Cesarean section in the interests of the fetus

Currently, in-depth development of questions about the role of Caesarean section in reducing perinatal morbidity and mortality. A number of studies found that with the expansion of indications for this operation, perinatal morbidity and mortality decreases, but these indicators largely depend on the timeliness of the determination of the fetus and the time of the operation. Scientists have made a significant contribution to the development of this problem. As early as 1908, NN Phenomenov wrote in his manual "Operative Obstetrics" that in the interest of the fetus, the operation of cesarean section should be undertaken as early as possible from the onset of the birth act. Scientists note that the role of Caesarean section in reducing perinatal morbidity and mortality can be clarified to some extent when studying the course of labor that resulted in stillbirth or the birth of children in a state of severe asphyxia. The authors showed that in 85% of the cases, these births were accompanied by a weakness of the ancestral force, which is not amenable to drug therapy. At some parturient women at the same time there was a malaise or large size of the fetus. In childbirth in the pelvic presentation of the fetus, the combination of weakness in labor and large child sizes is particularly unfavorable. At the same time, the weakness of the ancestral forces in the first stage of labor in each of the 2 nd parturient women is renewed or aggravated in the II period, which is the cause of the severe condition of newborns. Attention is drawn to a small percentage of the primigravid elders, whose children were born in serious condition. Consequently, the authors conclude, the perinatal morbidity and mortality can be reduced by expanding the indications for cesarean section in parturient women with a persistent weakness of the birth forces, especially in the presence of a large fetus, pelvic presentation, pregnancy masturbation. But the outcome of the caesarean section for the fetus is largely determined by the timeliness of the operation. Scientists indicate that in a cesarean section performed during pregnancy, perinatal mortality was 3%, the birth of children in severe asphyxia was detected in 4.3% of newborns. The severity of the condition of children was due to severe forms of late toxicosis, premature detachment of the placenta, deep prematureness of children.

At a caesarean section, performed during childbirth, lasting up to 16-17 hours, perinatal mortality is significant, the birth of children in asphyxia - 7%. The duration of childbirths that preceded the operation, more than 17 hours, contributed to an increase in perinatal mortality and the frequency of the birth of children in severe asphyxia. At a caesarean section, performed during childbirth, the severity of the condition of newborns was most often due to asphyxia and intracranial trauma.

The state of newborns depends on the severity of late toxicosis in the mother, timeliness and method of delivery. In the cesarean section, the state of the children was better when the operation was performed in a planned manner before the development of severe complications in the mother. Cesarean section, as a method of delivery in patients with concomitant toxicosis, does not have advantages over delivery through natural birth canals. However, with severe toxicosis and the absence of the effect of intensive therapy, delivery by caesarean section is justified, especially in women with suspected immune deficiency. When discussing the tactics of managing pregnancy and childbirth in intensive care for severe forms of late toxicosis, it is believed that abdominal delivery is appropriate in pregnant women with the most severe course of toxicosis in the absence of a therapeutic effect and the presence of a viable fetus in the immature cervix of the uterus, as well as deterioration of the maternity or fetus during spontaneous delivery.

It is necessary to pay attention to another circumstance. Thus, according to research, for the last decade the level of perinatal mortality has decreased in the following types of obstetric pathology: clinically narrow pelvis, scar on the uterus, abnormalities of labor. In these groups of pregnant women, there was no loss of children. At the same time, the rates of perinatal mortality in pregnant women with high-risk factors (age over 35 years in the first-pregnancy, weighted obstetric history, pelvic fetal presentation, extragenital diseases, late toxicosis, etc.) have not yet been reduced in the pathology of attachment and separation of the placenta. It is believed that the use of caesarean section in pathologies that threaten the life of the fetus and the newborn, the organization of a department for nursing preterm and traumatized newborns, and the availability of specially trained personnel for resuscitation and intensive care contribute to a reduction in perinatal mortality.

