C-section. Types of incisions for caesarean section. Small caesarean section: the essence of the operation, indications and contraindications, methodology, consequences

The caesarean section procedure is an operation in which a viable baby and child's place are removed from a woman by making an incision in the abdomen. On this moment This operation is not an innovation and is well common: every 7 women go into labor by cesarean section. Surgical intervention can be prescribed as planned (according to indications during pregnancy) and emergency (if complications arise during natural childbirth).

What is a caesarean section

Childbirth by Caesarean is an obstetric operation that refers to emergency care. Every obstetrician-gynecologist should know the method of implementation. This is, first of all, a salvation during complicated pregnancy and childbirth, which helps save the life of mother and child. In the process, it is not always possible to maintain the health of the child, especially in cases of fetal hypoxia, infectious diseases, severe prematurity or post-term pregnancy. Caesarean section is performed only for serious indications - the decision is made by the surgeon maternity ward.

Even with new technologies, High Quality suture material, the procedure may cause complications, such as:

• bleeding;
• amniotic fluid embolism;
• development of peritonitis;
• pulmonary embolism;
• divergence of postoperative sutures.

Why is it called that?

The word "Caesar" is a form of the Latin word "caesar" (i.e. ruler). There are suggestions that the name refers to Gaius Julius Caesar. According to an old legend, the emperor's mother died during childbirth. Doctors of that era had no choice but to cut open the pregnant woman’s belly to save the child. The operation was successful, the baby was born healthy. Since then, according to legend, this operation has been called that way.

According to another theory, the name may be associated with a law (issued in the time of Caesar) which stated: in the event of the death of a woman in labor, save the child by cutting the anterior abdominal wall and layers of the uterus, extracting the fetus. For the first time, Jacob Nufer performed an operation to give birth to a baby, with a happy ending for mother and child, for his wife. All his life he carried out operations - castration of boars. During the long and unsuccessful labor of his wife, he asked permission to make an incision for her with his own hands. The birth by caesarean section was successful - mother and child remained alive.

Indications

The main indications for the procedure are as follows:

• complete and incomplete placenta previa;
• premature, rapid placental abruption with intrauterine fetal suffering;
• failed scar on the uterus after a previous birth or other operations on the uterus;
• the presence of two or more scars after cesarean section;
• anatomically narrow pelvis, tumor diseases or severe deformities of the pelvic bones;
• postoperative conditions on the pelvic bones and joints;
• malformations of the female genital organs;
• the presence of tumors in the pelvic cavity or vagina that block the birth canal;
• presence of uterine fibroids;
• the presence of severe gestosis and lack of effect from treatment;
• severe heart and vascular diseases, central nervous system diseases, myopia and other extragenital pathologies;
• conditions after stitching fistulas of the genitourinary system;
• the presence of a 3rd degree perineal scar after a previous birth;
• varicose veins vaginal veins;
• transverse position of the fetus;
• multiple pregnancy;
• breech presentation of the fetus;
• large fruit (more than 4000 g);
• chronic hypoxia in the fetus;
• age of first-time mothers over 30 years old, with diseases internal organs, which can complicate childbirth;
• long-term infertility;
• hemolytic disease in the fetus;
• post-term pregnancy with unprepared birth canal, absence labor activity;
• cervical cancer;
• the presence of herpes virus with exacerbation.

Indications for emergency caesarean section

In some cases, surgery is necessary as an emergency. The indications will be:

• severe bleeding;
• clinically narrow pelvis;
• the amniotic fluid is discharged prematurely, but there is no labor activity;
• abnormalities of labor that are not responsive to medication;
• placental abruption and bleeding;
• situation threatening uterine rupture;
• loss of umbilical cord loops;
• incorrect insertion of the fetal head;
• sudden death women in labor, but the fetus is alive.

By woman's choice

In some clinics and countries, they practice surgery at will. With the help of a cesarean section, a woman in labor wants to avoid pain and muscle enlargement pelvic floor in size, avoid vaginal incisions. Having avoided some unpleasant sensations, women in labor are faced with others, which in most cases need to be feared much more - violation nervous system baby, difficulty lactation, separation of postoperative sutures, inability to give birth naturally in the future, etc. Before planning the operation yourself, weigh the pros and cons.

Caesarean section: pros and cons

Many women in labor see the obvious positive sides surgery, but do not weigh the pros and cons of a caesarean section. Pros:

1. removing the baby without pain and in a short period;
2. confidence in the health of the fetus;
3. no damage to the genital organs;
4. You can select the baby's date of birth.

Mothers are not even aware of the disadvantages of this procedure:

1. pain after surgery is very intense;
2. there is a possibility of complications after surgery;
3. there may be problems with breastfeeding;
4. it is difficult to care for the baby, there is a risk of seams coming apart;
5. long recovery period;
6. Difficulties may occur in subsequent pregnancies.

Kinds

Caesarean can be: abdominal, abdominal, retroperitoneal and vaginal. Laparotomy is performed to remove a viable baby; for a non-viable baby, vaginal and abdominal surgery is possible. Types of cesarean section differ in the location of the uterine incision:

• Corporal cesarean section - vertical incision of the uterine body along midline.
• Isthmicocorporeal - the uterine incision is located along the midline, partly in the lower segment and partly in the body of the uterus.
• An incision for caesarean section in the lower segment of the uterus, transverse with detachment of the bladder.
• In the lower segment of the uterus, a transverse incision is made without detachment of the bladder.

How it happens

The procedure or how a cesarean section is performed during planned hospitalization is described below:

1. Anesthesia (spinal, epidural or general anesthesia) the bladder is catheterized, the abdominal area is treated with a disinfectant. There is a screen on the woman’s chest to block access to inspection of the operation.
2. After the onset of anesthesia, the procedure begins. Initially, an abdominal incision is made: longitudinal - goes vertically from the symphysis pubis to the navel; or transverse - above the pubic joint.
3. After this, the obstetrician spreads the abdominal muscles, cuts the uterus and opens the amniotic sac. Once the newborn is delivered, the placenta is delivered.
4. Next, the doctor sutures the layers of the uterus with special absorbable threads, and then the abdominal wall is sutured.
5. Apply a sterile bandage to the abdomen and an ice pack (to intensively contract the uterus and reduce blood loss).

How long does a caesarean section take?

Normally, the operation lasts no more than 40 minutes, and the fetus is removed approximately in the tenth minute of the process. It takes a lot of time to suture the uterus and peritoneum layer by layer, especially when applying a cosmetic suture, so that the scar is not noticeable in the future. If complications arise during surgery ( long action anesthesia, acute blood loss in the mother, etc.), the duration can increase to 3 hours.

Anesthesia methods

Methods of pain relief are chosen depending on the condition of the woman in labor, the fetus, planned or emergency surgery. The drugs used for anesthesia must be safe for the fetus and mother. It is advisable to carry out conduction anesthesia - epidural or spinal. Rarely resort to the use of general endotrachial anesthesia. In general anesthesia, a preliminary anesthesia is first administered, followed by a mixture of oxygen and a drug that relaxes the muscles with an anesthetic gas.

During epidural anesthesia, nerve roots a substance is injected into the spinal cord through a thin tube. A woman feels pain only during the puncture (a few seconds), then it disappears painful sensations in the lower part of the body, after which relief occurs. She remains conscious throughout the procedure, fully present during the birth of the child, but does not suffer from pain.

Care after caesarean section

During the entire period of a woman’s stay in the maternity hospital, the sutures are treated by medical staff. To replenish fluid in the body for the first day, you need to drink a lot of water without gas. There is an opinion that a full bladder prevents the contraction of the muscles of the uterus, so you need to go to the toilet often without retaining fluid in the body for a long time.

On the second day it is already allowed to take liquid food, and from the third day (with the normal course of the postoperative period) you can resume the normal diet, which is allowed for nursing mothers. Due to possible constipation, it is not recommended to eat solid foods. This problem can be easily dealt with using enemas or glycerin suppositories. Should consume more fermented milk products and dried fruits.

