitoneal space. When a rupture occurs, the fetal heartbeat cannot be heard.
If the rupture occurs through the spreading of the pathologically altered wall of the uterus, then all its symptoms may not be so pronounced at first and increase gradually. This is due to the fact that scar tissue does not contain large blood vessels, so heavy internal bleeding usually does not occur with such ruptures. In the clinical picture, symptoms of shock and peritoneal phenomena come to the fore.
Any uterine rupture, in addition to shock and acute bleeding, threatens the woman’s life with the addition of an infection, as a result of which peritonitis and sepsis can develop.
Treatment for impending uterine rupture is to prevent its occurrence. Therefore, it is necessary to immediately stop labor and give birth to the woman surgically under deep anesthesia.
Complete uterine rupture, regardless of the mechanism of its development, shape and location, can only be treated surgically. Immediate transection is performed, the fetus, placenta, spilled water and blood are removed from the abdominal cavity. If there is extensive damage to the uterus with crushed tissue, as well as signs of infection, extirpation of the uterus without appendages is performed. However, often when the uterus ruptures, the uterus is not removed, but the rupture is sutured. Indications for this operation, which preserves a woman’s uterus, are a small fresh rupture without crushing tissue, no signs of infection, the woman’s young age and the severity of her condition. The last circumstance is very important: the more severe the condition of the woman in labor, the worse she tolerates such a traumatic operation as hysterectomy.
Rupture of the uterus in the lower segment or its separation from the vaginal vaults is often accompanied by injury to the bladder, which must be promptly diagnosed and eliminated.
When preparing a patient for surgery, during it and after the operation, a blood transfusion must be performed. At the same time, it is necessary to carry out antishock and antiseptic therapy.
The task of the entire obstetric service, all its stages and links, is to be able to anticipate and prevent the development of such a formidable and life-threatening complication for a woman as uterine rupture. In this regard, it is necessary to register all pregnant women in a timely manner and carefully monitor them throughout pregnancy. Those women who can expect uterine rupture are subject to special registration. This high-risk group includes the following:
1. Pregnant women with an anatomically narrowed pelvis (with a true conjugate size less than 11 cm).
2. Women who have undergone uterine surgery in the past (cesarean section, conservative removal of fibroid nodes, suturing of a uterine wound after perforation, etc.).
3. Multiparous women with a burdened obstetric history, especially if the previous birth was protracted due to weak labor. Lack of labor in the past, with a certain degree of probability, may indicate inferiority of the muscular wall of the uterus, which can progress with each subsequent birth. If we take into account that the size of the fetus may be larger than during previous births, then the incompetence of the uterine wall can lead to its rupture.
4. Pregnant women with a large fetus, abnormal fetal position, or post-term pregnancy.
5. Women who have suffered postpartum and post-abortion inflammatory diseases in the past. To identify this contingent of women, it is necessary to carefully collect anamnesis. As a result of endomyometritis, part of the muscle tissue of the uterus is replaced by connective tissue, which is unable to contract or stretch. These changes in the uterine wall are especially dangerous if they are localized in the isthmus area.
All pregnant women who are in the group at risk of uterine rupture should be prophylactically hospitalized in a maternity hospital 2-3 weeks before the expected date of birth. Women with a history of uterine surgery are sometimes hospitalized even earlier if they experience even the slightest abdominal pain. Childbirth in this contingent of women in labor is carried out under the supervision of a doctor.