It is important to pay attention to the other. Some authors believe that the extension of indications for cesarean section in the interest of the fetus does not solve the problem of reducing perinatal mortality. A more real factor in this aspect should be considered the widespread introduction of early diagnosis of intrauterine suffering and fetal hypoxia and their treatment, which reduces the frequency of cesarean sections according to indications from the fetus. In this connection, it is necessary to stop the attention in other works. Thus, scientists have shown that a fairly large group - 36.5% were women, whose abdominal delivery was performed in the interests of the fetus. A comprehensive examination of the fetal condition in 26.4% of cases of all those observed allowed the timely issue of the issue of delivery of women by caesarean section exclusively in the interests of the fetus. It is believed that the expansion of indications for surgery is in connection with the use of complex measures of early diagnosis of fetal hypoxia and the rejection of traumatic fetus of operative vaginal delivery. When analyzing the structure of indications for cesarean section in the interest of the fetus, the authors indicate that in the last three decades the frequency of the operation has increased from 19.5 to 51.3%, mainly due to early-identified fetal hypoxia, which contributes to an improvement in the outcome of labor for the fetus and reduction of perinatal mortality. At the same time, perinatal mortality after planned operations is much lower than after emergency. At the same time, some doctors emphasize that a cesarean section before the onset of labor is a risk factor for the newborn. The reason for this is the absence of the birth factor, which is a necessary physiological measure of the effect on the fetus, which ensures timely initiation of compensatory reactions of the fetus and the most optimal support for its transition to extrauterine existence. Also emphasize that the adaptation of children obtained by cesarean section in the first days of life is more difficult than with physiological births. Therefore, some doctors suggest that when babies are born by cesarean, insert them into the vessels of the umbilical cord.

According to some doctors, the reserves of reducing perinatal and maternal mortality are not associated with an increase in the cesarean section, but are laid in the rational management of pregnancy and childbirth, timely diagnosis and treatment of obstetric and extrgenital pathology in the women's consultation. Most scientists note that a timely operation reduces perinatal mortality. Thus, the current state of the issue of abdominal delivery in the interest of the fetus is not sufficiently developed, the most informative indicators for the operation at the end of pregnancy, in the process of the generic act, have not been worked out. Therefore, when developing indications and contraindications to cesarean section based on clinical and monitoring observations, two main aspects of this problem should be distinguished:

• revealing the most informative signs of fetal suffering by various objective methods;
• an integrated approach to eliminating fetal abnormalities and determining the time for cesarean section surgery, since a belated operation with irreversible changes in fetal organs and systems gives predictably poor results, both near and far.

In the foreign literature, significant progress was made in the work, which also discusses modern indications for cesarean section in the interests of the fetus. However, a critical analysis of a number of works does not give grounds for talking about the unity of the development of this question, even in general terms. It is the diversity of positions and points of view that testifies to the complexity of the problem. There have been quite a few studies on this subject in recent years. Their value is beyond doubt. However, another important point is that any significant methodological results, especially in the complex evaluation of the fetal condition, available to a wide range of practical doctors, were not fully achieved, and such results were expected with special hopes. At the same time, the role of monitored fetal monitoring in increasing the frequency of caesarean section in the US remains controversial. So, according to Mann, Gallant, for the last 4 years the cesarean section rate in the USA has increased from 6.8 to 17.1%, while about fetal suffering has increased to 28.2%, and then in the last two years has decreased to 11 , 7%. An identical regularity was noted in the work of Gilstrap, Hauth et al. A special increase in the frequency of cesarean sections in the fetus's interests was noted in hospitals functioning as perinatal centers. An analysis of the trends in the development of this problem of developing indications for this operation revealed significant changes in the disparity of the pelvis and fetal head, bleeding in the third trimester of pregnancy, and incorrect fetal positions. At the same time, it should be said that most US institutions disapprove of vacuum-traction and vacuum-extraction of fetus, obstetric forceps. At the same time, the complex evaluation of fetal heart disease in childbirth by cardiotocography and the determination of the actual pH from the skin of the fetal head (Zaling assay), the revealed correlations between the pH of the fetus and the fetal declerations made it possible to reduce the frequency of the threatened fetal status from 24.4 to 11.7%. At the same time, the reduced perinatal mortality was 9.8% per 1,000 newborns weighing more than 1000 g. Several authors recommend a wider use of cesarean section during hypertensive conditions during pregnancy, with severe forms of late toxicosis, eclampsia. Some authors consider in detail the issue of prenatal distress of the fetus in the group of pregnant women of high risk, in particular, with complications such as hypertension, late toxicosis, diabetes mellitus, fetal hypotrophy and fetal lag in development. Authors recommend that in such situations, an oxytocin test should be carried out and hypoxic de-hepatocytosis of diph-H type should be detected, for in such reactions, even normal births may be dangerous. Such pregnant women, according to the authors, should be delivered by the operation of cesarean section. Intranatal distress of the fetus occurs with complicated delivery. At the same time, fetal suffering (in the terminology of foreign authors - fetal distress) is possible with premature birth, presentation and placental abruption, the use of oxytocic agents. The presence of an admixture of meconium in the amniotic fluid during labor can be an objective indicator of low fruit pO ₂ and, thus, fetal suffering. These complications are an indication for monitoring during birth, which makes it possible to determine the fetal hypoxia in a timely manner, thereby increasing the rate of cesarean section with a simultaneous decrease in perinatal mortality. In this case, asphyxia of the fetus manifests itself in the form of hypoxic declerations. In addition, these decelerations can be caused by compression of the umbilical cord. In this case, if the pH of the scalp is 7.25 or lower, this is an indication for delivery in an operative way.