In the first months, it is not recommended to visit swimming pools or open bodies of water, take baths, you can only wash in the shower. It is recommended to start active physical activity to restore shape no earlier than two months after surgery. You should begin to have an active sex life only two months after cesarean section. If your condition worsens, you should consult a doctor.

Contraindications

When performing a cesarean section, contraindications should be taken into account. Moreover, if the procedure is prescribed for vital indications for a woman, they are not taken into account:

• Fetal death in utero or developmental abnormalities that are incompatible with life.
• Fetal hypoxia, without urgent indications for cesarean section on the part of the pregnant woman, with confidence in the birth of a viable baby.

Consequences

During surgery, there is a risk of the following complications:

• Painful sensations may appear near the seam;
• long recovery of the body;
• possible scar infection;
• having a scar on the abdomen for life;
• restriction of physical activity for a long time;
• impossibility of normal hygiene procedures for the body;
• restriction of intimate relationships;
• the likelihood of psychological shocks.

What is dangerous for a child?

Unfortunately, the operating process does not pass without a trace for the child. Possible Negative consequences for baby:

• Psychological. There is an opinion that children experience a decrease in adaptation reactions to the environment.
• There may be amniotic fluid in the baby’s lungs that remains after the operation;
• Anesthesia drugs enter the baby's bloodstream.

When can you give birth after a caesarean section?

It is recommended to plan your next pregnancy after 5 years. This time is enough for complete scarring and restoration of the uterus. To prevent pregnancy from occurring before this period, it is recommended to use various methods contraception. Abortions are not recommended, since any mechanical intervention can provoke the development of inflammatory processes the wall of the uterus or even its rupture.

Video

The operation of caesarean section is considered to be one of the most common in the practice of obstetricians in the world. The frequency of its implementation is steadily increasing. It is very important to correctly and accurately assess the existing indications, possible obstacles and risks of surgical delivery. You should think about the benefits of such an operation for the mother and the potential negative consequences for the baby. What types of cesarean section are there, should the expectant mother choose it, and how should she behave after such an intervention? You can learn about this from this article.

What it is?

Caesarean section (CS) is a delivery operation during which the fetus and placenta are removed by the doctor through an incision made in the uterus.

Every obstetrician-gynecologist must master the skill of performing such an operation. Sometimes a situation may arise when a caesarean section will have to be performed by a doctor of any specialty who is proficient in surgical techniques.

KS has a very great importance in modern obstetrics, because if pregnancy proceeds with complications, it is this type of surgical intervention that will provide a real chance to save both the health and the life of the mother and baby. It must be remembered that any such intervention may be fraught with serious adverse consequences in the near future. postoperative period(peritonitis, infection, bleeding) and subsequent pregnancy (placenta accreta, placenta previa, scar changes may appear in the area of ​​the uterine incision). Now the first place among the indications for caesarean section is that which arose after a previous operation.

Trying to save...

Although in last years in obstetric practice, improved CS methods are used, suture material high quality, registration of complications of operations in mothers continues. And a woman’s subsequent reproductive function may be impaired as a result of CS. Infertility develops, the resulting pregnancy is not carried to term, and the menstrual cycle is disrupted. In addition, even if such an operation is carried out, there is not always a chance of preserving the health of the toddler, especially if the fetus infection or severe hypoxia.

A doctor of any specialty must know well and adequately evaluate the indications for cesarean section, its benefits for both the mother and the baby. It is necessary to take into account the possible negative impact of the operation on the state the patient will be in later. female body. But if suddenly emergency indications arise from the mother, the doctor is obliged to perform surgical intervention.

We classify operations

Exist the following types Caesarean section, in other words, surgical approaches:

• laparotomy (abdominal, abdominal wall, possible retroperitoneal),
• vaginal.

To extract a viable child, doctors perform only laparotomy, but if the fetus is not viable (period from 17 to 22 weeks of gestation), it is customary to use abdominal and vaginal approaches. Nowadays, vaginal cesarean sections are practically not used due to technical difficulties and frequent complications.

Regardless of the access, CS, which is performed before 17-22 weeks, is called It is done when medical indications it is necessary to terminate the pregnancy early. In recent years, abdominal access has been preferred in obstetric practice.

We divide according to localization

A rather complicated procedure is a caesarean section. The types of operations performed depending on where the incision is located on the uterus are as follows:

• corporal caesarean section (the uterus is cut along the midline);
• isthmicocorporeal (the uterus is cut in the middle, a little in the lower segment and a little in the body of the uterus);
• in the lower segment of the uterus with a transverse incision (bladder detachment is present);
• in the lower segment of the uterus with a transverse incision (the bladder is not exfoliated).

In addition to these CS methods, previously (if the uterus was infected), doctors cut it in the lower segment, temporarily isolating abdominal cavity, or performed extraperitoneal CS. Today, due to the high quality of antibacterial drugs and suture material, there is no need to use these methods.

Divided by urgency and technology

Types of cesarean section can be divided not only into operations in relation to the peritoneum (as mentioned just above), but also according to urgency and technique.

Depending on the urgency of the CS, there are:

• planned;
• planned (with the onset of labor);
• emergency.

Planned should be six or seven tenths in relation to emergency, because it is thanks to it that injuries are reduced by half, complications in women by three, fetal hypoxia by three to four times, and also perinatal mortality.

By technique:

• vaginal CS;
• abdominal;
• provided that the CS is aimed at terminating pregnancy at 16-22 weeks, then it is performed as a corporal procedure.

Positive sides

We have already looked at what types of caesarean section there are. The advantages of such surgical intervention are, of course, important. The most important advantage is the birth of a baby in cases where there is a possibility of death of the baby or the woman in labor during natural childbirth. Therefore, if a woman has an undeniable indication for a cesarean section, she does not even need to think about the pros or cons of such an operation, but give consent to the CS. After all, the health of the child and his mother is most important.

The second advantage of the CS is that there are no seams or tears on the genitals, they remain as they were. Thanks to this, the woman will not have any problems with sex life after childbirth. Exacerbation of hemorrhoids, prolapse of the pelvic organs, and cervical ruptures are completely excluded.

Another important point is speed. The operation is much faster than the natural birth process. After all, during natural childbirth, women endure contractions for hours waiting for the birth canal to open. But with CS this is not required. A planned operation is usually scheduled for a time that is as close as possible to the expected date of birth, so the onset of labor is not of fundamental importance.

Regardless of what types of cesarean section exist (a photo can give a detailed understanding of the entire process), and which one will be offered in this particular case, if a CS is necessary, the expectant mother should agree with the doctor.

Existing contraindications to CS

Important role Contraindications and conditions for surgical delivery will play a role in what the outcome of the surgical intervention will be for the woman in labor and for the child. If a decision is made to undergo surgery, the doctor must take into account the following contraindications:

• the fetus died in utero, or the fetus has an anomaly that is incompatible with life;
• fetal hypoxia along with the absence of urgent indications for CS on the part of the mother, and if there is confidence that the baby will be born alive (single heartbeats can be detected) and a completely viable baby.

If there is important indications to CS from the mother, contraindications can be ignored.

Negative aspects of surgery

Although they bring their undoubtedly positive aspects different kinds Caesarean section, there are also disadvantages to this operation. It just so happens that even if there are absolute indications for such surgical intervention, disadvantages also exist. First of all, this concerns possible risk complications - purulent processes with peritonitis, sepsis; bleeding; injuries neighboring organs. Moreover, it should be taken into account that if the operation is emergency, the risk of consequences will be several times higher.

In addition to complications, the disadvantages include the scar, which causes psychological discomfort to the woman, especially if it is located along the abdomen. It can deform the abdominal wall and contribute to the occurrence of hernial protrusions. Not every young mother will be able to wear tight-fitting clothes due to the fact that such a scar can be noticed by others through the fabric.

