One of the complications after a cesarean section is suture divergence. The external seam can disperse, and this will immediately become obvious, or the integrity of the internal one may be violated, and this can only be seen with the help of diagnosticians. The discrepancy can happen after the operation, and years later, when the woman wants to feel the joy of motherhood again. In this article, we will talk about why the seams diverge, what to do if this happens, and how to prevent this situation.
Internal and external seams
During an operative delivery, the surgeon dissects not only the abdominal wall, but also the anterior wall of the uterus. Immediately after the birth of the fetus and removal of the placenta, separate stitches are applied to each incision. Various suturing techniques are used for the inside and outside seams, as well as special materials.
When the operation is planned, a horizontal section is most often done just above the pubis (in the lower segment of the uterus). An emergency caesarean section can be performed with an abdominal dissection, both horizontally and vertically, depending on how urgently the baby needs to be removed.
When forming the inner seam, the surgeon has no right to make a mistake - the edges of the wound should match as closely as possible. Even a slight displacement can lead to the formation of a rough and inconsistent scar. Sutures for suturing the uterus are usually self-absorbable, and then these sutures do not need to be removed or processed. Most often, the uterus is sewn with a single-row continuous suture.
Outside seams can be overlaid with stitches. Materials for the external suture can be different - silk surgical sutures, self-absorbable sutures, medical alloy staples. Recently, in a number of clinics, a new method of soldering the seam with liquid nitrogen has been practiced, that is, without the use of threads at all.
External seams can be cosmetic or conventional. The first ones then look more aesthetically pleasing. If we talk about the external seams, then the horizontal section according to the Pfannenstiel is always more preferable, since the probability of its divergence is much lower than with the corporal section (vertically from the navel to the pubic zone). Horizontal outer seams heal better than vertical ones.
The healing process takes place in different ways. Internal sutures on the uterus take about 8 weeks to heal. After this time, a long, almost two-year formation of a strong and reliable scar begins. If negative factors do not intervene in this process, it will be quite strong and will be able to withstand the bearing of the next child and even in some cases physiological childbirth in the most natural way without any problems.
If more coarse connective tissue is formed during formation, then the scar may be incompetent. This would pose a risk of his discrepancy in the future if the woman becomes pregnant.
The outer suture heals in a little over a week, after which the sutures are removed if they are not self-absorbable. A vertical suture after a corporal caesarean section heals in about 2 months and requires more careful maintenance.
Types of violation
All problems with the condition of the seam can be roughly divided into early and late. The early ones are those that make themselves felt in the coming days or weeks after the operation. The late ones include problems that are significantly removed in time from the moment of surgical intervention.
Early complications can include:
- bleeding from the external seam area;
- internal bleeding;
- the formation of hematomas in the area of scars;
- inflammatory process (both internal and external);
- divergence of the inner or outer seam.
Late complications are the formation of fistulas, hernias and divergence of the uterus along the scar during the next pregnancy or in childbirth.
Reasons for discrepancy
There are a lot of reasons that can lead to divergence of the seams both inside and outside, but the leading place is given to the violation of the regimen recommended during the rehabilitation period. So, both external and especially internal seams can suffer due to improper motor activity of the puerpera.
It is recommended to get up after the operation only after 8-10 hours, but some try to do it earlier, which leads to early injury to the sewn up areas. Inaccurate attempts to get up, sit down after the operation, and subsequently ignore the requirement to limit the lifting of weights to 3-4 kilograms are the main reason why the seam has come apart.
The reason for the discrepancy of the postoperative sutures may be infection. Both the internal and external wound surfaces can be infected. In general, infectious complications after a cesarean section are one of the most formidable and most probable, despite the sterility in the operating room and technical progress. Inflammation or suppuration disrupts the process of healing the edges of the wound, which may well be expressed in a violation of the integrity of the seam.
Another reason, not the most common, but very likely, is the immune response of the woman's body to the surgical material that has been sutured. Immunity is generally quite difficult to understand, and therefore it is never possible to say in advance whether the sutures will take root, especially internal self-absorbable ones. If the immune system begins to reject them, an inflammatory process will inevitably begin, which will lead to a violation of the integrity of the scar. A certain negative immune reaction can also occur on the external suture material.
The reason for the violation of the state of the internal seams may be too active contractions of the uterus after surgery. But hypertonicity of the reproductive organ after surgery is quite rare.
Signs and symptoms
With the definition of problems in the state of the external seam, usually no questions arise. The area of overlapping threads is reddened, hematomas can be observed, blood or blood oozes from the wound, pus can be observed. In this case, the body temperature usually rises. The suturing area hurts, the seam “burns”, pulls, worries even in the supine position. The discrepancy in itself is manifested by the formation of a hole of a certain size (depending on how many stitches did not take root or were rejected as a result of inflammation or mechanical injury).
