In what cases is emergency caesarean section prescribed? Indications. C-section. Types of incisions for caesarean section

According to the World Health Organization, in Russia 13% of children are born through caesarean section, this figure is growing every year. Nowadays, childbirth with surgical intervention is carried out not only for medical reasons - some women themselves choose this method of delivery. What happens to the body during a caesarean section? Will it hurt? What are the indications for surgery? How to prepare for a caesarean section? What is the advantage of this method of delivery over natural childbirth? What are the disadvantages of a caesarean section? How long does rehabilitation take after such a birth?

In what cases is surgery required?

Caesarean section is performed either planned or urgently. A planned caesarean section is prescribed according to indications or at the request of the pregnant woman. However, without medical indications, perinatal centers and maternity hospitals refuse to perform cesarean sections, so many Russian women go to have the operation in Belarus.

The decision to perform an urgent CS is made already during childbirth if a woman cannot give birth on her own or complications arise that require surgical intervention (fetal hypoxia, placental abruption). There is no preparation for a caesarean section if it is an emergency.

The reasons for the operation are absolute and relative. Absolute specialists include:

• Narrow pelvis of a woman in labor. If the pelvic bones are not wide enough, the baby's head will not be able to pass through the birth canal.
• Pathologies in the structure pelvic bones.
• Ovarian tumor.
• Uterine fibroids.
• Acute gestosis.
• Weak labor.
• Early placental abruption.
• Scars and sutures on the uterus. During childbirth, wounds that have not yet healed may rupture, which will lead to rupture of the tissue of the muscular organ.

If there are relative indications, a woman in labor has the opportunity to give birth on her own, but natural childbirth can harm her health. In this case, doctors need to consider all the risks before prescribing a planned cesarean section. Relative indications for cesarean section are as follows:

• Vision problems in a pregnant woman. When a woman pushes, the strain on her eyes increases. For the same reason, it is not recommended to give birth on your own if the woman in labor has undergone eye surgery less than a year before the due date.
• Kidney diseases.
• Dysfunctions nervous systems s.
• Oncology.
• Diseases of the cardiovascular system.
• Sexually transmitted infections in the mother.
• Repeated births, provided that the first one had complications.

Are there any contraindications?

There are no contraindications under which a caesarean section cannot be performed under any circumstances. If a woman's life is at risk, a caesarean section is prescribed in any case. All contraindications are mainly associated with the risk of the onset of a purulent-septic process after childbirth. A caesarean section may be refused if the patient has had inflammatory diseases pelvic organs and lower genital organs and there is a high probability of infection of the fetus.

Factors that may cause the development of complications associated with the inflammatory process include:

• labor lasting more than a day;
• acute form chronic diseases- ARVI, influenza, pyelonephritis, etc.;
• long period from the rupture of amniotic fluid to the birth of the child (more than 12 hours);
• more than 5 vaginal examinations during childbirth;
• delivery before the 33rd week of pregnancy;
• death of the fetus inside the womb.

Technique

During a surgical birth, the surgeon cuts the anterior abdominal wall above the pubis, then the wall of the uterus. Where and how the incision is made depends on the skill of the doctor and the type of operation. There are three techniques: classical, isthmicocorporal and Pfannenstiel.

Technique of corporal (classical) caesarean section

Corporal caesarean section is prescribed only if the following indications are present:

• adhesive disease;
• varicose veins;
• removal of the uterus after the end of childbirth;
• thinned or modified scars on the uterus;
• fetal prematurity (up to 33 weeks);
• Siamese twins;
• there is a threat to the woman’s life when it is possible to save the fetus;
• position of the fetus at an angle of 90 degrees relative to vertical axis bodies.

By classical method access to the child is obtained using a lower-median laparotomy. An incision is made along the uterus, exactly in the middle. The uterine cavity is cut very quickly - if you cut slowly, the woman in labor can lose a lot of blood. The amniotic sac is opened with a scalpel or manually, then the fetus is removed from it and the umbilical cord is clamped. To speed up the process, the woman is given oxytocin intravenously or intramuscularly. To prevent purulent-inflammatory processes, an injection of antibiotics is given.