Some mothers may experience some difficulty breastfeeding. It is believed that due to the fact that the birth did not end naturally, the woman may experience deep stress.

Judging by the reviews of women who underwent a CS, their greatest discomfort was due to the fact that the wound hurt very much in the first days, which is why they were prescribed analgesics, and also due to the fact that a noticeable skin scar subsequently formed .

Preparing for surgery

The specifics of preparing for this type of delivery will depend on whether it is carried out as planned or for emergency reasons.

If the doctor prescribes a planned operation, then you should prepare for it in the same way as for any other:

• follow a light diet the day before;
• in the evening before the day of surgery and in the morning a couple of hours before it, you should cleanse the intestines with an enema;
• twelve hours before surgery, exclude any food and water;
• carry out the usual hygiene procedures(a woman takes a shower, shaves hair from her pubic area and belly) in the evening.

According to the list of examinations, pass the necessary tests - general clinical blood, urine, ultrasound and CTG of the fetus, determine blood clotting, tests for sexually transmitted infections, HIV, hepatitis. Consultations should also be scheduled narrow specialists and a therapist.

If there is an emergency intervention, it is necessary to administer an enema. But the tests require studies of urine, blood composition and blood clotting. Already in the operating room, the surgeon places a catheter in the bladder, and he also needs to install an intravenous catheter to infuse the necessary drugs.

Types of anesthesia for caesarean section are selected depending on the specific situation, the wishes of the patient herself and the preparedness of the anesthesiologist. Moreover, a woman’s desire will be taken into account only if it is consistent with common sense.

Stitches and cuts

And now about what types of incisions there are for a caesarean section. During the operation, the doctor makes two incisions.

The first will be external, which cuts the abdominal wall ( connective tissues, subcutaneous fat, abdominal skin).

The second is performed on the uterus.

Naturally, it is the first incision that will be visible, which subsequently turns into a “scar after the CS”. And the second incision is not visible to the ordinary eye - it will be seen by a specialist using an ultrasound scan. Both cuts may or may not coincide according to the cut line. There are two main combinations.

Classic (or vertical, or corporal) external incision. It is either combined with a similar vertical one on the uterus, or - which happens more often - with a transverse uterine incision.

Transverse external section. Its shape is arched. It is located just above the pubis in skin fold. It is combined with both a similar transverse incision on the uterus and a vertical uterine incision.

Now let's talk about what types of sutures there are for a caesarean section.

Cosmetic, as a rule, is applied with a Pfannenstiel incision (the skin and subcutaneous tissues are cut longitudinally, along the suprapubic fold). The strength in the connection of tissues during a corporal incision must be very high, and this requires interrupted sutures. Cosmetic after such a CS will not work.

Internal sutures placed on the wall of the uterus offer various options. The most important thing here is to reduce blood loss and ensure that the uterus heals well. The strength of such sutures will determine the outcome of subsequent pregnancies.

Methods of pain relief

Doctors use different types of anesthesia for caesarean section. Reviews from women who have undergone such an operation indicate that a strictly defined anesthesia was selected for each case. Regional anesthesia is considered to be one of the best options for CS anesthesia.

When preparing for a caesarean section (this is different from a large number of other operations), the doctor must take into account not only the need for pain relief. He needs to think about possible consequences from administering certain medications to the baby. This is why not all types of anesthesia are suitable for caesarean section. The optimal one is considered to be the one that excludes toxic effect funds necessary for anesthesia per child.

It should be noted that spinal anesthesia is not always possible. In this case, obstetricians perform the operation using general anesthesia. It is imperative to take medication to prevent the reflux of gastric contents into the trachea. Since abdominal tissue must be cut, muscle relaxants and ventilator(artificial pulmonary ventilation).

Try to provide for everything

Since this operation is accompanied by significant blood loss, it would not be superfluous, when preparing for it, to take the pregnant woman’s blood and prepare plasma from it, returning the red blood cells. If necessary, the woman will be given her own frozen plasma.

To replace lost blood, the pregnant woman is prescribed blood substitutes, donor plasma, shaped elements. In some cases, if it is known in advance about possible significant blood loss due to obstetric pathology, during the operation itself, washed red blood cells will be returned to the woman through a reinfusion apparatus.

If a fetal pathology was diagnosed during pregnancy, the presence of a neonatologist is necessary in the operating room for premature birth. He will immediately be able to examine the newly born baby and, if necessary, carry out resuscitation measures.

After operation

The types of sutures after cesarean section differ from each other in appearance. One is quite noticeable: it runs along the abdomen from the navel to the pubic region - if the operation was performed. The other scar will be much less visible - if a suprapubic transverse approach was performed. This is what is considered to be one of the advantages of the Pfannenstiel incision.

Women who have undergone such an operation need the help of their family. The first weeks are still healing internal seams and the pain is still strong, it is difficult for them to care for the baby at home. After discharge from the maternity hospital, doctors do not recommend that young mothers who have undergone a CS should stay in the sauna or take a bath. But you shouldn’t give up your daily shower.

So, we learned what types of cesarean sections there are, incisions, stitches, and what kind of anesthesia is used. Based on the above, every woman who wants to experience the miracle of motherhood should understand that it is not worth going to a CS just to “not suffer for a long time.” But if the need arises for this, there will be a question of saving the life of the baby and his mother, you cannot think twice. Indeed, in this case, the doctor will help the baby see this world.

Surgical intervention during childbirth has saved many lives and allowed parents to enjoy the process of raising children. But there are also many disadvantages to this method of giving birth to a child. Those who have had a caesarean section can tell you a lot about severe consequences this operation for both the woman and the baby.

Types of Caesarean section incisions

How exactly the incision is made depends largely on the condition of the mother and child. Therefore, the operation will be planned or urgent. The incision cuts through the abdominal tissue. And this is the skin, fat cells, and muscles. And then there is an incision into the uterus itself. At the same time, it is important that the incisions are of sufficient size. Otherwise, ruptures may form in the mother herself or, when removed, the child will receive injuries and damage.

Vertical section

In this case, the scalpel cuts the tissue from the navel to the pubis. This type of operation is called corporate. Most often, a vertical incision is made in cases premature birth, bleeding or when a woman in labor is dying. This type of operation is also appropriate when a woman already has a vertical suture due to a previous caesarean section or when performing certain other operations.

The biggest disadvantage of a vertical cut is that it is untidy appearance seam Because this area of ​​the abdomen goes huge pressure, an interrupted suture must be placed on the incision, which is removed after 10 days. It’s modern, the seam is getting wider and it’s already embarrassing to go to the beach.

When removing stitches, you should be very careful so that not a single small thread remains. Otherwise, it can cause suppuration and fistula. If this happens, you need to quickly go to the doctor so that he can prevent the infection from multiplying.

The most difficult month for a woman will be the first month. There may be some bleeding and pain. To avoid problems with the healing of the suture, you should adhere to the doctor’s instructions and, at the slightest deviation, contact specialists for help.

Horizontal section

This incision is made over pubic bone. It is placed in a skin fold and is therefore practically invisible. The advantage of this operation is the absence of penetration into the abdominal cavity. At the end of the caesarean section, cosmetic stitch. There is no need to make an interrupted suture because the area does not experience strong pressure from internal organs. Therefore, the cut is superimposed self-absorbing suture material. With further ultrasound examination, a specialist can check the quality of the suture. If it is strong enough, then another pregnancy and even natural childbirth is possible. However, sufficient time is required for healing. Definitely at least two years.

When is a caesarean section required?

Considering how weak young people are today, it becomes obvious that over time there will be more caesarean sections performed. Therefore, every mother should understand the main warning signs that will lead to this operation. Then parents will be able to properly prepare financially and emotionally.

