When is a cesarean section done?

A doctor can recommend a cesarean section well in advance of labor (a planned cesarean section) or during the course of labor, he must decide to do this surgery for the safety of the mother and child.

An unscheduled caesarean section is done in the following cases:

• difficult and slow labor;
• sudden termination of labor;
• slowing or accelerating the child's heart rate;
• placenta previa;
• clinical incompatibility of the pelvis of the mother and fetal head.

When all these moments in advance become obvious, the doctor plans a cesarean section. You can recommend a planned cesarean section in the case of:

• breech presentation of the fetus on late pregnancy lines;
• heart disease (the condition of the mother can significantly worsen during natural labor);
• infection of the mother and an increased risk of transmission of infection to the child during vaginal delivery;
• multiple fertility;
• increased risk of rupture after previous caesarean section.

In some cases, a woman with a caesarean section may very well have a baby. This is called vaginal delivery after cesarean section. However, only a doctor can determine the possibility of such births.

Over the past 40 years, the number of cases of cesarean section has increased from 1 of 20 deliveries to 1 out of 4. Experts are concerned that this surgical intervention is done more often than necessary. There is a certain risk in carrying out this operation, so experts recommend doing caesarean section only in emergency cases and with clinical indications.

The operation of caesarean section occupies an important place in modern midwifery:

• correct use of it can have a significant effect on reducing maternal and perinatal morbidity and mortality;
• for the favorable outcome of the operation, planning and timeliness of surgical intervention (absence of a long anhydrous interval, signs of infection of the birth canal, prolonged delivery) are of great importance;
• the outcome of the operation is largely determined by the qualifications and surgical training of doctors. Each doctor, who is on duty at an obstetric hospital, is obliged to own the technique of surgical interventions, in particular, the technique of cesarean section operation in the lower segment of the uterus and supravaginal amputation of the uterus;
• the method of choice is the caesarean section in the lower uterine segment with a transverse incision;
• corporal caesarean section is acceptable in the absence of access to the lower segment of the uterus, with pronounced varicose veins in this area, cervical uterine myoma, repeated cesarean section and localization of an incomplete scar in the uterus, with complete placenta previa;
• if there is an infection or a high risk of its development, it is recommended to use transperitoneal Caesarean section with abdominal cavity delimitation or its drainage. In hospitals that have highly skilled staff who have the appropriate operational training, it is possible to use extraperitoneal Caesarean section;
• with severe manifestations of infection after the extraction of the child shows the extirpation of the uterus with the tubes followed by drainage of the abdominal cavity through the lateral canals and vagina.

Expanded indications for cesarean section:

• premature detachment of a normally located placenta in the absence of conditions for a fast, gentle delivery;
• incomplete placenta previa (bleeding, lack of conditions for rapid delivery);
• transverse position of the fetus;
• persistent weakness of the clan forces and unsuccessful medication;
• severe forms of late toxicosis of pregnant women, not amenable to drug therapy;
• the elderly age of the first-born and the presence of additional adverse factors (pelvic presentation, improper insertion of the head, narrowing of the pelvis, weakness of the birth forces, pregnancy retention, pronounced myopia);
• pelvic presentation of the fetus and the complicated course of childbirth, regardless of the age of the parturient woman (weakness of labor, pelvic narrowing, large fetus, pregnancy retention);
• presence of a scar on the uterus after a previous surgery;
• the presence of intrauterine hypoxia of a fetus that is not amenable to correction (fetoplacental insufficiency);
• diabetes maternal (large fetus);
• long-term infertility in the history in combination with other aggravating factors;
• diseases of the cardiovascular system that are not subjected to medical or surgical correction, especially in combination with obstetric pathology;
• myoma of the uterus, if the nodes are an obstacle to the birth of a child, with chronic fetal hypoxia during pregnancy, and if there are additional complications that worsen the prognosis of childbirth.

Over the last decade, indications for cesarean section have changed significantly. So, according to the data of modern foreign authors, a large clinical material revealed that in 9.5% the first cesarean section was made and in 4% it was repeated. The most frequent indications for cesarean section (weakness of labor activity, clinically narrow pelvis, pelvic presentation of fetus, repeated operation and fetal distress) remained unchanged during the analyzed period.

Despite the fact that the frequency of pelvic presentation of the fetus remains within 4%, the incidence of cesarean section has increased during the last 10 years and has reached 64%. The frequency of repeated cesarean section for the above periods, respectively, was 2.6, 4 and 5.6%. Over the past 4 years, there has been a stabilization of this indicator. However, the role of monitoring of fetal status in increasing the cesarean section in both the US and other countries remains controversial: with the onset of monitors, the frequency of surgery for fetal distress has been increased to 26%, and in subsequent years it has decreased up to the level that existed before the monitoring observation in childbirth. There was a decrease in perinatal mortality from 16.2% to 14.6%, despite a parallel decrease in the frequency of the first cesarean section. Some authors believe that not always an extension of the indications for cesarean section leads to an improvement in peri- and postnatal outcomes. Expansion of indications for cesarean section is necessary only for certain types of pathology - pelvic presentation of the fetus, scar on the uterus, etc.

Summarizing the literary information of various methods of delivery, it is possible to emphasize a number of important points. Thus, the perinatal mortality of children extracted from cesarean section is from 3.06 to 6.39%. Incidence among newborns taken by caesarean section, according to Beiroteran et al. Is 28.7%. The first place is occupied by the pathology of the respiratory tract, then jaundice, infection, obstetric trauma. These children have a higher risk of developing distress syndrome, which, according to Goldbeig et al, is associated with the operation itself, the other factors are of secondary importance.

