Cesarean section

Caesarean section is a surgical operation with the purpose of extracting the fetus and the afterbirth from the uterus after its dissection.

Caesarean section is the delivery with the help of band surgery, when the child is extracted through the abdominal incision of the uterine wall. In most cases, a woman is conscious during labor and may soon after the procedure be completed with the newborn.  

If you are pregnant, remember that your chances of giving birth naturally 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 give birth to a child in a vaginal way, you still need to know all about the caesarean section in case of emergency.

Epidemiology

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

[1], [2], [3], [4], [5],

Indications for cesarean delivery

Absolute indications of cesarean section

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

• complete placenta previa;
• severe and moderately severe forms of premature detachment of the normally located placenta in unprepared birth canals;
• threatening rupture of the uterus;
• absolutely narrow pelvis;
• Tumors and scarring, which prevent the birth of the fetus.

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

[6], [7], [8], [9],

Relative indications of cesarean section

Relative (from the mother and fetal) indications arise if the possibility of delivery through the natural birth can not be ruled out, but with a high risk of perinatal mortality and a threat to the health or life of the mother. At the heart of this group of indications is the principle of preserving the health and life of the mother and fetus, therefore the cesarean section is performed with the obligatory consideration of the conditions and contraindications that determine the timing and method of the operation.

Indications for caesarean section during pregnancy

• Full placenta previa.
• Incomplete presentation of the placenta with marked bleeding.
• Premature detachment of a normally located placenta with marked bleeding or intrauterine hypoxia.
• The inconsistency of the scar on the uterus after cesarean section or other operations on the uterus.
• Two or more scars on the uterus after cesarean section.
• Anatomically narrow pelvis of II-IV degree of narrowing, tumor or deformity of pelvic bones.
• Condition after operations on hip joints and pelvic bones, spine.
• Malformations of the uterus and vagina.
• Tumors of the pelvic organs blocking the birth canal.
• Multiple uterine fibroids of large size, degeneration of myoma nodes, low node location.
• Severe forms of gestosis in the absence of the effect of therapy and unprepared birth canal.
• Severe extragenital diseases.
• Cicatricial narrowing of the cervix and vagina after plastic surgeries of urogenital and intestinal vaginal fistulas.
• Condition after rupture of the third degree perineum with the preceding birth.
• Pronounced varicose veins in the vagina and vulva.
• The transverse position of the fetus.
• Fused twins.
• Pelvic presentation of the fetus with fetal mass over 3600 g and less than 1500 g or with anatomical changes of the pelvis.
• Pelvic presentation or transverse position of one fetus in multiple pregnancies.
• Three or more fetuses in multiple pregnancies.
• Chronic intrauterine fetal hypoxia, fetal hypotrophy, not amenable to drug therapy.
• Hemolytic disease of the fetus with unprepared birthmarks.
• Prolonged infertility in the history in combination with other aggravating factors.
• Pregnancy resulting from the use of assistive technologies (in vitro fertilization, artificial insemination of sperm) with a complicated obstetric-gynecological anamnesis.
• Migrated pregnancy in combination with a burdened obstetric-gynecological anamnesis, unpreparedness of the birth canal and lack of the effect of induction.
• Extragenital cancer and cervical cancer.
• Exacerbation of herpetic infection of the genital tract.

Indications for cesarean delivery during labor

• Clinically narrow pelvis.
• Premature discharge of amniotic fluid and lack of effect on births.
• Anomalies of labor, not amenable to drug therapy.
• Acute fetal intrauterine hypoxia.
• Premature detachment of a normal or low-lying placenta.
• A threatening or beginning rupture of the uterus.
• Presentation or prolapse of the umbilical cord.
• Incorrect insertion or presentation of the fetal head (frontal, front view of the facial, posterior view of the high direct standing of the sagittal seam).
• The state of agony or the sudden death of a woman in labor with a live fetus.

Indications for consultation of other specialists

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

What is the cesarean section for?

Effective delivery with a favorable prognosis for the mother and newborn.

Indications for hospitalization

Presence of indications for cesarean section.

Conditions for cesarean section

• A living and viable fetus (not always feasible with absolute indications).
• Absence of symptoms of the infectious process in childbirth.
• Empty bladder.
• The choice of the optimal operation time (do not do it too hastily or as an "operation of desperation").
• The presence of a doctor who owns the operation technique, an anesthesiologist.
• The consent of the pregnant woman (the mother in childbirth) to the operation.

[10], [11], [12], [13], [14], [15]

Drug therapy

Anesthesia: general multi-component anesthesia, regional anesthesia.

[16], [17]

Screening

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

Cesarean section classification

• The abdominal cesarean section is performed by cutting the anterior abdominal wall. Performed as a delivery operation and, more rarely, for termination of pregnancy for medical reasons at a period of 16-28 weeks.
• Vaginal cesarean section is performed through the anterior part of the vaginal vault (currently not applied).
• The intra-peritoneal Caesarean section is performed in the lower segment of the uterus by a transverse incision.
• The corporal caesarean section is performed with:
  • pronounced adhesion process in the lower uterine segment after the previous operation;
  • pronounced varicose veins;
  • a large myomatous node;
  • an inferior rumen after the previous corporal caesarean section;
  • full placenta previa with the transition to the front wall of the uterus;
  • premature fetus and undivided lower uterine segment;
  • fused double;
  • the transverse position of the fetus;
  • dead or dying patient, if the fetus is alive;
  • provided that the surgeon does not own the technique of cesarean section in the lower segment of the uterus.
• The ismiko-corporal caesarean section is performed with premature pregnancy and the undersplit inferior segment of the uterus.
• An extraperitoneal caesarean section or a cesarean section in the lower segment of the uterus with temporal isolation of the abdominal cavity is indicated with the possible or already existing infection, a living and viable fetus and the lack of conditions for delivery through the natural birth canal. This method was practically abandoned after the introduction of effective antibiotics into practice and in connection with frequent cases of damage to the bladder and ureters.