Fetal problems

The baby may have incorrect placement: pelvic or transverse. Then childbirth cannot be natural. The same applies to multiple pregnancies, when babies have a complex presentation. There may also be fusion of twins or underdevelopment of one of the fetuses. Here the mother will not be able to give birth on her own. In cases of dehydration of the child or his premature birth, a caesarean section is prescribed.

Problems on the mother's side

Here the list is much longer: narrow pelvis, uterine scars, risk of uterine rupture, plastic surgery of the genital organs, herpes on the genitals, HIV infection. If you have uterine cancer or other ovarian tumors, then you need to forget about normal childbirth. Diseases of other organs also require a caesarean section. If the mother has problems with cardiovascular system, then she will not be able to give birth safely. This includes eye diseases. During natural birth It takes a lot of strength to push, this can aggravate the condition of the eyes and vision will deteriorate even more. Therefore, in order to see your baby and his growth through the eyes, you need to focus on surgical intervention during childbirth. It is impossible to give birth independently and sick diabetes mellitus, with pathologies of a neurological or gastroenterological nature.

The cesarean section operation was introduced into obstetric practice a very long time ago. True, in ancient times it was performed on a deceased mother in order to save the intrauterine fetus. The introduction of the following made it possible to make a caesarean section safer: medical technologies: infusion therapy, transfusiology, antibacterial therapy, endotracheal anesthesia, improvement of surgical techniques, implementation modern methods aseptics and antiseptics, invention of new surgical instruments and suture material.

Types of caesarean section operations:

By stage of pregnancy:
- minor caesarean section (if the miscarriage is due);
- caesarean section (at due date).
According to indications:
- absolute and relative indications;
- emergency and planned indications.
By access:
- abdominal caesarean section (as a result of transection);
- vaginal cesarean section (now practically not used).
According to the method of entering the abdominal cavity:
- mid-lateral laparotomy,
- transverse suprapubic incision.
According to the section of the uterus:
- transverse incision in the area of ​​the lower segment (the most common technique);
- rare forms of incision as an exception: longitudinal in the area of ​​the lower segment, corporal, T-shaped.
In relation to the peritoneum:
- intraperitoneal cesarean section (the most common operation);
- extraperitoneal surgery, which is performed on infected women, is technically more difficult.

Indications for surgery:

Absolute readings:
3-4th degree of pelvic narrowing;
obstruction of the birth canal due to cicatricial changes in the cervix or tumors of the uterus and vagina;
complete placenta previa and bleeding with incomplete placenta previa;
premature detachment a normally located placenta in the absence of conditions for rapid delivery through the natural birth canal;
transverse position of the fetus with a viable fetus;
anomalies of head insertion: frontal insertion, etc.;
clinical discrepancy between the head and pelvis;
threatening and incipient uterine rupture and some others.

Strictly absolute indications are those in which delivery without surgery is mortally dangerous and technically impossible.
When the cesarean section operation itself was very dangerous and caused many complications, the list of indications was sharply limited. Gradually, as operative obstetrics developed, cesarean section became a common and much safer operation, and the list of absolute indications increased significantly.

They began to take into account not only the result for the mother, but also the child. For example, in the case of a clinical discrepancy, in the old days they could perform a fetal-destroying operation, dooming the child to death; in the case of a transverse position, the fetus could be turned onto a leg; and in case of partial placenta previa, amniotomy, head-cutaneous forceps and other minor operations were used. Now, eclampsia and severe preeclampsia, serious extragenital diseases, in which severe complications are possible in the case of vaginal delivery, can be considered absolute indications.
True, when the specified pathology possible use obstetric forceps, but this operation is quite traumatic and can worsen the situation.

Relative readings:

foot presentation of the fetus;
large fruit;
narrow pelvis of the 1st-2nd degree of narrowing;
post-term pregnancy;
threat of fetal hypoxia;
scar on the uterus;
cicatricial changes in the cervix after diathermoexcision;
some extragenital diseases, etc.

Relative indications are those in which delivery through the natural birth canal is possible, but the results for the mother and fetus will be much better due to surgical delivery. For example, delivery with leg presentation, threatening fetal hypoxia. In case of a scar on the uterus, in the vast majority of cases, a cesarean section is performed as planned.
In the case of an incompetent scar, the operation is performed according to absolute indications. In recent years, the indication for surgery may be the woman’s age (primipara over 30 years old), a burdened obstetric history, especially a history of infertility, or the use of in vitro fertilization.

A woman's desire alone should not be an indication for a caesarean section; a medical justification is necessary. Despite the successes of surgical obstetrics, complications for the mother and child are likely as a result of the operation. In addition, after the operation, the woman feels pain for several days, suffers from helplessness, and cannot care for the child herself. It must be remembered that both the operation and the care after it are very expensive, and it is unjustified to resort to it without indications.
An example of emergency indications for surgery: premature abruption of a normally located placenta, threatening uterine rupture, and the onset of fetal hypoxia. Example elective surgery: pre-diagnosed narrowing of the pelvis, large fetus, uterine scar, high myopia.

Contraindications for surgery:

signs of any infection - clinical or according to test data;
temperature increase;
long waterless period;
stillbirth;
the head is located in the pelvic cavity - in this case, delivery is carried out through the natural birth canal.

Sometimes situations arise when the indications more important than contraindications, for example, if there is extensive placental abruption with an unprepared birth canal, then a cesarean section is indicated for absolute, life-saving reasons, even with signs of infection. However, since septic complications may arise in this situation, the operation is performed under the guise of antibacterial therapy, an extraperitoneal surgical technique is performed, and even removal of the uterus is possible. Conversely, if the indications are relative and the contraindications are very serious, then a cesarean section is not performed.

Preparing for planned surgery:

Planned operations are always safer, since preventive measures have been taken in advance. Early hospitalization is required one or two weeks before the planned delivery. In addition to the standard examinations that are carried out for all pregnant women, additional examinations are carried out in the hospital: smears to detect vaginal flora, blood for RW, form 50, hepatitis, clinical and biochemical analysis blood, coagulogram, control of blood group, Rh factor, urine test, ultrasound. A consultation is held regarding the choice of delivery method; consultation with a therapist and anesthesiologist is required. If an infection is detected, sanitation is carried out. If a coagulation pathology is detected, correction is carried out. If the birth canal is not ready, prepare it, since it is necessary to ensure the discharge of lochia after childbirth through the cervix.

The woman's consent is required for both planned and emergency surgery. During a planned operation, a day is selected in advance and it is performed on morning time, usually at 10 o'clock. Medicines are prepared in advance, including infusions, blood substitutes, plasma and blood of the required group, and individual selection of blood.

On the eve of the operation, complete readiness is checked. The choice of tactics and method of delivery is made by the doctor in agreement with the woman. Responsibility for preparing for the operation rests with the midwife. After early lung After dinner, a pregnant woman is not recommended to take food or liquid in the morning. In the evening, it is recommended to empty your bowels on your own or after an enema. In the evening, sanitization is carried out, the woman takes a shower.

The anesthesiologist prescribes evening premedication - medications to reduce anxiety and promote sleep, which are performed by the midwife. Usually these are drugs with a sleeping pill or sedative effect: phenobarbital, seduxen, diphenhydramine, or others. The midwife’s task is to ensure that the woman sleeps and to exclude exciting conversations with other women. It is necessary to help the woman pack her things (provide delivery to the postpartum ward after surgery).

In the morning, monitor blood pressure, pulse and temperature, perform additional sanitization, change the woman into a sterile shirt, tuck her hair under a cap, make sure that ophthalmic lenses, dentures. Before the operation, the woman is examined by an obstetrician and an anesthesiologist. Half an hour before surgery, premedication is performed as prescribed by the anesthesiologist (usually diphenhydramine 1% - 1.0-2.0 ml and atropine 0.1% - 0.5-1.0 ml).

