Ultrasound diagnostics and scar assessment
Modern imaging methods play a key role in assessing tissue condition. The niche sign is detected by ultrasound using HDlive technology in non-pregnant patients with a uterine scar after a previous cesarean section.
During gestation, the echographic picture may demonstrate critical thinning of the myometrium in the scar area. Specifically, an objective criterion of scar incompetence can be a lower uterine segment thickness of only 1.3 mm.
Hospitalization and delivery options
Planned hospitalization of patients with a uterine scar is carried out at 38–39 weeks of gestation provided there is a competent postoperative scar. The main goal of hospitalization is to determine the further management of labor.
There are two main delivery options:
- Surgical delivery (repeat cesarean section).
- Vaginal birth.
Indications for re-operation
The need for a repeat cesarean section is due to the following factors:
- Persistence of the indications for the primary CS: complications of the previous surgery, such as an anatomically narrow pelvis, advanced maternal age, or visual impairment.
- Complications of the current pregnancy: conditions requiring surgical intervention (placenta previa, multiple pregnancy, or breech presentation combined with fetal macrosomia).
- Scar incompetence: objective and indirect data indicating inadequacy of the lower uterine segment in the suspected scar area.
Vaginal birth after cesarean
The possibility of a trial of labor is determined by strict conditions:
- Absence of signs of scar incompetence, confirmed by clinical data and ultrasound results.
- Sufficient cervical ripening at term pregnancy.
- Voluntary and informed consent of the patient.
During labor, careful monitoring of uterine activity, as well as maternal and fetal condition, is required. In case of labor dystocia, oxytocin may be used, but strictly in the absence of symptoms of uterine rupture. In the early postpartum period after spontaneous delivery, manual exploration of the uterine cavity is mandatory.
Briefly: answers to topical questions
What are the main causes of symphysis pubis diastasis?
The main causes of symphysis pubis diastasis are traumatic pelvic injuries.
- Traumatic injuries occur when significant force (high-energy trauma) is applied to the pelvic ring: external rotation, internal rotation, and vertical shear forces. These include type B1 injuries ("open book") and anteroposterior compression.
What are the characteristic symptoms of symphysis pubis diastasis?
The characteristic symptoms of symphysis pubis diastasis are severe pain and impaired motor functions.
- Pain syndrome — pain is localized in the area of the pubic symphysis, sacrum, and coccyx. Sharp pain occurs when abducting the thighs and increases with walking.
- Static and gait disorders — the patient's gait is impaired (a "waddling gait" may develop in the long term).
- Urological disorders — urinary disorders may occur in the long term due to prolapse of the anterior bladder wall.
In obstetric practice, symptoms usually manifest on the 2nd–3rd day postpartum.
What are the treatment and rehabilitation methods for symphysis pubis diastasis?
Treatment and rehabilitation for symphysis pubis diastasis include conservative, surgical, and restorative methods.
- Conservative treatment — includes rest, bed rest (side-lying or in a hammock), tight pelvic binding, the use of corsets and special belts, as well as skeletal traction. The lower extremities must be flexed and adducted.
- Surgical treatment — indicated for significant bone diastasis or failure of conservative therapy. Open reduction and internal fixation with a fixing plate or an external fixation device is used.
- Rehabilitation — requires the development of individual programs, consultation with a medical rehabilitation specialist, and the prescription of physical therapy in the postpartum period to accelerate tissue repair.
Hospitalization at 38–39 weeks, 1.3 mm — critical scar, and mandatory manual uterine exploration after delivery.
Class and exam questions
When are pregnant women with a uterine scar hospitalized?
Hospitalization is carried out at 38–39 weeks of gestation, provided there is a competent postoperative scar, to determine the management of labor.
What are the mandatory conditions for vaginal delivery?
Requirements include the absence of signs of scar incompetence based on ultrasound and clinical findings, cervical ripening at term, and mandatory patient consent.
What mandatory procedure is performed in the early postpartum period after spontaneous delivery?
Manual exploration of the uterine cavity is mandatory.
What else to study on this topic
- Classification of types of uterine rupture during pregnancy and childbirth
- Etiology and mechanisms of mechanical uterine rupture (spatial disproportion)
- Etiology and mechanisms of histopathic uterine rupture (uterine wall alterations)
- Stages of the clinical picture of mechanical uterine rupture (threatened, incipient, complete)
- Stages of the clinical picture of histopathic uterine rupture
- Intraoperative picture of an incompetent uterine scar
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