Scarred uterus re-pregnant women through the vaginal delivery of the nursing care, these points you mastered?

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 woman with a history of caesarean section who is pregnant again and attempts vaginal delivery [1]. Vaginal delivery after another pregnancy after caesarean section refers to a successful vaginal delivery during this pregnancy by a woman with a previous history of caesarean section [1]. 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 placenta previa and placental implantation in re-pregnancy after successful vaginal delivery; low incidence of respiratory disease in newborns of 2% to 3%," and low maternal mortality rate of 0.004%[2]. 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

(1) The contraindications to vaginal trial delivery after caesarean section are: the previous surgical method is longitudinal incision; the history of lower uterine caesarean section ≥ twice; the previous history of uterine rupture; and the contraindications to vaginal delivery, such as placenta previa, placental abruption, and refusal of trial labor by pregnant women [3].

(2) After the contraindications are excluded, a prenatal predictive assessment is performed [4]. In the study of foreign scholars Kalok et al. [5], the safety and feasibility of post-caesarean section vaginal trial obstetric trial were evaluated by using the post-caesarean section vaginal trial obstetric scoring table as a tool for judging the success rate or risk of failure of vaginal trial after caesarean section, including 5 items: lower uterine transverse incision, no dilation of the incision, on schedule, no late postpartum hemorrhage and postpartum infection, ≥ 18 months from the previous caesarean section; there was a history of vaginal delivery and trial delivery; the pregnant woman's age < 35 years; and the body mass index <30 Through clinical evaluation or ultrasonography, the gestational age of this 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, the establishment of 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 obstetrics after caesarean section ≥4 points, and the success rate of vaginal delivery after caesarean section is 81 percent [5].

Observation and care of labour

(1) Strengthen the observation of labor in the first stage of labor, and implement one-on-one midwives 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. Slowing of fetal heart sounds, forced contractions, abnormal pain and tenderness at the uterine incision, vaginal bleeding, bloody urination, and unclear fetal position suggest a risk of uterine rupture, of which slow fetal heart rate is the most important factor suggestive of uterine rupture [6]. 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 [7], 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.

(2) The second stage of labor 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 labour after caesarean section is 12.3% [8], and it has been suggested that the use of sitting, lateral recumbent, or standing positions 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 [9]. 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.

(3) Immediately after the delivery of the fetus in the third stage of labor, hysterolone intravenous drip is given, 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. Persistent vaginal bleeding in pregnant women 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 volume, and blood clots, it is necessary to quickly establish an intravenous channel, under the guidance of a doctor, transvaginal uterine cavity exploration or pelvic ultrasound examination to rule out the possibility of uterine rupture, check for active bleeding, and take effective hemostasis or transfusion measures [10]. 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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