Recently, droperidol, cerucal and antacids have been used to prevent complications of regurgitation. The pregnant woman is transferred on a gurney to the preoperative room, where urine is released and a permanent urinary catheter is installed. It is very important to prepare a woman for surgery psychologically, to set her up for a successful outcome, and to reassure her of the responsibility and competence of the operating team. The last step is to place the woman on the operating table, after which the anesthesiologist will attend to her.

Preparing for emergency surgery:

If possible, perform minimal sanitization, take into account the examination, and take urgently necessary tests. If the woman has recently eaten, perform gastric lavage. Premedication and bladder catheterization are required. The number of complications during emergency operations is greater, since they are performed against the background of a woman’s more serious condition than during a planned operation, and in a hurry.

Anesthesia:

Over the past fifty years, caesarean section has been performed most often under endotracheal anesthesia, less often under epidural anesthesia. IN modern conditions More primitive methods of pain relief are practically not used. But more recently, twenty years ago, this operation was sometimes performed under local novocaine anesthesia or inhalation mask anesthesia.

Caesarean section technique:

1. Treatment of the surgical field.
2. Laparotomy.
3. Autopsy of the uterus.
4. Removing the baby and placenta.
5. Curettage and bleeding prevention.
6. Suturing the uterus.
7. Inspection and sanitation of the abdominal cavity.
8. Counting instruments and dressings.
9. Recovery abdominal wall.
10. Processing postoperative wound.
11. Sanitation of the vagina and urine control.

The midwife should not perform the operation, but must ensure the supply of instruments in an extreme situation. The operating nurse prepares for the operation first: she sets the table according to general principles preparation for surgery abdominal surgery; prepares sterile instruments, dressing, syringes, disinfectant solutions, gloves, underwear, gowns. She helps the obstetricians get dressed and provides supplies for treating the surgical field.

The surgical field is treated with disinfectant solutions (this can be iodine and alcohol, iodonate, degmicide, chlorhexidine, etc.). For processing, forceps and cotton-gauze swabs are used. The doctor, together with the operating nurse, covers the woman with sterile sheets, which are secured around the surgical field using pins. The incision site is additionally treated with iodine using a shaving stick.

During laparotomy, the skin, subcutaneous tissue, aponeurosis and rectus abdominis muscles are subsequently dissected. Inferomedian laparotomy is now performed very rarely. This is a very quick access, it does not dissect the muscles, however, the healing of the abdominal wall is slow, sometimes with complications, remains noticeable scar. Nowadays, a transverse suprapubic Pfanenstiel incision is often performed.
The skin and subcutaneous tissue are cut along the line of the natural suprapubic fold at 16-18 cm. The scalpel used to open the skin is no longer used. The aponeurosis is incised in the middle with another scalpel, then peeled off in the transverse direction and dissected; for this stage, in addition to the scalpel, scissors and tweezers are used.

The edges of the aponeurosis are captured with Kocher clamps, the aponeurosis is bluntly peeled off from the muscle above and below. According to Cherny's modification, the aponeurotic legs of the rectus muscles are dissected in both directions by 2-3 cm. When opening the abdominal wall, blood loss is insignificant compared to surgical and gynecological operations due to the peculiarity of blood clotting; if necessary, hemostatic clamps and ligatures are applied to bleeding vessels, use cotton gauze swabs to dry the wound. Diathermocoagulation can also be used.

The parietal peritoneum is dissected longitudinally, first with a scalpel and then with scissors. In order not to damage the intestinal loops, the peritoneum is lifted with two soft tweezers with the help of an assistant. The edges of the peritoneum are fixed with Mikulicz clamps to sterile napkins to delimit the wound. For better review and protecting the bladder, a suprapubic mirror is inserted into the wound, which is removed before removing the child, but then reinserted during suturing of the uterus and revision of the abdominal cavity.

The opening of the uterus is usually performed according to the Gusakov method with preliminary opening of the vesicouterine ligament and partial detachment of the bladder. In the area of ​​the lower segment of the uterus, a small transverse incision is made 2 cm below the level of the incision of the vesicouterine fold. Using the index fingers of both hands, carefully stretch the edges of the wound up to 10-12 cm, sometimes more with large sizes fetus The wound is moon-shaped due to the characteristic muscular structure of the uterus. An arcuate incision of the uterus as modified by Derfler is rarely done. Open carefully amniotic sac. Sometimes a towel is first inserted into the abdominal cavity behind the uterus, into which amniotic fluid and blood are absorbed. Suction may be used.

The child is removed by the head or pelvic end by hand. In some countries, such as England, the head is removed using obstetric forceps. The afterbirth is removed by pulling the umbilical cord or removed by hand. Curettage of the uterine cavity is carried out with a large curette; to prevent bleeding, uterotonic agents are injected into the muscle: 1 ml of a 0.02% solution of methylergometrine, 1 ml or 5 units of oxytocin. If the cervix is ​​closed, it must be dilated with a Hegar dilator or a finger to ensure the outflow of blood and lochia.

Suturing the uterus is carried out using various techniques. Often two rows of muscular-muscular sutures are applied and peritonization is carried out with the third row through the vesico-uterine fold (gray-serous suture). All these sutures are made of catgut, and thicker catgut is used for the muscles, and thinner catgut is used for the peritoneum. The seams can be separate or continuous. The peritoneum is usually sutured with a continuous suture. Previously, the uterine muscle was often sutured with separate sutures. With the Eltsov-Strelkov technique, the first sutures are first placed at the corners of the wound.

When placing the first row in a stake, on one side, the stake is made from the mucous side, and the puncture is made through the muscle, and on the other hand, the stake is made through the muscle, and the puncture is made through the mucous membrane, thus, the nodes end up inside the uterine cavity. The second suture is placed so as to cover the first, forming a roller. Many obstetricians prefer to apply stitches without piercing the uterine lining. In recent years, due to the production of new suture materials, it is recommended to suture the uterine muscle with a single-row suture. V. I. Krasnopolsky received good results healing of the uterus when applying a single-row continuous vicryl suture. A continuous seam is more reliable when it is made with an overlap according to Reverden.

For suturing, the uterus is often brought out into the wound, but not always. For better reduction A napkin with hot saline solution is placed on the uterus. At the suturing stage, needle holders, needles, anatomical tweezers, suture material, napkins and tampons are used to dry the wound (a forceps or window clamp is used to fix them).

Revision and sanitation of the abdominal cavity. The uterus is immersed in the wound, it and its appendages are examined, the wet towel is removed, and the abdominal cavity is dried using napkins. A count of instruments and dressings is carried out.

Restoration of the abdominal wall is carried out in the reverse way. First, the parietal peritoneum is sutured with a continuous catgut suture, then the muscles (catgut is used for these purposes). Then the aponeurosis is sutured with separate silk sutures or a continuous vicryl suture. The assistant improves visibility using Farabeuf hooks.

Sparse catgut sutures are placed on the subcutaneous tissue. Interrupted silk sutures or metal staples are applied to the skin. When suturing the skin, surgical tweezers are used. Before suturing the aponeurosis and skin, the edges of the skin are treated with iodine.

In recent years, the cesarean section technique, modified by Stark, using Joel-Cohen's method of cesarean section is sometimes used. The skin is cut transversely 2.5 cm below the line connecting the anterosuperior iliac spines. Using a scalpel, a depression is made along the midline in the subcutaneous fatty tissue, the aponeurosis is incised and dissected to the sides.

The surgeon and assistant simultaneously spread the subcutaneous fat and rectus abdominis muscles along the skin incision line. The peritoneum is opened with the index finger in the transverse direction. The uterus is sutured with a disposable continuous Reverden suture. Both layers of the peritoneum and the rectus muscles are not sutured. A continuous vicryl suture according to Reverden is placed on the aponeurosis. The skin is sutured with rare Donati stitches. The modification, according to the authors, makes it possible to reduce the time from the start of the operation to the extraction of the fetus, as well as the time of the operation itself, to reduce the amount of blood loss and the percentage of complications, however, this is not recognized by many obstetricians.
Some authors offer special devices for stitching fabrics, but they are rarely used in our country.

