Caesarean section

Caesarean section is a surgical operation performed to remove the fetus and placenta from the uterus after it has been cut.

A cesarean section is a birth performed through an open operation where the baby is removed through an abdominal incision in the uterine wall. In most cases, the woman is conscious during labor and can be with her newborn soon after the procedure is completed.

If you are pregnant, remember that your chances of having a natural birth are quite high. But in some cases, for the safety of the mother and child, it is better to have a cesarean section. Therefore, even if you intend to have a vaginal birth, you should still learn everything about cesarean sections as a last resort.

Epidemiology

The cesarean section rate in the United States was 21–22%.

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Indications for cesarean section

Absolute indications for cesarean section

Absolute indications are complications of pregnancy and childbirth, in which another method of delivery (even taking into account the fetal-destroying operation) poses a mortal danger to the mother:

• complete placenta previa;
• severe and moderate forms of premature detachment of a normally located placenta with unprepared birth canal;
• threatening uterine rupture;
• absolutely narrow pelvis;
• tumors and cicatricial stenosis that prevent the birth of the fetus.

In cases where there are absolute indications for performing a cesarean section, all other conditions and contraindications are not taken into account.

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Relative indications for cesarean section

Relative (from the side of the mother and fetus) indications arise if the possibility of delivery through the natural birth canal cannot be excluded, but with a high risk of perinatal mortality and a threat to the health or life of the mother. This group of indications is based on the principle of preserving the health and life of the mother and fetus, therefore, cesarean section is performed with mandatory consideration of the conditions and contraindications that determine the timing and method of the operation.

Indications for cesarean section during pregnancy

• Complete placenta previa.
• Incomplete placenta previa with severe bleeding.
• Premature detachment of a normally located placenta with severe bleeding or the presence of intrauterine hypoxia.
• Failure of the uterine scar after cesarean section or other operations on the uterus.
• Two or more scars on the uterus after a cesarean section.
• Anatomically narrow pelvis of II-IV degree of narrowing, tumor or deformation of the pelvic bones.
• Condition after operations on the hip joints and pelvic bones, spine.
• Malformations of the uterus and vagina.
• Tumors of the pelvic organs blocking the birth canal.
• Multiple large uterine fibroids, degeneration of myomatous nodes, low node location.
• Severe forms of gestosis with no effect from therapy and unprepared birth canal.
• Severe extragenital diseases.
• Cicatricial narrowing of the cervix and vagina after plastic surgery to suture urogenital and intestinal-vaginal fistulas.
• Condition after third degree perineal rupture during previous birth.
• Pronounced varicose veins in the vagina and vulva.
• Transverse fetal position.
• Conjoined twins.
• Breech presentation of the fetus with a fetal weight of more than 3600 g and less than 1500 g or with anatomical changes in the pelvis.
• Breech presentation or transverse lie of one fetus in multiple pregnancies.
• Three or more fetuses in multiple pregnancy.
• Chronic intrauterine fetal hypoxia, fetal malnutrition, not amenable to drug therapy.
• Hemolytic disease of the fetus with an unprepared birth canal.
• A history of long-term infertility in combination with other aggravating factors.
• Pregnancy resulting from the use of assisted technologies (in vitro fertilization, artificial insemination with sperm) with a complicated obstetric and gynecological history.
• Post-term pregnancy in combination with a complicated obstetric and gynecological history, unprepared birth canal and lack of effect from labor induction.
• Extragenital cancer and cervical cancer.
• Exacerbation of herpes infection of the genital tract.

Indications for cesarean section during childbirth

• Clinically narrow pelvis.
• Premature rupture of membranes and lack of effect from labor induction.
• Anomalies of labor that do not respond to drug therapy.
• Acute intrauterine hypoxia of the fetus.
• Premature detachment of a normally or low-lying placenta.
• Threatened or incipient rupture of the uterus.
• Presentation or prolapse of the umbilical cord loops.
• Incorrect insertion or presentation of the fetal head (frontal, anterior view of the facial, posterior view of the high straight standing of the sagittal suture).
• A state of agony or sudden death of a woman in labor with a living fetus.