It is more difficult to understand that there are problems with the inner seam. In this case, the picture will be somewhat blurred and similar to a number of other complications after surgery. But an experienced doctor will first of all suspect the discrepancy of the scars and check these suspicions using certain diagnostic methods.
If there are problems with the healing of the suture on the uterus, the woman will have a high temperature. Discharge from the genitals will be much more abundant than after normal uncomplicated surgery, and large fragments of suture material may be present in them. The general condition of the pregnant woman will rapidly deteriorate. Blood pressure decreases, episodes of loss of consciousness, heart palpitations may occur. The skin becomes pale, sweating increases.
The appearance of bumps on the external scar area cannot be ignored. It can be both a hernia and a fistula, if the bumps themselves are filled with pus and ichor.
Discrepancy in repeated pregnancy
The danger of a suture after a cesarean section on the uterus lies in the fact that it may not withstand the next pregnancy and disperse. Especially the risks of discrepancy increase when:
- pregnancy that came too quickly after the first operation (less than 2 years have passed);
- inconsistent, heterogeneous internal scar;
- large fruit.
To control the stretching of the internal scar on the uterus during pregnancy, a woman repeatedly does an ultrasound scan to determine the thickness and zones of thinning of the internal suture. But to stop the beginning of the rupture of the uterus, alas, it is impossible.
Why such a discrepancy is dangerous is quite obvious - the death of the fetus and its mother. Moreover, the woman dies from massive bleeding into the abdominal cavity, and the fetus from acute sudden hypoxia, which occurs due to a violation of the uteroplacental blood flow at the time of rupture of the uterus.
The first stage - the stage of a threatening rupture - cannot be felt in any way. It has no symptoms, and only an ultrasound diagnostician is able to determine this condition. In this case, the woman undergoes an emergency caesarean section.
The beginning rupture of the suture on the uterus is characterized by sharp abdominal pain, the development of pain shock is not excluded. Blood pressure drops, tachycardia appears. The baby's normal heart rate slows down sharply.
A completed rupture may be accompanied by the development of heavy, profuse bleeding. If this happens during childbirth, if a woman decides to give birth with a scar on the uterus on her own, then an emergency cesarean section is also performed. The uterus is removed in most cases.
How to behave in such cases?
Given the seriousness of the situation, if any problems with the seams are found, the woman should immediately inform the doctor about them. If problems are found in the maternity hospital, a woman's temperature rises, postpartum discharge becomes more abundant, there are signs of a problem with the external scar, then this cannot be hidden from the medical staff. The woman will be helped. If the problem is found already at home, after discharge, the woman needs to take a horizontal position, call an ambulance and wait for the arrival of the brigade. You should not go to clinics and antenatal clinics on your own, since the discrepancy may increase, and if we are talking about the inner seam, it goes on for hours.
When calling an ambulance, you must inform that you suspect scar dehiscence and describe in detail your current state of health. This is important, because in this case, an obstetrician on duty will be included in the team of doctors.
Suture infections are usually treated with antibiotics, both systemically and topically. With an internal discrepancy, a woman undergoes a surgical operation to impose new sutures or remove the uterus if it is not possible to close the gap.
If a rupture of the internal scar is found at any stage during a subsequent pregnancy, it cannot be prolonged. A delivery operation is performed. If the baby is very premature, he, alas, may not survive. If a woman is taken to a medical facility late, she, unfortunately, also may not survive.
Prevention
Suture problems are easier to prevent than to cure. Given the severity of the consequences of the discrepancy of the postoperative sutures, a woman should strictly follow the recommendations after a cesarean section:
- lifting weights is strictly prohibited, the limitation is 3-4 kg for at least six months;
- squat, fall, jump abruptly, the press should not be pumped up to six months after the operation;
- after discharge, the outer seam must be treated every day - dried with hydrogen peroxide, lubricate the area around it with brilliant green;
- before removing the stitches, it is imperative to wear a surgical bandage on the wound; after removal, the decision to wear it is made individually, depending on the condition of the seam;
- sex earlier than 2 months after surgery is contraindicated - the likelihood of mechanical injury to the internal seams and infection increases;
- when performing hygiene procedures, a woman should make sure that tap water does not get into the vagina, you cannot douche;
- before planning a re-pregnancy, you need to be examined and an ultrasound scan done to determine the thickness of the scar.
For information on how to care for a suture after a cesarean section, see the next video.