In the discharge summary for efficiency analysis various techniques For cesarean section operations, it is necessary to indicate which method was used to perform the operation, otherwise it is difficult to assess the result of treatment.

The postoperative wound is treated with iodine. An alcohol pad is applied to the wound. Then cover with a dry cloth, which is fixed with cleol. Or they use special modern postoperative bactericidal self-adhesive wipes.

Vaginal sanitation is carried out to prevent infection. To do this, the woman’s legs are bent at the knees and hip joints and move apart. The mirrors are inserted and first removed using a forceps. blood clots with a dry cotton-gauze ball, then treat the vagina with a ball of alcohol. Urine monitoring is carried out. If there is blood in the urine, injury to the ureter or bladder is suspected.

The midwife is obliged:

Prepare the woman for the operation, take the child from the doctor’s hands, perform the initial toilet after examining the child by the pediatrician, monitor the child until he is transferred to the neonatal department. In the absence of an assistant, operating nurse, or anesthetist, the midwife is obliged to fulfill her duties as prescribed by the doctor (in a district hospital, a small maternity hospital, or in the event of a sudden illness of one of the staff). The midwife must be able to care for the postpartum mother after a caesarean section in the recovery room and on the postpartum ward.

The midwife is required to know the indications for caesarean section in order to hospitalize the woman in a timely manner and call a doctor. She must understand the urgency of the operation and facilitate the prompt provision of assistance. She must know the complications of cesarean section and be able to prevent them in the postoperative period.

Postoperative complications:

Complications of anesthesia (regurgitation, vomiting, aspiration, respiratory complications, pneumonia).
Allergic complications due to the administration of drugs, up to anaphylactic shock.
Complications associated with large blood loss, since the minimum blood loss during a caesarean section is 500 ml.
Coagulation disorders, thrombophlebitis, anemia.
Bleeding.
Subinvolution of the uterus.
Complications associated with massive infusion therapy and transfusion.
Infectious complications caused by surgery: peritonitis, parametritis, postoperative wound complications, septicemia.
Disorders of urination and bowel function, intestinal paresis.

After a cesarean section, just like after childbirth, any postpartum complications are likely.
There may also be rare complications associated with trauma during bladder surgery, but these are usually identified in the operating room.

Postoperative care:

The first day after the operation, the postpartum woman is observed in the recovery room. Features of care are determined by the severity of the condition, blood loss, concomitant pathology. In an uncomplicated course, an approximate observation scheme will be as follows.

Mode:

On the first day, the woman lies down; due to the aftereffects of anesthesia and the administration of painkillers, she sleeps a lot. The position of the head should be such that the root of the tongue does not sink in, and that in case of vomiting Airways no vomit got in. You need to cover her well and warm her (warmers for her arms and legs). Ice and weight on the uterus. With the doctor's permission, by the end of the first day, in as a last resort on the second day, sit the woman down and let her stand and walk around the bed. On the 2-3rd day, the woman should walk first under the supervision of a midwife, then on her own. In the following days, the usual regimen is prescribed; discharge was previously carried out on the 10th day. Now it is possible to be discharged on the day the sutures are removed or the next day, i.e. on the 7th-8th day.

Diet:

On the first day, diet 0. A small amount of liquid is allowed, for example unsweetened cranberry juice. On the second day, broth, puree, and abundant nutrition are not required, since the woman receives infusion therapy, which is parenteral nutrition. From the 3rd day, a varied diet is prescribed, and from the 5th day there can be a regular common table.

Care:

Intensive general care, especially on the first day, help with care on the 2nd and 3rd days. From the 3-4th day, a healthy woman can carry out self-care. On the 1st-2nd day, the newborn is cared for by a nurse or midwife. From the 3rd day the woman should try to do it herself, but she needs support and help. When observing and caring for a woman, it should be taken into account that the patient is both a postoperative patient and a postpartum woman. Care and prescriptions are carried out to prevent the following complications.

Prevention of infectious complications:

Prevention of infectious complications (it is most rational to start antibacterial therapy during surgery and continue in the postoperative period). The choice of antibiotic and the duration of the course are determined by the doctor. Currently have healthy women try to prescribe antibiotics short courses so that by the time feeding begins, there is no effect on the newborn. If this is not possible, the course is determined by the state of health of the mother. On average, by the time the stitches are removed, the course ends.

Most often now prescribed are third-generation cephalosporins, semi-synthetic penicillin drugs, i.e. wide range actions effective against aerobic infection. To prevent the development of anaerobic infection, metragil is administered intravenously. The remaining preventive measures are aseptic and antiseptic measures used in the operating room, postoperative and postpartum ward.

In order to prevent infectious complications in the area of ​​the postoperative wound, daily treatment is carried out until the sutures are removed. Region postoperative suture covered with a sterile napkin, which is changed daily. The seams are treated with hydrogen peroxide, dried and then treated with a 5% solution of potassium permanganate. In case of high risk, treatment may be more intensive. The surgical wound is irradiated with ultraviolet rays, which have a bactericidal and epithelializing effect.

Prevention of bleeding:

The risk of bleeding after a caesarean section without special prescriptions is higher than after normal birth. Uterotonic drugs are prescribed for prophylactic purposes. Oxytocin is usually prescribed 1 ml (5 units) 2 times a day for 5 days. This drug also promotes better intestinal motility and normal urination and milk discharge. It is possible to prescribe other reducing agents. Feeding the baby, getting up early and having bowel movements on the second or third day also contribute to better involution of the uterus.

Prevention of pain:

In the first hours after surgery, the drugs administered during the operation are effective. Then, as directed by the doctor, the midwife administers the prescribed painkillers. Narcotic analgesics are prescribed for no more than 3 days, no more than 3 times on the first day, no more than 2 on the second and third days. (Usually promedol 1% is used, no more than 1-2 ml.) It is necessary to remember about strict drug records, entries in the birth history and a special journal, and storage of ampoules. It is possible to use trigan and torgestic for pain relief. Analgin 50% - 2 ml is often used in combination with diphenhydramine 1% - 1-2 ml.

Prevention of respiratory disorders:

:
After any endotracheal anesthesia, especially during emergency surgery, respiratory complications are possible. Previously, mustard plasters and cupping were prescribed for this purpose on the first day after surgery. Now they are used much less frequently. But more attention is paid to breathing exercises, chest massage, postural drainage (the postpartum woman is helped to turn on her side in one direction or the other). The midwife should teach the woman how to perform breathing exercises and monitor their implementation. Breathing exercises are facilitated by inflating balloons, rubber toys, and using special exercise equipment. In some cases, it is necessary to use expectorants.

Prevention of violations by gastrointestinal tract, including intestinal paresis. After surgery, you may experience nausea and vomiting. This may lead to severe complications. Therefore, for preventive purposes during pain relief, droperidol and cerucal, which have an antiemetic effect, can be used. Cerucal in the postoperative period also promotes normal peristalsis of the underlying sections. Intestinal paresis after surgery is facilitated by hypokinesia (relative immobility) and the use of muscle relaxants during surgery.

Therefore, getting up early, turning in bed, and a thoughtful diet contribute to normal operation gastrointestinal tract. On the second and, if necessary, on the third day, 1 ml of 0.5% proserin solution is prescribed. Half an hour after its administration, a hypertensive enema (on the second day) and a cleansing enema (on the third day) are prescribed. Preventive measures may be slightly different as prescribed by the doctor. In any case, the midwife must monitor the state of physiological functions. The administration of proserin is also useful for the prevention of uterine bleeding.