A bottom caesarean section is a type of corporal section. With this type of cesarean section, access to the fetus is provided through the fundus of the uterus.

Sutures are placed at a distance of 1 cm from the edge of the incision. Each layer of the uterus is stitched separately. Immediately after suturing, the organs are re-examined abdominal cavity and stitch up the stomach.

A type of KKS - isthmicocorporeal section

An isthmicocorporal cesarean section differs from a classic one in that the obstetrician cuts the fold of the peritoneum and moves the bladder down. After isthmicocorporal cesarean section on the skin a little higher Bladder a scar 12 cm long remains. Otherwise, the procedure is completely similar to a corporal cesarean section.

Pfannenstiel operation

According to the Pfannenstiel technique, the abdominal wall is cut along the suprapubic line 3 cm above the symphysis pubis (the junction of the pelvic bones above the entrance to the vagina). This method is used more often than the classic one, since it causes fewer complications and a shorter recovery period. The seam with this approach is less noticeable than with the classic one.

Preparing a woman in labor in the maternity hospital

Before a caesarean section, if it was planned, the woman undergoes a full examination in the maternity hospital. Women in labor are examined by a therapist and an otolaryngologist. Also, pregnant women are required to have an electrocardiogram and ultrasound. Diseases that have become indications for CS must be cured if possible. This also includes conditions accompanying the indications, for example, anemia. Iron deficiency during pregnancy is often accompanied by a lack of protein, so anemia is treated with drugs containing protein compounds. Be sure to check blood clotting.

On the eve of the day of birth, the anesthesiologist examines the pregnant woman and selects the safest method of pain relief for her. Thanks to preliminary preparation, the risks for a planned CS are much lower than for an emergency one.

Types of anesthesia

The method of birth being considered involves surgical intervention, so delivery cannot take place without pain relief. The types of anesthesia used for caesarean section differ in the mechanism of action and the injection site - the analgesic can be injected into a vein (general anesthesia) or into the spinal cord (epidural and spinal anesthesia).

Epidural anesthesia

Before a cesarean section, a catheter is placed in lumbar region spine, where the spinal nerves are located. As a result painful sensations in the pelvic area become dull, although the woman in labor remains conscious, which means she can monitor the progress of the operation. This method of pain relief is suitable for women with bronchial asthma and heart problems. Epidural anesthesia is contraindicated in cases of bleeding disorders, allergies to anesthetics, and spinal curvature.

Spinal anesthesia

Spinal anesthesia is a type of epidural in which the drug is injected into the spinal lining. A needle, thinner than for epidural anesthesia, is inserted between the 2nd and 3rd or 3rd and 4th vertebrae so as not to damage the bone marrow. Spinal anesthesia requires less anesthetic, and the likelihood of complications is low due to precise needle insertion, and the effect occurs quickly. However, the anesthesia does not last long - no more than two hours from the moment of administration.

General anesthesia

General anesthesia caesarean section is currently rarely used due to possible consequences in the form of central nervous system pathologies in the newborn and the risk of hypoxia. The anesthetic is administered intravenously to the woman, after which she falls asleep, and an oxygen tube is inserted into her trachea. General anesthesia is indicated for obesity, fetal presentation, emergency CS, or if the woman in labor has had spinal surgery.

Sequence

The operation takes place in stages. The procedure is as follows:

1. The patient's peritoneal wall is cut. This procedure is called laparotomy. Different types of cesarean sections require different approaches to laparotomy. With an inferomedian laparotomy, the incision is made 4 cm below the navel along the linea alba of the abdomen and ends slightly above the pubis. The Pfannenstiel incision is made along the suprapubic skin fold, its length is about 15 cm. How is laparotomy done using the Joel-Cohen method? First, a superficial transverse incision is made 2.5-3 cm below the high point pelvic bones. Then the incision is deepened to the subcutaneous fat, dissected white line abdomen and spread the abdominal muscles to the sides. The latter method is faster, and there is less blood loss than with Pfannenstiel laparotomy, but the scar from the incision looks less aesthetically pleasing.
2. The woman's uterus is cut to allow access to the fetus. By classical technique an incision is made along the midline of the anterior wall of the uterus, from one uterine angle to another, or at the fundus of the uterus (fundus KS). Sometimes the bottom of the uterus is cut - the junction of the body reproductive organ in the neck.
3. The fruit is removed. If the child lies head up, he is pulled out by the leg or groin fold; if across - behind the shin. The umbilical cord is then clamped and the placenta is removed manually.
4. Surgeons sew up the uterus. One (musculoskeletal) or two (musculoskeletal and mucomuscular) rows of sutures are placed on the incision.
5. Finally, the abdominal wall is sutured in two stages. The aponeurosis is sutured with a continuous suture. The skin is sutured with cosmetic sutures or metal plates.

