A second cesarean section is recommended for women who cannot or do not want to give birth to a second child on their own, since the very fact of having the first operation does not exclude the possibility of giving birth on their own in a second pregnancy. If the second surgical delivery is coming, it is important for a woman to know some of their peculiarities. In this article we will tell you how long the reoperation is carried out, how it differs from the first one.
The need for reoperation
A second birth after a caesarean section does not need to be performed surgically. Subject to certain conditions, a woman may well be allowed to give birth on her own. But no more than a third of pregnant women with one cesarean section in history go to this. The patient's categorical disagreement with physiological childbirth with a scar on the uterus is the first and most compelling reason for reoperative labor.
But even when a pregnant woman dreams of giving birth on her own, she may not be allowed to do so if there are absolute indications for a second operation.
- Small or long time after the first birth. If less than 2 years or more than 7-8 years have passed, then the “reliability” of the connective tissue of the uterine scar will cause justified concerns among doctors. Only 2 years after the birth of the first child, the healing site of the scar becomes quite strong, and after a long break it loses its elasticity. In both cases, the danger is the likely rupture of the reproductive organ at the site of the scar at the time of strong contractions or attempts.
- Complications after a previous birth. If the rehabilitation period after surgical delivery is difficult: with fever, inflammation, associated infections, uterine hypotonia, then the second child, with a high probability, will also have to give birth on the operating table.
- Inconsistent scar. If at the time of pregnancy planning its thickness is less than 2.5 mm, and by 35 weeks - less than 4–5 mm, then there is a possibility of uterine rupture during spontaneous childbirth.
- Large baby (regardless of his presentation). Multiparous after cesarean section can give birth to a baby through natural physiological pathways only if the estimated weight of the child is less than 3.7 kg.
- Wrong position of the baby. Options with manual reversal of the baby for a woman with a scar are not even considered.
- Low location of the placenta, placenta previa in the scar area. Even if the “child's place” touches the scar area with the edge, it is impossible to give birth - only to be operated on.
- Vertical scar. If the incision during the first delivery was made vertically, then independent labor in the future is excluded. Only women with a well-to-do horizontal scar in the lower uterine segment can theoretically be allowed to give birth on their own.
In addition, fatal reasons that led to the first operation are considered absolute indications for repeated surgical childbirth: a narrow pelvis, anomalies of the uterus and birth canal, etc.
There are also relative indications for a second operation. This means that the woman will be offered a caesarean section in her second pregnancy, but if she refuses, a natural delivery option can be chosen. These indications include:
- myopia (moderate);
- oncological tumors;
- uterine fibroids;
- diabetes.
The decision to re-operate, if the woman does not object to this method of delivery and there are contraindications from the category of absolute, is made when the pregnant woman is registered. If there are no contraindications, the woman wants to give birth herself, then they will choose the method of childbirth after 35 weeks of pregnancy at a medical consultation.
Dates
The Russian Ministry of Health strongly advises maternity hospitals and clinics to adhere to clinical guidelines when performing a caesarean section. This document (Letter of the Ministry of Health of the Russian Federation dated May 6, 2014 No. 15-4 / 10 / 2-3190) prescribes an operation after 39 weeks of pregnancy. This applies to both the first and the second cesarean section. As a justification, the risk of possible immaturity of the lung tissue of the fetus before 39 weeks is indicated.
In practice, they try to carry out the second caesarean section a little earlier than the first, since the onset of labor on its own, the contractions that appear can pose a mortal danger to the child and mother associated with rupture of the uterus. Most often, the second surgical delivery is done at 38–39 weeks of gestation.
If, at a scheduled examination at a later date, the doctor discovers the precursors of a woman: the passage of the plug, the readiness and maturity of the cervix, its smoothing, the timing of the operation can be postponed to an earlier time.
For emergency indications, the operation in the second pregnancy is carried out at any time to save the life of the fetus and mother. Emergencies include prolapse of the umbilical cord, signs of the onset of uterine rupture during gestation, placental abruption ahead of schedule, signs of acute hypoxia and other fetal problems, in which it is mortally dangerous for him to remain in the mother's womb.
If a woman is a supporter of the opinion that the COP should be done as close as possible to the expected date of birth, then theoretically the operation can be performed (in the absence of contraindications for expectant tactics) at any time from 39 to 40 weeks.
Training
Preparation for the second elective surgery begins during pregnancy. A woman with a scar on her uterus should visit her obstetrician-gynecologist more often than other pregnant women. In the third trimester, it is necessary to monitor the condition of the scar in order to notice possible signs of its thinning in time. To do this, it is recommended to do an ultrasound scan with a Doppler every 10 days.
The woman is hospitalized in the maternity hospital in advance. If during the first planned operation you need to go to the hospital about a week before the operation, then for a second CS, you need to go to the hospital under the supervision of doctors at 37-38 weeks in order to prepare for the upcoming birth.