Prevention of urinary disorders:

Usually within the first day in bladder A permanent catheter is installed, which is best removed at the end of the first day and promotes normal urination. The prevention of infectious complications is facilitated by antibacterial therapy; factors that stimulate contractions of the uterus and intestines also activate the work of the urinary organs. If there are residual effects of gestosis, appropriate therapy is carried out.

Prevention of thromboembolic disorders:

Considering many risk factors, coagulation factors and blood vessels in the extremities are monitored. If there is a risk, anticoagulant therapy is carried out as prescribed by a doctor (from aspirin to heparin).

Prevention of anemia:

Hemostimulating therapy is carried out. For more quick recovery Infusion therapy and vitamins are prescribed.

Active movement of a woman helps prevent adhesions:

From the 3rd day, physiotherapy is prescribed: ultrasound in the area of ​​the postoperative wound, electrophoresis with absorbable and anti-inflammatory drugs.

During observation on the first day, monitoring is used, constant monitoring of cardiovascular activity, breathing, temperature is measured after 3 hours, and after blood transfusion for the first 4 hours every hour. First, hourly and then daily diuresis is measured.

During observation, monitor daily:
well-being and complaints, assess the condition;
temperature, blood pressure, pulse;
control for skin;
monitoring the condition of the mammary glands;
control of the abdomen, postoperative wound;
control over uterine involution based on the height of the uterine fundus and lochia;
control over physiological functions.

In the first three days, weakness, lethargy are observed, and pain is felt in the area of ​​the postoperative wound. Therefore, painkillers are prescribed for three days. When palpating the abdomen, pain is observed along the periphery of the wound (it is not allowed to touch it closely). The dressing must be dry.

Rehabilitation after caesarean section:

In the postoperative period, conversations are held on the same topics as with other postpartum women. It is necessary to explain to the postpartum woman that she needs to especially strictly avoid physical activity, sexual activity, and the risk of infection in the first two months. Due to the presence of a scar on the uterus during next pregnancy, especially in the coming months, there is a high probability of uterine rupture. Therefore, it is necessary to convince the woman to protect herself from pregnancy. Protection with an intrauterine device is not recommended. The next birth is no earlier than in 3 years. Postpartum maternity leave 86 days.

Caesarean section is an operation, in which the pregnant uterus is surgically opened and the fetus with all its embryonic formations is removed from it. This operation has been known since ancient times. In the Roman Empire (late 7th century BC), the burial of pregnant women without first removing the child by Caesarean section was prohibited.

The first historically reliable fact of caesarean section on a living woman was performed on April 21, 1610 by surgeon Trautmann from Wittenburg. In Russia, the first cesarean section with a favorable outcome for mother and fetus was performed by G. F. Erasmus in 1756.

In 1780, Daniil Samoilovich defended his first dissertation on caesarean section.

The introduction of asepsis and antisepsis rules did not improve the consequences of the operation for the reason that mortality was due to bleeding or infectious complications associated with the fact that a caesarean section was completed without suturing the uterine wound.

In 1876, G.E. Rein and, independently, E. Porro proposed a method of removing a child followed by amputation of the uterus.

Since 1881, after F. Kehrer sewed up the uterine incision with a three-layer suture, new stage development of cesarean section. It began to be performed not only according to absolute, but also according to relative indications. The search began for a rational surgical technique, which led to the technique of intraperitoneal retrovesical cesarean section, which is the main method at present.

Types of Caesarean section

There are abdominal caesarean sections (sectio caesarea abdominalis) and vaginal caesarean sections (sectio caesarea vaginalis). The latter is almost never implemented under modern conditions. There is also a minor caesarean section, which is performed during pregnancy up to 28 weeks.

Abdominal caesarean section can be performed using two methods:

intraperitoneal and extra-abdominal.
The intra-abdominal method of cesarean section is divided into:

1. Caesarean section in the lower segment:
a) cross section;
b) longitudinal section (isthmic-corporeal caesarean section).

2. Classic caesarean section (corporal) with an incision of the uterine body.

3. Caesarean section followed by amputation of the uterus (Reynaud-Porro operation).

Indications for caesarean section

Indications for caesarean section are divided into absolute, relative, combined and those that are rare. Absolute indications are considered to be those complications of pregnancy and childbirth in which the use of other methods of delivery poses a threat to the woman’s life. Caesarean section under such conditions is carried out without taking into account all necessary conditions and contraindications.

In a clinical situation where the possibility of vaginal delivery cannot be ruled out, but is associated with a high risk of perinatal mortality, relative indications for surgery are spoken of.

Combined indications combine a set of several pathological conditions, each of which individually is not a reason for surgical intervention. Such indications, which are very rare, include cesarean section on a dying woman. In addition, indications for caesarean section are identified with documents from the mother and fetus.

I. Indications from the mother:

— Anatomically narrow pelvis of III and IV degrees of soundness (p. vera<7см) и формы узкого таза, редко встречаются (косозмищенний, поперечнозвужений, воронкообразный, спондилолистичний, остеомалятичний, сужен екзостазамы и костными опухолями и др..)
— Clinically narrow pelvis;
— Central placenta previa;
— Partial placenta previa with severe bleeding and lack of conditions for urgent delivery per vias naturalis;
— Premature detachment of a normally located placenta and the absence of conditions for urgent delivery per vias naturalis;
- Uterine rupture, which is fraught or has begun;
- Two or more scars on the uterus;
— Inconsistency of the uterine scar;
— Scar on the uterus after a corporal cesarean section;
— Cicatricial changes in the cervix and vagina;
— Anomalies of labor that are not amenable to medical correction
— Severe varicose veins of the cervix, vagina and vulva;
— Malformations of the uterus and vagina;
— Condition after a third degree perineal rupture and plastic surgery on the perineum;
— Conditions after surgical treatment of genitourinary and intestinal fistulas;
— Tumors of the pelvic organs that interfere with the birth of a child;
- Cervical cancer;
— Lack of effect from the treatment of severe forms of gestosis and the impossibility of urgent delivery;
— Traumatic injuries of the pelvis and spine;
— Extragenital pathology if there is a note from a corresponding specialist about the need to exclude the second stage of labor according to methodological recommendations;

II. Indications from the fetus:

— Fetal hypoxia is confirmed by objective research methods in the absence of conditions for
urgent delivery per vias naturalis;
— Breech presentation of the fetus with a body weight of more than 3700 g when combined with other obstetric pathology and a high degree of perinatal risk;
– Loss of pulsating umbilical cord loops
— Incorrect position of the fetus after the rupture of amniotic fluid;
— High straight position of the swept seam;
— Extensor insertion of the fetal head (frontal, anterior facial view)
— Treated infertility with a high risk of perinatal pathology;
— Fertilization “in vitro”;
— State of agony or clinical death of the mother with a living fetus;
— Multiple pregnancy with breech presentation and fetus.

Contraindications to delivery by cesarean section:

— Extragenital and genital infections;
— Duration of labor is more than 12 hours;
— The duration of the water-free period is more than 6 hours;
— Vaginal examinations (more than 3);
— Intrauterine fetal death.

Conditions for the operation:

- Live fruit;
— No infection;
- Mother's consent to the operation.

Preparation for the operation depends on whether it is carried out as planned before the onset of labor or during childbirth. It should be noted that during childbirth the lower segment of the uterus is well defined, which makes the operation easier.

If the operation is carried out as planned, then you should first prepare everything necessary for blood transfusion to the woman and for resuscitation of the child, who may be born in. On the eve of the operation, they give a light lunch (thin soup, broth with white bread, porridge), and sweet tea in the evening. A cleansing enema is done in the evening and morning on the day of surgery (2 hours before surgery). Amniotomy is performed 1.5-2 hours before surgery. On the eve of the operation, a sleeping pill is given at night (luminal, phenobarbital (0.65), pipolfen or diphenhydramine 0.03-0.05 g).