Below you can watch a video of the operation.

Recovery period

For the first 24 hours after a CS, a woman lies in the intensive care unit under IV drips. On the second day, the woman in labor is transferred to the ward. From this time on, she is allowed to get up, move around, cook and eat food on her own. On the 3rd day, a woman can sit down.

During the day after the operation, the woman in labor can only drink water. From the second day, you can introduce foods that do not cause constipation into your diet. You can ask your doctor for a list of such products.

Women's menstrual cycle takes longer to recover. If the mother does not breastfeed, menstruation will return in about 3 months. Otherwise, it may take about six months to restore the cycle. During the first 1.5-2 months, lochia may be released - a mixture of remnants of the placenta, ichor, parts of the mucous membrane and blood.

The seam must be treated with antiseptics and the bandage must be changed regularly. You need to wash so as not to wet the area of ​​the scar on the skin. It is better to prepare for this in advance and practice at home. You cannot go to the pool, much less swim in bodies of water - you can get an infection. While the stitch is being tightened (this takes 3-4 weeks), your stomach may hurt.

Possible consequences for mother and child

KS - abdominal surgery, after which complications are possible. Women who are about to have a surgical birth should be prepared for the following:

• With epidural anesthesia, there is a risk of damaging the spinal cord, which is dangerous due to injuries and pain in the sacral area, headaches, problems with urination, nausea and vomiting after surgery.
• If an allergy test has not been performed, the mother may have a toxic reaction to the pain medication.
• If the incision was made along the lower part of the uterine cavity, a scar may remain.
• You may lose a lot of blood, which can cause anemia.
• A long recovery period during which you cannot exercise or lift weights. Because of the latter, it will be more difficult to care for the child.
• Adhesions form between the tissues - scars on the uterus or pelvic organs. These formations can cause pain. If adhesions have formed on the intestines, digestive problems are likely. Scarring on the uterus can prevent a woman from becoming pregnant again.
• The next pregnancy is possible no earlier than 2 years from the date of birth.
• In most cases, natural childbirth in the future is excluded: with a high probability, if pregnancy occurs after surgery, the woman will be offered a repeat cesarean section.

For a newborn, surgery is not without consequences either. Anesthesia can cause disturbances in the functioning of the heart, respiratory and nervous systems. As a result, the baby may refuse to take the breast. Due to pathologies of the central nervous system, it may be more difficult for the baby to adapt.

Intraperitoneal cesarean section with lower segment transverse incision is the operation of choice in modern obstetrics. During the operation, 4 moments can be distinguished: 1) transection; 2) opening of the lower segment of the uterus; 3) extraction of the fetus and placenta; 4) suturing the uterine wall and layer-by-layer suturing of the abdominal wall.

1) Transection– can be performed in two ways: a midline incision between the navel and pubis and a transverse suprapubic Pfannenstiel incision. The suprapubic incision has a number of advantages: with it there is less reaction from the peritoneum in the postoperative period, it is more in harmony with the incision of the lower segment of the uterus, it is cosmetic, and it rarely causes postoperative hernias. When performing a transverse suprapubic incision:

A) the skin and subcutaneous tissue are cut along the line of the natural suprapubic fold over a sufficient length (up to 16-18 cm).

B) The aponeurosis is incised in the middle with a scalpel, and then peeled off with scissors in the transverse direction and dissected with them in the form of an arc. After this, the edges of the aponeurosis are captured with Kocher clamps, and the aponeurosis is peeled off from the rectus and oblique abdominal muscles down to both pubic bones and up to the umbilical ring. 3 ligatures or clamps are applied to both edges of the dissected aponeurosis, picking up the edges of the napkins that cover the surgical field.