Indications for consultation with other specialists

• Anesthesiologist: need for abdominal delivery.
• Neonatologist-resuscitator: the need for resuscitation measures at the birth of a newborn with moderate and severe asphyxia.

Why is a cesarean section performed?

Effective delivery with a favorable prognosis for mother and newborn.

Indications for hospitalization

The presence of indications for a cesarean section.

Conditions for performing a cesarean section

• A living and viable fetus (not always feasible with absolute indications).
• Absence of symptoms of an infectious process during childbirth.
• Empty bladder.
• Selecting the optimal time for the operation (it should not be performed too hastily or as a “desperate operation”).
• The presence of a doctor who is proficient in the technique of surgery, an anesthesiologist.
• Consent of a pregnant woman (woman in labor) for surgery.

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Drug therapy

Anesthetic care: general multicomponent anesthesia, regional anesthesia.

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Screening

Timely registration and monitoring of pregnant women who are subject to delivery by caesarean section, especially with a scar on the uterus after surgical interventions.

Classification of cesarean section

• An abdominal cesarean section is performed by making an incision in the anterior abdominal wall. It is performed as a delivery operation and, less commonly, to terminate a pregnancy for medical reasons at 16–28 weeks.
• Vaginal cesarean section is performed through the anterior part of the vaginal fornix (not currently used).
• Intraperitoneal cesarean section is performed in the lower segment of the uterus through a transverse incision.
• Corporal cesarean section is performed in cases of:
  • pronounced adhesion process in the lower segment of the uterus after a previous operation;
  • pronounced varicose veins;
  • large myomatous node;
  • an inadequate scar after a previous corporal cesarean section;
  • complete placenta previa with its transition to the anterior wall of the uterus;
  • premature fetus and undeployed lower uterine segment;
  • fused twins;
  • neglected transverse fetal position;
  • a dead or dying patient, if the fetus is alive;
  • provided that the surgeon does not have experience in performing a cesarean section in the lower segment of the uterus.
• Isthmic-corporeal cesarean section is performed in cases of premature pregnancy and non-deployed lower segment of the uterus.
• Extraperitoneal cesarean section or cesarean section in the lower uterine segment with temporary isolation of the abdominal cavity is indicated in cases of possible or existing infection, a living and viable fetus, and the absence of conditions for vaginal delivery. This method has been practically abandoned after the introduction of effective antibiotics into practice and due to frequent cases of damage to the bladder and ureters.

The optimal method is a cesarean section in the lower segment of the uterus with a transverse incision.

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Stages of a cesarean section

Stages of performing a cesarean section in the lower uterine segment with a transverse incision.

• Dissection of the anterior abdominal wall: transverse suprapubic incision according to Pfannenstiel (used most often), transverse incision according to Joel-Cohen, longitudinal lower midline incision.
• Identification and correction of uterine rotation: bringing the uterus into a midline position to avoid an incision along the uterine edge and injury to the vascular bundle.
• Opening of the vesicouterine fold: after dissection of the vesicouterine fold, the peritoneum is peeled back by no more than 1–1.5 cm to prevent bleeding and the formation of hematomas under the peritoneal fold after surgery.
• Uterine dissection: transverse dissection of the lower segment of the uterus according to Gusakov or Derfler.
• The fetus should be removed carefully, especially if the fetus is large or premature.
  • In case of cephalic presentation, the palm of the right hand grasps the head and turns the occiput forward, shifting the head forward. The assistant presses lightly on the bottom of the uterus, and the head comes out of the uterus.
  • If the head is located high above the incision line of the uterus, you should grab it with your hand in the area of the fetus’s neck and lower it down.
  • After the head has been removed from the uterus, it is grasped with the palms of both hands by the cheek-temporal areas and, with careful traction, both shoulders are gradually removed.
  • In a pure breech presentation, the fetus is removed by the inguinal fold; in a foot presentation, by the leg facing forward.
  • In the transverse position of the fetus, the anterior leg is found by hand inserted into the uterine cavity, the fetus is turned and extracted. The head is brought out using a technique identical to the Morisot-Levre technique. In order to prevent purulent-septic complications after clamping the umbilical cord, one of the broad-spectrum antibiotics from the penicillin and cephalosporin group (ampicillin, cefazolin, cefotaxime 1 g, etc.) should be administered intravenously and their administration should be continued 6 and 12 hours after the operation.