In the case of an emergency caesarean section, before the operation with a full stomach, it is emptied through a tube and an enema is given (in the absence of contraindications: bleeding, eclampsia, rupture of the uterine body, etc.). In these cases, anesthesiologists should always remember the possibility of acid regurgitation stomach contents into the respiratory tract (Mendelssohn syndrome). Urine is removed with a catheter on the operating table.

An appropriate method of pain relief is endotrachial anesthesia with nitrous oxide in combination with neuroleptic and analgesic drugs.

In modern obstetrics, caesarean section is often used with a transverse incision in the lower segment of the uterus, since this method gives the least number of complications. When performing a cesarean section using this method, there is less blood loss, and it is easier to insert the edges of the wound and stitch them together. But this is not always justified, especially in the presence of a large fetus, when it is difficult to remove it and the edges of the incision become adjacent to the ribs of the uterus and injury to the uterine arteries.

Technique of surgery in the lower segment with a cross section.

An incision in the anterior abdominal wall can be made by lower median or upper median laparotomy or by Pfannenstiel. The first two autopsies are recommended in urgent cases. During a planned caesarean section, a Pfannenstiel approach is possible.

The pregnant uterus is brought out into the surgical wound. Several sterile napkins are inserted into the abdominal cavity, the outer end of which is attached with clips from the outer underwear. The uterovesical fold is incised 2 cm above the bottom of the bladder and bluntly separated up and down. A longitudinal incision 1-2 cm long is made on the anterior wall of the uterus with a scalpel, and then bluntly or with the help of scissors it is continued up to 12 cm. The amniotic membranes are torn through the wound, and the fetus is removed with a hand held behind the lower pole of the head. The umbilical cord is cut between two clamps. The child is handed over to the midwife. If the placenta does not separate on its own, perform manual separation and removal of the placenta. After this, a control inspection of the uterine cavity is carried out with a curette and sutures are applied, starting from the edges of the wound in layers:

1) muscle-muscular sutures numbering 10-12 at a distance of 0.5-0.6 cm from each other;
2) muscular-serous with the sutures of the first row immersed in them;
3) a catgut-like serous-serous suture connecting both edges of the peritoneum.

All instruments and napkins are taken from the abdominal cavity, after which the wall is sutured in layers
belly.

Main stages of the operation:
1. Opening of the anterior abdominal wall and peritoneum.
2. Opening the lower segment of the uterus 2 cm below the vesicouterine fold.
3. Removal of the fetus from the uterine cavity.
4. Removal of droppings by hand and inspection of the uterine cavity with a curette.
5. Suturing the uterus.
6. Peritonization due to the vesicouterine fold.
7. Revision of the abdominal cavity.
8. Suturing the anterior abdominal wall.

Technique of classical (corporal) caesarean section.

In case of premature pregnancy, in order to carefully remove the premature fetus, an isthmic-corporal cesarean section is recommended, in which, after transverse dissection, visual separation and removal with the help of mirrors of the vesico-uterine fold, the uterus is expanded in the lower segment with a longitudinal incision, which then continues to 10-12 cm. Further actions of the surgeon and the method of suturing the uterine wound are similar to the previous operation.

The corporal cesarean incision is used less frequently in modern obstetrics. It is performed in the absence of access to the lower segment, or when the lower segment has not yet been formed, in case of pronounced varicose veins in the area of ​​the lower segment, in case of presentation, low attachment or complete detachment of a normally located placenta, as well as in the presence of a scar on the uterus after earlier performed corporal caesarean section.

The anterior abdominal wall is dissected along the linea alba in layers. The incision starts above the pubis, leading to the navel. The anterior surface of the uterus is fenced off from the abdominal cavity with napkins to prevent amniotic fluid from entering it. A longitudinal incision about 12 cm long is made on the anterior wall of the uterus and through it the fetus is removed by the stem or head, which is grabbed by hand.

The umbilical cord is cut between two clamps. The child is handed over to the midwife. After this, the droppings are removed, the uterine cavity is checked with a hand or a curette, and the uterine wall is sutured in layers (muscular-muscular, seromuscular and serous-serous sutures). All instruments and napkins are removed and the abdominal wall is sutured in layers.

In case of rupture of amniotic fluid (more than 10-12 hours), after numerous vaginal examinations and if there is a threat of infection or its existing manifestations, it is advisable to perform an extraperitoneal cesarean section according to the Morozov method or a cesarean section with temporary restriction of the abdominal cavity according to Smith.

Smith's surgical technique.

The anterior abdominal wall is opened using a Pfannenstiel technique (transverse incision) or a lower median laparatomy is performed. The peritoneum extends 2 cm above the bottom of the bladder. The vesicouterine fold is incised 1-2 cm above the bladder, its leaves are separated down and up so that the lower segment of the uterus is removed (at a height of 5-6 cm). The edges of the vesicouterine fold are sutured to the parietal peritoneum from above and below, and the bladder, together with a fixed fold of the peritoneum, is pulled down. A semilunar incision is used to open the uterine cavity. The operation is then performed as a regular caesarean section.
Technique of posturethral caesarean section.

Laparatomy using the Pfanenstiel technique with a 14-15 cm incision. Next, the rectus abdominis muscles are separated, and the pyramidal muscles are cut with scissors. The muscles (especially the adductus) move the side apart and separate it from the anterior tissue, exposing a triangle: from the outside - the right side of the uterus, from the inside - the lateral vesical fold, from above - the fold of the parietal peritoneum. Next, the tissue in the triangle area is peeled off, the bladder is separated and moved to the right until the lower segment of the uterus is exposed. A transverse incision 3-4 cm long is made in the lower segment and bluntly expanded to the size of the head. The fetus is removed by the head or legs in a breech presentation. The droppings are isolated, the integrity of the bladder and ureters are checked, the walls of the uterus are sutured, and the wound of the anterior abdominal wall is sutured in layers.

The Reynaud-Porro operation is a cesarean section with supravaginal amputation of the uterus. In 1876, G.E. Rein experimentally substantiated, and E. Porro performed, a cesarean section in combination with removal of the uterus (the operation was intended to prevent the development of a postpartum infectious disease). Currently, this operation is performed very rarely.

Indications for its implementation are:

— Infection of the uterine cavity;
— Complete atresia of the genital apparatus (impossibility of drainage of lochia)
— Cases of uterine cancer;
- Atonic bleeding that cannot be stopped by conventional methods;
— True placenta accreta;
- Uterine fibroids.

Postoperative management:

After the operation is completed, cold and weight are immediately applied to the lower abdomen for 2 hours;

In order to prevent hypotonic bleeding in the early postoperative period, intravenous administration of 1 ml (5 units) of oxytocin or 0.02% - 1 ml of methylergometrine per 400 ml of 5% glucose solution is indicated for 30-40 minutes;

in the postoperative period, carefully monitor the function of the bladder and intestines (catheterization every 6 hours, normalization of potassium levels, proserin)

in order to prevent thromboembolic complications, bandaging of the lower extremities and the use of anticoagulants according to indications are indicated;

The patient is allowed to get up at the end of the first day and walk on the second day; breastfeeding in the absence of contraindications after a few hours; discharge from the maternity ward is carried out on days 11-12 after surgery;

after discharge from the hospital, all women with a uterine scar should be registered at the antenatal clinic;

During the first year after the operation, contraception is mandatory: in case of uncomplicated course of the operation and postoperative period, and in conditions of a normal menstrual cycle, the use of intrauterine contraceptives is indicated; in other cases, preference should be given to synthetic progestins;

the time of subsequent pregnancy is decided taking into account the assessment of the postoperative uterine scar, but not earlier than 2 years from the date of surgery;

During the normal course of subsequent pregnancy, ultrasound must be performed at least 3 times (upon registration, at 24-28 weeks of pregnancy and at 34-37 weeks);

planned hospitalization to prepare for delivery is indicated at 36-37 weeks; It is advisable to perform delivery of women with an operated uterus at 38-39 weeks of pregnancy;