C) to achieve better access, in some cases a suprapubic incision is made in Czerny’s modification, in which the aponeurotic pedicles of the rectus muscles are dissected in both directions by 2-3 cm.

D) the parietal peritoneum is dissected longitudinally from the umbilical ring to the upper edge of the bladder.

2) Opening of the lower segment of the uterus:

a) after delimiting the abdominal cavity with napkins, the vesicouterine fold of the peritoneum is opened at the place of its greatest mobility with scissors, which are then made under the peritoneum in each direction, and the fold is dissected in the transverse direction.

B) the bladder is easily separated from the lower segment of the uterus with a tuffer and is displaced downward.

C) the level of incision in the lower segment of the uterus is determined, which depends on the location of the fetal head. At the level of the largest diameter of the head, a small incision is made with a scalpel in the lower segment until the amniotic sac is opened. The index fingers of both hands are inserted into the incision, and the hole in the uterus is moved apart until the fingers feel that they have reached the extreme points of the head.

3) Extraction of the fetus and placenta:

A) the surgeon’s hand is inserted into the uterine cavity so that its palmar surface is adjacent to the fetal head. This hand turns the head with the back of the head or face anteriorly and extends or flexes it, due to which the head is released from the uterus. If there is a breech presentation, the baby is removed by the anterior inguinal fold or leg. When the fetus is in a transverse position, the hand inserted into the uterus finds the fetal leg, the fetus is turned onto the leg and then removed.

B) The umbilical cord is cut between the clamps and the newborn is handed over to the midwife.

C) 1 ml of methylergometrine is injected into the uterine muscle

D) by gently pulling the umbilical cord, the placenta is separated and the placenta is released. If there is difficulty, the placenta can be separated by hand.

D) after the release of the placenta, the uterine walls are checked with a large, blunt curette, which ensures the removal of fragments of membranes, blood clots and improves uterine contraction.

4) Suturing the uterine wall and layer-by-layer suturing of the abdominal wall:

a) two rows of muscular-muscular sutures are applied to the uterine wound. The extreme sutures are placed 1 cm lateral to the angle of the incision on the uninjured uterine wall to ensure reliable hemostasis. When applying the first row of sutures, the Eltsov-Strelkov technique is successfully used, in which the nodes are immersed in the uterine cavity. In this case, the mucous membrane and part of the muscle layer are captured. The injection and puncture of the needle are made from the side of the mucous membrane, as a result of which the nodes after tying are located on the side of the uterine cavity. The second layer of muscular-muscular sutures corresponds to the entire thickness of the muscular layer of the uterus. Knotted catgut sutures are applied so that they are located between the sutures of the previous row. Currently, the method of suturing the muscle layer with a single-row continuous suture made of biologically inactive material (Vicryl, Dexon, Polysorb) has become widespread.

b) peritonization is carried out due to the vesicouterine fold, which is sutured with a catgut suture 1.5-2 cm above the incision. In this case, the opening line of the lower segment of the uterus is covered bladder and does not coincide with the line of peritonization.

C) napkins are removed from the abdominal cavity, and the abdominal wall is sutured tightly in layers

D) a continuous catgut suture is applied to the peritoneum, starting from top corner wounds.

D) the rectus abdominis muscles are brought together with a continuous catgut suture, then interrupted sutures are applied to the aponeurosis and interrupted catgut sutures are applied to the subcutaneous tissue

E) the skin wound is sutured with silk, lavsan or nylon with interrupted sutures.

Even with the strongest intention of a pregnant woman to give birth on her own, sometimes circumstances develop in such a way that only an emergency caesarean section can help the delivery.

Indications for surgical intervention often arise when labor has begun, even if the pregnancy proceeded well and complications were not expected.

What is a caesarean section?

Although the concept of caesarean section seems to be familiar to everyone, not all women experience this method of childbirth, and do not know what an emergency caesarean section is.

- this is the most used abdominal surgery among women, helping to give birth to a baby when the normal process is disrupted due to diseases and pathological characteristics of the mother and child.

Emergency caesarean section is distinguished by the spontaneity of the operation, which is performed for vital indications.

