Modes of delivery for women with scarring uterus re-pregnancy include trial of labor after cesarean section (TOLAC) and elective repeated cesarean section (ERCS). Vaginal trial after caesarean section refers to a second pregnancy attempt at vaginal delivery by a woman with a history of caesarean section. Re-pregnancy vaginal delivery after caesarean section refers to a successful vaginal delivery in this pregnancy by a woman with a previous history of caesarean section. Compared with repeated caesarean section, the advantages of re-pregnancy vaginal delivery after caesarean section are: short hospital stay and rapid maternal recovery; low absolute risk of maternal perinatal death; lower incidence of pelvic adhesions; low risk of previa and placenta implantation in re-pregnancy after successful vaginal delivery; low incidence of neonatal respiratory diseases of 2% to 3%; and low maternal mortality rate of 0.004%. Although post-caesarean vaginal trial delivery is suitable for most women who re-conceive after caesarean section, some influencing factors increase the possibility of failure of vaginal trial after caesarean section, so it is necessary to assess the adaptability and risk of vaginal delivery after caesarean section, and to manage the vaginal delivery for women.
Safety assessment of vaginal trial delivery after caesarean section
01
Contraindications to vaginal trial delivery after caesarean section are: previous surgical procedure is longitudinal incision; history of lower uterine caesarean section with two ≥; previous history of uterine rupture; contraindications to vaginal delivery, such as placenta previa, placental abruption, and refusal of a pregnant woman to try labor.
02
After contraindications are ruled out, a prenatal predictive evaluation is performed [4]. In a study by foreign scholars Kalok et al. [5], the safety and feasibility of vaginal trial obstetric trial after caesarean section were evaluated using the prenatal scoring table for vaginal trial after caesarean section, as a tool for judging the success rate or risk of failure of vaginal trial after caesarean section, including 5 items:
Transverse incision of the lower uterus, no dildont fissure, recovery as scheduled, no late postpartum haemorrhage and postpartum infection, 18 months ≥ from the previous caesarean section;
History of vaginal delivery and trial labour;
Pregnant women < 35 years;
Body mass index<30;
Through clinical evaluation or ultrasonography, the gestational age of the delivery < 40 weeks, the fetal body mass < 4000g, ultrasound measurement of the thickness of the lower uterine muscle layer and the continuity of the uterine incision muscle layer, to establish a personalized independent evaluation form.
In the above scores, there are 2 points and 1 point each, for a total score of 7 points. The prenatal prediction score for vaginal trial delivery after caesarean section ≥ 4 points, and the success rate of vaginal delivery after caesarean section is 81%.
Observation and care of labour
Strengthen the observation of labor in the first stage of labor, and implement one-on-one midwifery to accompany delivery, special supervision and nursing. Close observation of uterine contractions, the frequency of which is appropriate 3 to 4 times every 10min, especially whether there is a pathological contraction ring, whether there is persistent pain and tenderness at the uterine incision. Closely monitor fetal heart sounds and detect fetal heart rate abnormalities in time. If there is a slow fetal heart sound, forced contractions, abnormal pain and tenderness at the uterine incision, vaginal bleeding, bloody urination, and unclear fetal position, it indicates a risk of uterine rupture, of which slow fetal heart rate is the most important factor suggesting uterine rupture. During the progression of labor, the mother is instructed to urinate once every 2 to 3 hours to prevent the bladder from compressing the fetal exposed part due to excessive urine output, which affects the decline of fetal prelude and the intensity of uterine contractions. Pay attention to the timing of amniotic membrane rupture and operate under the guidance of a doctor to prevent the occurrence of emergency caesarean section. Cervical maturity score >7 points, and low-concentration, low-dose infusions of oxytocin can be used when indications for induction of labour are indicated. However, contractions should be controlled according to the frequency of contractions and the subjective feelings of the mother, with a frequency of 3 to 4 times every 10 minutes, to prevent the risk of uterine rupture caused by forced contractions. When the course of labour is active, cervical dilation stops for 3 h or more, the risk of uterine rupture increases, and caesarean section is recommended.
The second stage of labour closely observes the progress of labor and trains the mother to effectively cooperate with the midwife. Continuous monitoring of fetal heart sounds and maternal vital signs ensures the presence of an experienced obstetrician and anesthesiologist. The incidence of perineal trauma in women undergoing vaginal trial delivery after caesarean section is 12.3%, and some studies have pointed out that the use of sitting, lateral recumbent or standing position in the second stage of vaginal trial delivery after caesarean section has a slight protective effect on the maternal perineum, while the use of lithotripsy for delivery increases the risk of perineal injury. Therefore, in the second stage of labour, the position can be adjusted according to maternal needs and comfort to meet maternal needs and agency. When maternal contractions are weak or ineffective through the correct use of abdominal pressure, or when there is a frequent late fetal heart rate deceleration, shorten the second stage of labor as much as possible, and immediately give perineal cut forceps to end delivery after the exclusion of obvious cephalic asymmetry and fetal exposure has reached the level of sciatic spines 2 to 3 cm, reducing the probability of scarring of the lower uterus.
03
Intravenous infusions of oxytocin are given immediately after the delivery of the fetus in the third stage of labour, and the treatment of the placenta is not special. Although uterine rupture occurs less frequently in the third stage of labour than in other labours, the maternal situation still needs to be closely observed and monitored. Maternal persistent vaginal bleeding should be vigilant against the occurrence of uterine rupture, timely assessment of the amount of bleeding and maternal vital signs, if the mother has decreased blood pressure, irritability, increased heart rate, vaginal bleeding, and blood clots, it is necessary to quickly establish a venous channel, under the guidance of a doctor for transvaginal uterine probe or pelvic ultrasound, to exclude the possibility of uterine rupture, check for active bleeding, and take effective hemostasis or transfusion measures. At the same time, the common symptom of vaginal delivery after caesarean section is contraction weakness, so the postpartum hemorrhage caused by uterine rupture should be distinguished from the postpartum haemorrhage caused by uterine rupture to buy time for first aid.
brief summary
Scarred uterus pregnant women will face more risks when undergoing vaginal trial labor, in the clinic should be timely analysis of relevant factors, through detailed interpretation, clear need to take targeted measures to ensure that the success rate of maternal vaginal trial delivery is steadily improved, to protect the safety of women and fetuses.
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