Monitoring blood loss: after the baby is removed, 1 ml of a 0.02% solution of methylergometrine is injected into the uterine muscle and intravenous drip administration of 5 U of oxytocin diluted in 400 ml of a 0.9% sodium chloride solution is started.

• Hemostatic clamps are applied to the corners of the uterine incision.
• Removal of the placenta: The placenta must be removed immediately after the baby is delivered by pulling the umbilical cord or by manually separating the placenta and discharging the placenta, followed by inspection of the uterine walls.
• Dilation of the cervical canal: to ensure unimpeded discharge of lochia during surgery during pregnancy, it is necessary to dilate it with a finger or a Hegar dilator.
• Suturing of the uterine wound: application of a single-row continuous vicryl (dexone) suture to the uterus with puncturing of the mucous membrane, peritonization due to the vesicouterine fold of the peritoneum using a single-row continuous vicryl (dexone) suture.
• Suturing of the anterior abdominal wall:
  • when it is cut longitudinally, the peritoneum and muscles are sutured with a continuous dexon or vicryl suture, the aponeurosis - with separate vicryl or nylon sutures, the subcutaneous tissue - with separate absorbable sutures, and separate nylon or silk sutures are applied to the skin;
  • when it is transversely dissected, the peritoneum and muscles are sutured with a continuous Dexon or Vicryl suture, the aponeurosis - with a continuous encircling Maxon or polydioxanone suture, a Reverdin suture is applied in the center to strengthen it, separate sutures (Dexon, Vicryl, Dermalone, Ethylone) are applied to the subcutaneous tissue, a continuous intradermal suture (Dermalone, Ethylone), separate sutures, surgical staples are applied to the skin.

How to prevent cesarean section?

• Adequate management of pregnancy and childbirth.
• Rational management of labor through the natural birth canal in case of labor anomalies using modern uterotonic, antispasmodic, and analgesic drugs.

Contraindications to cesarean section

• Failed attempt at vaginal delivery (obstetric forceps, vacuum extraction of the fetus).
• Adverse conditions of the fetus (intrauterine death, severe prematurity, long-term intrauterine hypoxia of the fetus, in which stillbirth or early death of the fetus cannot be ruled out, fetal deformities incompatible with life).

These contraindications are only important if the operation is performed in the interests of the fetus. If there are indications for a cesarean section on the part of the mother, the contraindications are not taken into account.

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Complications after cesarean section

• Surgical: extension of the incision on the uterus towards the parametrium and damage to the vascular bundles, injury to the bladder, ureter, intestines, injury to the presenting part of the fetus, suturing of the bladder, suturing the upper edge of the wound of the lower segment of the uterus to its posterior wall, internal and external bleeding, hematomas of various localizations.
• Anesthesiological: aortocaval syndrome, aspiration syndrome (Mendelson syndrome), failed attempt at tracheal intubation.
• Postoperative purulent-septic: subinvolution of the uterus, endometritis, peritonitis, sepsis, thrombophlebitis, deep vein thrombosis.

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Prognosis after cesarean section

With a caesarean section rate of 16.7%, the mortality rate was 0.08%. Deaths after caesarean section accounted for more than 50% of all maternal deaths.

The perinatal mortality rate was 11.4 per 1000 live and stillborn births, with the ratio of stillbirths to early neonatal mortality being 1:1 (53 and 47%, respectively).

Patient education

The mother must be taught how to care for her mammary glands, external genitalia, and control the functions of her bladder and intestines.

Further management of the patient

If the postoperative period is smooth, patients are recommended to turn over in bed a few hours after the operation, and to walk on the 2nd day. On the 5th day, an ultrasound is performed to assess the size of the uterus, its cavity, the condition of the sutures after the cesarean section, and to detect hematomas. On the 6th-7th day, the sutures are removed from the anterior abdominal wall. On the 9th-10th day, the patient is discharged home.

ICD-10 code

• 082 Singleton birth, delivery by caesarean section
• 084.2 Multiple births, entirely by caesarean section.