It is also important to take into account also the gestational age, since the cesarean section, produced between the 37-38th weeks of pregnancy, increases the risk of developing hyaline membranes 10-fold. This leads to a significant logical conclusion and recommendation - to determine by amniocentesis the lecithin / sphingomyelin ratio for solving the issue of the time of operation. Some authors note that the frequency of cesarean section has increased throughout the world, and in most cases this increase in the frequency of surgery is associated with indications from the fetus. According to Manuel, Mohan, Sambavi, the cesarean section in the fetus's interests was produced in 22.5% of women. Jones, Caire, when analyzing trends in the development of indications for cesarean section according to own data and materials of 50 other US institutes, showed that cesarean section for mother and fetus is better than heavy obstetric forceps. Elert and others noted that in connection with fetal hypoxia, a caesarean section was performed in 32.1%. Thus, in modern obstetrics, the frequency of cesarean section according to the testimony from the fetal ranges from 26.1% according to Patek, Larsson, to 61.6% according to Eberhardinger, Hirschfeld, and according to the mother's testimony, only 5% , in other women, mainly in pelvic presentation of the fetus.

Another difficulty is that the question of indications for cesarean section is not clear enough, depending on the results of monitoring of the fetus during pregnancy and childbirth. As for special research methods, they are known to have appeared later with the development of clinical perinatology. It is believed that, in principle, indications for cesarean section operation should be based on the fullest possible examination of the fetus. The authors emphasize that it is necessary to have a good knowledge of the ability to analyze monitoring data, then the indications for cesarean section can be revealed in the initial stages of fetal suffering. The results of several studies show that monitoring monitoring does not entail an increase in the cesarean section, and more accurately intranatally assesses the fetal condition. Given the complexity of this problem, scientists propose to use ultrasound determination of biparietal size to determine the time of production of a re-operation of cesarean section. So, if the biparietal size at 38 weeks of gestation was 9.3 cm or more, the operation could be performed without additional methods of determining the degree of maturity of the fetus. In these observations, no child had hyaline membranes. In half of the clinical observations, the authors performed amniocentesis to determine the ratio of lecithin / sphingomyelin, while all the children were healthy.

In a number of works, no less attention is paid to the issues of indications for cesarean section and the risk of respiratory distress syndrome with some complications of pregnancy and childbirth. So, Goldberg, Cohen, Friedman believe that the presence of labor before the operation of cesarean section did not reduce the risk of developing respiratory distress syndrome, but only premature placental abruption increased it. The risk of development of respiratory distress syndrome in newborns is strictly in accordance with the term of pregnancy and, probably, higher in children born in cesarean section than in delivery through natural birth canals.

Some researchers report an increased risk of developing respiratory distress syndrome depending on the indications for cesarean section, including prenatal bleeding, diabetes mellitus, late toxicosis, pathological curves of cardiotocography. Fedrick, Butler indicate that there has been an increase in the frequency of respiratory distress syndrome among newborns recovered from a caesarean section in a planned manner (without labor), compared to children who were delivered operatively through the development of labor. Therefore, some doctors propose for the prevention of respiratory distress syndrome, hyaline membranes intravenous oxytocin with 3-4 uterine contractions in 10 minutes for 30-60 minutes before the operation. Thus, the development of respiratory distress syndrome was prevented in 70 newborns, delivered between the 34th and 41st weeks of pregnancy, and in the control group - in 13.3%.

Finally, the question remains that the increase in the frequency of cesarean section is noted in cases where monitored fetal condition was used in both pregnant women and women in labor. At the same time Neutra et al. They did not detect an increase in the frequency of the operation when monitoring the fetus. Hollmen noted a decrease in blood flow in the intervillar space by 35% during a caesarean section using general anesthesia. Hollmen et al. When using long epidural analgesia revealed severe Sang-reflexes in newborns in the first two days of life.

Thus, the analysis of recent literature shows that it is impossible to speak about clearly formed indications for the operation of Caesarean section in the fetus's interests, nor about absolutely different points of view on this issue.

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