When is a cesarean section done?

The doctor may recommend a cesarean section well in advance of the birth (planned cesarean section) or during labor he or she may have to make a decision to perform this surgical intervention for the safety of the mother and baby.

An unplanned caesarean section is performed in the event of:

• difficult and slow labor;
• sudden cessation of labor;
• slowing or speeding up the baby's heart rate;
• placenta previa;
• clinical discrepancy between the mother's pelvis and the fetal head.

When all of these things become clear in advance, the doctor plans a cesarean section. You may be advised to have a planned cesarean section if:

• breech presentation of the fetus in late pregnancy;
• heart disease (the mother's condition may worsen significantly during natural labor);
• maternal infection and increased risk of transmission to the baby during vaginal delivery;
• multiple pregnancy;
• increased risk of incision rupture after a previous cesarean section.

In some cases, a woman with previous cesarean section experience may be able to give birth to a baby on her own. This is called vaginal birth after cesarean section. However, only a doctor can determine whether such a birth is possible.

Over the past 40 years, the rate of cesarean sections has increased from 1 in 20 births to 1 in 4. Experts are concerned that this surgery is being done more often than necessary. There are risks associated with this procedure, so experts recommend that cesarean sections be performed only in emergency situations and when clinically indicated.

Caesarean section occupies an important place in modern obstetrics:

• its correct use can have a significant impact on reducing maternal and perinatal morbidity and mortality;
• For a favorable outcome of the operation, the planned and timely nature of the surgical intervention is of great importance (absence of a long anhydrous period, signs of infection of the birth canal, prolonged labor);
• the outcome of the operation is largely determined by the qualifications and surgical training of the doctors. Each doctor on duty in the obstetric hospital must be proficient in the technique of surgical interventions, in particular, the technique of cesarean section in the lower segment of the uterus and supravaginal amputation of the uterus;
• the method of choice is a cesarean section in the lower uterine segment with a transverse incision;
• a corporal caesarean section is permissible in the absence of access to the lower segment of the uterus, with pronounced varicose veins in this area, cervical uterine myoma, repeated caesarean section and localization of an incomplete scar in the body of the uterus, with complete placenta previa;
• in the presence of infection or a high risk of its development, it is recommended to use transperitoneal caesarean section with delimitation of the abdominal cavity or its drainage. In hospitals with highly qualified personnel with appropriate surgical training, it is possible to use extraperitoneal caesarean section;
• In case of severe manifestations of infection after the extraction of the child, extirpation of the uterus with tubes is indicated, followed by drainage of the abdominal cavity through the lateral canals and vagina.

Extended indications for cesarean section:

• premature detachment of a normally located placenta in the absence of conditions for a quick and gentle delivery;
• incomplete placenta previa (bleeding, lack of conditions for rapid delivery);
• transverse fetal position;
• persistent weakness of labor forces and unsuccessful drug treatment;
• severe forms of late toxicosis of pregnancy that do not respond to drug therapy;
• advanced age of the primiparous woman and the presence of additional unfavorable factors (breech presentation, incorrect insertion of the head, narrowing of the pelvis, weak labor forces, post-term pregnancy, severe myopia);
• breech presentation of the fetus and complicated labor regardless of the age of the mother (weak labor forces, narrowing of the pelvis, large fetus, post-term pregnancy);
• the presence of a scar on the uterus after a previous operation;
• the presence of intrauterine fetal hypoxia that cannot be corrected (fetoplacental insufficiency);
• diabetes mellitus in the mother (large fetus);
• long-term history of infertility in combination with other aggravating factors;
• cardiovascular diseases that are not amenable to drug or surgical correction, especially in combination with obstetric pathology;
• uterine fibroids, if the nodes are an obstacle to the birth of a child, in case of chronic fetal hypoxia during pregnancy, as well as in the presence of additional complications that worsen the prognosis of childbirth.

Indications for caesarean section have changed significantly over the last decade. Thus, according to modern foreign authors, using large clinical material, it was found that in 9.5% of cases the first caesarean section was performed and in 4% - a repeat one. The most frequent indications for caesarean section (weakness of labor, clinically narrow pelvis, breech presentation of the fetus, repeat surgery and fetal distress) remained unchanged during the analyzed period.

Despite the fact that the frequency of breech presentation remains within 4%, the frequency of cesarean sections in this case has increased in the last 10 years and reached 64%. The frequency of repeat cesarean sections for the above periods was 2.6, 4 and 5.6%, respectively. Over the last 4 years, stabilization of this indicator has been observed. At the same time, the role of fetal monitoring in increasing the frequency of cesarean sections both in the USA and in other countries remains controversial: with the beginning of the use of monitors, an increase in the frequency of operations for fetal distress to 26% was noted, and in subsequent years there was a decrease to the level that existed before monitoring during labor. A decrease in perinatal mortality was noted from 16.2% to 14.6%, despite a parallel decrease in the frequency of the first cesarean section. Some authors believe that expanding the indications for cesarean section does not always lead to an improvement in peri- and postnatal outcomes. Expanding the indications for cesarean section is necessary only for certain types of pathology - breech presentation of the fetus, scar on the uterus, etc.