The caesarean section in the lower segment of the uterus is transverse.

[18], [19],

Stages of cesarean section operation

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

• Dissection of the anterior abdominal wall: transverse suprapubic incision along Pfannenstil (used most often), transverse in the Joel-Cohen, longitudinal lower anterior incision.
• Identification and correction of the rotation of the uterus: removal of the uterus in the middle position to exclude a cut along the rib of the uterus and wound the vascular bundle.
• Opening of the vesicle-uterine fold: after dissection of the vesicle-uterine fold, exfoliate the peritoneum by no more than 1-1.5 cm to exclude bleeding and formation of a bruise under the fold of the peritoneum after the operation.
• Dissection of the uterus: a transverse dissection of the lower segment of the uterus according to Gusakov or Derfler.
• Removing the fetus should be carefully, especially with a large or premature fetus.
  • At the head presentation with the palm surface of the right hand, grasp the head and rotate the occiput anteriorly, shifting the head anteriorly. The assistant slightly presses on the bottom of the uterus, and the head is removed from the uterus.
  • When the head is located high from the incision line, the uterus should be taken by hand in the neck of the fetus and lowered downwards.
  • After removing the head from the uterus, it is grasped by the palms of both hands behind the cheek-temporal areas and the two shoulders are gradually removed with careful traction.
  • With a purely breech presentation, the fetus is removed from the inguinal fold, with the leg presentation - by the foot facing the front.
  • In the transverse position of the fetus, the arm, inserted into the uterine cavity, is searched for the front leg, the fetus is rotated and extracted. The head is removed by a technique identical to that of Moriso-Levre. In order to prevent purulent-septic complications, after the umbilical cord is compressed intravenously, one of the broad-spectrum antibiotics from the penicillin and cephalosporins (ampicillin, cefazolin, cefotaxime for 1 g, etc.) should be injected and continue their administration 6 and 12 hours after the operation.

Control for hemorrhage: after extraction of the child into the muscle of the uterus, 1 ml of 0.02% solution of methylergometrine is injected and intravenous injection of oxytocin 5 ED diluted in 400 ml of 0.9% sodium chloride solution is started.

• At the corners of the incision of the uterus, hemostatic clamps are applied.
• Removal of the afterbirth: the latter must be removed immediately after removal of the child by pulling on the umbilical cord or by manually separating the placenta and isolating the placenta followed by monitoring the walls of the uterus.
• Expansion of the cervical canal: for unhindered allocation of lochias during the operation during pregnancy, it is necessary to expand it with the finger or expander of Gegar.
• Suturing a wound on the uterus: the imposition of a single-row continuous vikrilovogo (dexon) suture on the uterus with piercing the mucous membrane, peritonization due to the vesicle-uterine fold of the peritoneum using a single-row continuous vikrilovogo (dexonic) suture.
• Sewing the front abdominal wall:
  • with longitudinal dissection, the peritoneum and muscles are sutured with a continuous dexon or vikrilov suture, aponeurosis - with separate vikrilovymi or nylon sutures, subcutaneous tissue - with separate absorbable sutures, individual nylon or silk sutures are applied to the skin;
  • with a transverse dissection, the peritoneum and muscles are sutured with a continuous dexon or vikril suture, the aponeurosis is a continuous inclined maksonovym or polydioxanone suture, to reinforce it in the center, a reverden seam is applied, separate seams (dexo, vikril, dermalon, ethyl) are applied to the skin - continuous intradermal suture (dermalon, ethyl), separate seams, surgical staples.

How to prevent caesarean section?

• Adequate management of pregnancy and childbirth.
• Rational management of births through natural birth canals during anomalies of labor activity with the use of modern uterotonic, antispasmodic, analgesics.

Contraindications to caesarean section

• An unsuccessful attempt at vaginal delivery (obstetric forceps, vacuum extraction of the fetus).
• Adverse conditions of the fetus (intrauterine death, deep prematurity, long-term intrauterine fetal hypoxia, in which stillbirth or early death of the fetus, fetal malformations, incompatible with life can not be ruled out).

These contraindications are important only if the operation is performed in the interests of the fetus. If there are indications for caesarean section from the part of the parturient, contraindications are not taken into account.

[20], [21]

Complications after caesarean section

• Surgical: prolongation of the incision on the uterus towards the parameter and damage to the vascular bundles, wounding the bladder, ureter, intestine, injuring the fetus, bluing the suture, sewing the upper edge of the wound of the lower segment of the uterus to its posterior wall, internal and external bleeding, hematomas of various localization.
• Anesthesia: aortocaval syndrome, aspiration syndrome (Mendelssohn syndrome), failed attempt at intubation of the trachea.
• Postoperative purulent-septic: subinvolution of the uterus, endometritis, peritonitis, sepsis, thrombophlebitis, deep vein thrombosis.

[22], [23], [24],

The prognosis after cesarean section

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

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

Student training

Rodilnitsu need to teach the care of the mammary glands, external genital organs, control the functions of the bladder and intestines.

Further management of the patient

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

ICD-10 code

• 082 Single births, delivery by caesarean section
• 084.2 Births are multiple, completely by cesarean section.