Doctors prepare in their own way: they must once again examine the pregnant woman, establish the exact location of the scar, its features, take tests, and agree on the method of anesthesia with the patient.
The day before the operation, the anesthesiologist conducts a conversation with the woman. In the evening before the operation, premedication begins: the expectant mother is given a strong sedative (usually barbiturates) so that she can get the best sleep and rest at night. This will protect her from changes in blood pressure under anesthesia.
In the morning of the day of surgery, a woman's pubis is shaved, an enema is given to cleanse the intestines, and it may be recommended to bandage the legs with elastic medical bandages to prevent thrombosis.
Features of the operation
The main feature of a repeated cesarean section is that the operation takes a little longer than the first one. A woman should warn her relatives about this so that they do not worry in vain. Surgeons need additional time to remove the first scar. Each subsequent surgical delivery is performed on the previous scar. Therefore, situations are completely excluded in which after the first operation the woman had a vertical suture, and after the second there will be a horizontal one.
If the operation was with a longitudinal incision, then the second time the incision will be made in the same place, excising the old connective tissue so that a new scar can form without hindrance. Needless to say, with each cesarean section, the scar becomes thinner and thinner, and the risks for gestation increase!
If the woman no longer plans to give birth, then she can sign a consent for surgical sterilization in advance. After removing the baby, doctors begin to ligate the fallopian tubes - the onset of subsequent pregnancy becomes impossible. This simple manipulation can extend the total time the patient will spend in the operating room by another 10-15 minutes.
Having opened the abdominal cavity, the doctor carefully, so as not to injure, removes muscle tissue aside, as well as the bladder. Then an incision is made directly on the walls of the uterus, the fetal bladder with amniotic fluid and the baby is pierced. The water is drained, the child is taken out of the incision, the umbilical cord is cut off and handed over to neonatologists. If a woman is not in a state of deep medication sleep (general anesthesia), then at this stage she can already look at her baby, touch him. Such an opportunity is provided by such types of pain relief as epidural or spinal anesthesia.
While the mother admires the child or is sound asleep under general anesthesia, the doctor separates the placenta with his hands, checks if there are any particles left in the uterine cavity, and puts several rows of internal sutures on the reproductive organ. In the final part of the operation, the normal anatomical location of the muscles and bladder is restored and external sutures or braces are applied. This completes the operation. For the next few hours, the parturient woman is assigned to the intensive care unit for close observation of her in the early postoperative period. The baby is sent to the children's department, where he will be treated, bathed, examined by doctors, and blood tests will be taken from the baby.
How is the recovery going?
The recovery period after a second cesarean section also has its own characteristics. A woman recovers longer than after the first operation, and this is quite natural, because the muscles of the uterus are more stretched, and reopening of this muscular organ complicates the postpartum involution of the uterus. After the operation, the uterus remains quite large, but looks more like a deflated balloon or empty sac. She needs to shrink to its previous size. This process is considered the most important in involution.
To help the postpartum woman, doctors from the first hours after transfer from the operating room to the intensive care unit begin to inject her with reducing drugs. After a few hours, the woman is transferred to the general postpartum ward, where she is advised not to lie down for a long time. It is optimal to get up within 10-12 hours after the operation. Physical activity will promote the involution of the uterus. For the same purpose (and not only for this!) it is recommended to attach the baby to the breast as soon as possible. The baby will receive nourishing and healthy colostrum, and the production of its own oxytocin in the body of his mother will increase, which will definitely have a positive effect on the contractility of the uterus.
The woman is shown a diet up to 4 days after the operation, aimed at preventing constipation and bowel pressure on the injured uterus. The first day is only allowed to drink, on the second day you can eat broth, jelly, white croutons without salt and spices. Only by the fourth day can a woman eat everything, but avoid foods that stimulate the production of intestinal gases.
Lochia (postpartum discharge) after the second surgery usually ends completely by 7-8 weeks after surgery. The stitches are removed 8-10 days after the operation (in consultation at the place of residence), the woman is discharged from the maternity hospital in the absence of complications on the fifth day, as in the case of the first surgical delivery.
Reviews
A repeated cesarean section, according to women, practically does not differ from the first in the subjective feelings of the woman in labor herself. The difference begins to be felt only after the operation, during the rehabilitation process. But, despite its longer nature, women usually get out of bed faster, since they already know exactly how to do this. Also, those giving birth to a second child surgically know well what complications can be after surgery, and therefore listen more closely to changes in their body in the first days after the birth of a baby.
Lactation after the second operation is most often established earlier than after the first one. This is due to the better preparation of the nipples and milk ducts for the upcoming breastfeeding.
According to reviews, few agree to surgical sterilization during the second operative delivery, since women want to maintain fertility, because the third cesarean section today is not a curiosity, and all life circumstances are difficult to predict in advance.
For information on what you need to know about preparing for a caesarean section, see the next video.