Summarizing the literature data on various methods of delivery, a number of important points can be emphasized. Thus, perinatal mortality of children delivered by caesarean section ranges from 3.06 to 6.39%. Morbidity among newborns delivered by caesarean section, according to Beiroteran et al., is 28.7%. The first place is occupied by respiratory pathology, then jaundice, infection, obstetric trauma. These children have an increased risk of developing distress syndrome, which, according to Goldbeig et al., is associated with the operation itself, other factors are of secondary importance.

Newborns delivered by caesarean section have hyperkalemia associated with impaired permeability of cell membranes under the influence of drugs used during anesthesia. Metabolic and endocrine processes are impaired. The adrenal link of the sympathetic-adrenal system predominates, which does not exclude the presence of a stressful situation for the fetus associated with a rapid change in living conditions without prior adaptation, which undoubtedly occurs during physiological birth. Newborns delivered by caesarean section also have a low level of steroid hormones, which are necessary for the resynthesis of surfactant, the decay time of which is 30 minutes, which leads to the development of distress syndrome and hyaline membrane disease.

According to Krause et al., metabolic acidosis was detected in 8.3% of children born by cesarean section, which is 4.8 times higher than in children born vaginally.

The impact of caesarean section on the mother is also unfavorable. That is why in recent years the voices of a number of clinicians have been increasingly insistent about the advisability of narrowing the indications for caesarean section and finding rational methods of conducting labor through the natural birth canal. It is believed that caesarean section increases maternal morbidity and mortality, the length of stay of mothers in hospital, is an expensive method of delivery and poses a danger during subsequent pregnancies. According to Swedish scientists, the maternal mortality rate due to the operation was 12.7 per 100,000 caesarean sections, and for vaginal delivery the mortality rate was 1.1 per 100,000 births.

Thus, the risk of maternal mortality after caesarean section in Sweden is 12 times higher than after vaginal delivery. All deaths, except one, were associated with emergency surgery. The most common causes of death after caesarean section were pulmonary thromboembolism, amniotic fluid embolism, coagulopathy and peritonitis. At the same time, it should be mentioned that according to research data, the degree of risk to the life and health of a woman during caesarean section is very high, which requires that this type of delivery be performed only for justified indications, if possible, refusing the operation in the case of a long anhydrous interval, the presence of a large number (10-15) of vaginal examinations in the preoperative period. According to the author, in recent years it has been possible to reduce the frequency of caesarean sections in the clinic from 12.2% to 7.4%. The issues related to the high economic costs of surgical intervention, the cost of which in Switzerland is almost 3 times higher than that of spontaneous uncomplicated childbirth, are considered.

Another difficulty is that even the use of extraperitoneal cesarean section is not always a surgical method of preventing infection. Thus, doctors, in order to test the hypothesis that extraperitoneal cesarean section can be a measure to prevent infection, based on their own data come to the conclusion that extraperitoneal cesarean section itself, even performed by experienced surgeons, does not prevent infection compared to transperitoneal cesarean section. However, with it, intestinal paresis is observed less often, women in labor switch to a normal diet faster, the length of hospital stay is reduced, and fewer painkillers are required in the postoperative period. Therefore, with extraperitoneal cesarean section, the risk of endometritis is reliably reduced only in the case of antibacterial therapy. Since the rate of cesarean sections has increased significantly in the last 5 years, and in many hospitals one in 4-5 pregnant women delivers abdominally, some obstetricians view this phenomenon as positive and a natural consequence of the modern obstetric approach, while more conservative obstetricians, according to Pitkin, find this fact alarming. Such trends, Pitkin points out, are based more often on emotional factors than on subjective grounds.

According to research, a cesarean section is associated with a significant decrease in cell-mediated immunity and a slower recovery than after a physiological birth. The partial immunodeficiency observed in women in labor and in childbirth after a cesarean section is one of the reasons for the increased sensitivity of women in labor to infection.

Despite the 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 cesarean section are noted in 8.7% of women. Postoperative complications occur in cesarean section in 14% of women. 1/3 of complications are inflammatory processes and urinary tract infection.

Thus, the impact of caesarean section on both mother and fetus is not indifferent; therefore, in recent years, there has been a tendency to limit the indications for this operation. The overall frequency of caesarean sections without harm to the fetus can be reduced by 30%. Obstetricians should carefully evaluate the indications for each caesarean section based on the use of fetal assessment methods, trying to deliver through the natural birth canal as often as possible.

In the last decade, new data have been obtained in many areas of clinical perinatology, which have not yet been adequately covered in the development of indications for cesarean section in the interests of the fetus. The expansion of indications for abdominal delivery in the interests of the fetus required an in-depth comprehensive assessment of its intrauterine condition using modern research methods (cardiotocography, amnioscopy, amniocentesis, acid-base balance and blood gases of the mother and fetus, etc.). Previously, the problem of cesarean section in the interests of the fetus could not be resolved at the proper level, since clinical perinatology began to develop only in the last two decades.

What are the risks of having a cesarean section?

Most mothers and babies do fine after a C-section. But a C-section is a major surgical procedure, so the risks are much greater than with a vaginal birth.

Complications:

• infection of the incision area of the uterine wall;
• major blood loss;
• formation of blood clots;
• trauma to mother or child;
• negative effects of anesthesia: nausea, vomiting and severe headache;
• Difficulty breathing in the baby if the caesarean section is performed earlier than scheduled.

If a woman becomes pregnant again after a cesarean section, there is a small risk of placenta rupture or placenta previa during a vaginal birth.