In newborns extracted by cesarean section, there is hyperkalemia associated with impaired permeability of cell membranes under the influence of drugs used in the process of anesthesia. There is a violation of metabolic and endocrine processes. The predominance of the adrenal link of the sympathetic-adrenal system is noted, which does not exclude the presence of a stressful situation for the fetus associated with a rapid change in the conditions of existence without previous adaptation, which is undoubtedly present in physiological births. In newborns removed at caesarean section, there is also a low level of steroid hormones, which are necessary for the resynthesis of the surfactant, the decay time of which is 30 minutes, which leads to the development of distress syndrome and hyaline membrane disease.

Based on the data of Krause et al. After cesarean section metabolic acidosis was detected in 8.3% of children, which is 4.8 times higher than in children born through natural birth canals.

The impact of Caesarean section on the mother is also unfavorable. That is why in recent years more and more persistently voices of a number of clinicians have been heard about the advisability of narrowing the indications for cesarean section and the search for rational methods of conducting labor through natural birth canals. It is believed that caesarean section increases maternal morbidity and mortality, the length of stay in hospital, is an expensive method of delivery and represents a danger in subsequent pregnancy. According to Swedish scientists, the maternal mortality rate was 12.7 per 100,000 cesarean sections, and for the vaginal delivery, the death rate was 1.1 per 100,000 births.

Thus, the risk of maternal mortality in cesarean section in Sweden is 12 times higher than after birth through natural birth canals. All deaths, except one, were associated with an operation performed in an emergency. The most frequent causes of death after cesarean section were pulmonary thromboembolism, embolism with amniotic fluid, coagulopathy and peritonitis. At the same time, it should be mentioned that, according to the research, the risk to the life and health of a woman during a caesarean section is very high, which requires carrying out this type of delivery only with justified indications, if possible, refusing surgery for a long anhydrous interval, a large number (10-15) of vaginal examinations. According to the author, in recent years, the rate of cesarean section in the clinic has been reduced from 12.2% to 7.4%. Questions concerning high economic costs in surgical intervention are considered, the cost of which is almost 3 times higher in Switzerland than in cases of spontaneous uncomplicated birth.

Another difficulty is that even the use of extraperitoneal Caesarean section is not always a surgical way of preventing infection. So, doctors to test the hypothesis that extraperitoneal Caesarean section may be a measure of preventing the development of infection, based on their own data, conclude that in itself an extraperitoneal Caesarean section, even produced by experienced surgeons, does not prevent the development of infection in comparison with transperitoneal Caesarean section. However, with it there is less paresis of the intestine, the puerperas quickly pass to the usual diet, the length of stay in the hospital is reduced, and less analgesics are needed in the postoperative period. Therefore, with an extraperitoneal Caesarean section, the risk of developing endometritis is reliably reduced only if antibiotic therapy is used. Since the rate of cesarean section has significantly increased over the past 5 years, and in many clinics, one in 4-5 pregnant women is given an abdominal route, a number of midwives view this phenomenon as positive and is a natural consequence of the modern midwifery approach, while more conservative obstetricians, according to opinion Pitkin'a, find this fact disturbing. Such trends, Pitkin points out, are built more often on emotional factors than on subjective grounds.

According to studies, a significant reduction in the indices of cell-mediated immunity is observed in cesarean section and their recovery is slower than after physiological birth. The observed partial immunodeficiency in parturients and puerperas in cesarean section is one of the reasons for the increased sensitivity of the puerperas to infection.

Despite widespread use of antibiotics for prophylaxis, a significant number of women develop postpartum infection. Of the later complications of cesarean section, infertility is most often observed. Severe septic complications after caesarean section were noted in 8.7% of women. Postoperative complications occur in cesarean section in 14% of women. One third of the complications are inflammatory processes and infection of the urinary tract.

Thus, the impact of cesarean section surgery on both the mother and the fetus is not indifferent; so in recent years there has been a tendency to limit the indications for this operation. The total frequency of cesarean section without damaging the fetus can be reduced by 30%. The obstetricians should carefully assess the indications for each caesarean section based on the use of methods for assessing the fetal condition, trying to lead the birth more often through the natural birth canal.

In the last decade, new data have been obtained on many sections of clinical perinatology, which until now have not been adequately covered in the development of indications for a cesarean section in the interest of the fetus. Expanding indications for abdominal delivery in the interest of the fetus required an in-depth comprehensive assessment of its intrauterine state by modern methods of research (cardiotocography, amniocentry, amniocentesis, study of the acid-base state and blood gases of the mother and fetus, etc.). Previously, the problem of cesarean section in the interests of the fetus could not be solved at the proper level, as clinical perinatology began to develop only in the last two decades.

What is the risk of caesarean section?

Most mothers and children are quite normal after caesarean section. But a cesarean section is a vast surgical intervention, so the risk is much greater than with vaginal births.

Complications:

• infection of the area of the uterine wall;
• great loss of blood;
• formation of thrombi;
• trauma of mother or child;
• negative consequences of anesthesia: nausea, vomiting and acute headache;
• difficulty breathing in a child, if the cesarean section is performed earlier than prescribed.

If a woman after the Cesarean section becomes pregnant again, there is an insignificant risk of a suture or placenta previa during vaginal delivery.