Reasons for the increase in the number of operations

A caesarean section allows you to avoid not only health problems, its main task is to preserve the life of the woman in labor and the fetus.

Recently, there has been an increase in such operations. In Europe, a third of births occur by caesarean section.

Obstetricians attribute this growth to completely objective reasons:

1. Age of primiparas - women giving birth for the first time rapidly age. Increasingly, the first birth occurs at the age of 30 years. Such women in labor acquire many gynecological and somatic diseases. This complicates the course of pregnancy and childbirth. Pregnancies are often interrupted and are accompanied by the development of the child and his hypoxia. During childbirth, the fetal membrane occurs, observed in the natural course of labor, weak labor, immaturity, and other pathologies.
2. The incidence of diseases such as heart disease, obesity, and pathologies is increasing every year. Chronic diseases do not contribute healthy birth, the course of pregnancy, worsen the development of the fetus.
3. Physiological reasons - women in labor, abnormal presentation of the fetus and prolapse of the umbilical cord before the birth of the baby.
4. Attribution to absolute indications of those that were previously classified as relative.

Types of caesarean section

Types of surgical delivery are classified according to the location of the incision, technique and urgency.

According to the technique of execution, there are different types of cesarean:

1. Abdominal - used more often than others. The operation is performed under general anesthesia and lasts 10-15 minutes. The incision is made transversely above the pubis or longitudinally from the navel to the pubis. After this, the uterus is dissected in the lower segment. The amniotic sac is ruptured, the baby and placenta are removed, and the incision is sutured.
2. The vaginal view is used for abortion in the second trimester of pregnancy. It is performed extremely rarely - in case of scarring on the cervix, severe illnesses of the pregnant woman. Carry out two methods. The first, more gentle, consists of dissecting the uterus along the anterior wall. In this case, the cervix and internal organs are not affected. happens in a short time. In the second method, an incision is made along the walls of the vagina and uterus. The operation is very traumatic, the recovery period is long and is accompanied by postoperative complications.

In relation to the peritoneum, there are the following types of cesarean section:

• corporal - the incision is made along the midline with a dissection of the uterine body;
• isthmic-corporal - the abdominal cavity is dissected from the navel to the pubis, the uterus is dissected along the midline in the lower segment and along the body;
• the incision is made in the lower segment of the uterus with or without bladder detachment.

By dates:

• planned according to indications;
• emergency, which is carried out to save the life of the woman in labor and the baby.

Indications for elective surgery

Caesareans are performed according to relative and absolute indications. There is no exact division, it all depends on the woman and her state of health.

List of indications for elective surgery identified during pregnancy:

• birth canal that prevents the child from passing through it - narrow pelvis, fractures or congenital pathologies of the pelvic bones, tumor neoplasms of internal organs located in the pelvis;
• kidney transplantation;
• complete placenta previa;
• scars on the uterus, cervix, cicatricial constrictions;
• breech presentation of the fetus;
• plastic surgeries performed on the genitals, perineal ruptures;
• death of a child in a previous birth or birth injury leading to disability;
• multiple pregnancy with breech presentation of the first fetus;
• gestosis and eclampsia in severe form;
• fetal growth retardation.

Indications for emergency surgery

Surgery is performed in case of complications of childbirth or pregnancy that arose at the last moment.

Indications for emergency caesarean section:

• placenta previa;
• open bleeding;
• early abruption of the placenta with its normal location;
• uterine rupture along the scar, its threat;
• acute oxygen starvation fetus;
• near-death condition or death of a woman in labor;
• Not gynecological diseases, leading to a sudden deterioration in the health of the pregnant woman;
• weakness of labor;
• foot presentation of the baby;
• uterine rupture;
• prolapse of the umbilical cord during childbirth.

Stages of caesarean section

The operation is performed in several stages:

• opening of the peritoneum;
• uterine dissection;
• birth of a child;
• birth of placenta;
• suturing the uterus;
• check and toilet;
• suturing the abdominal incision;
• treatment with antiseptics, applying an antiseptic sticker to the seams.

During a caesarean section, amniotic fluid is sucked out by the surgeon before removing the baby, or it drains on its own.

Complications of caesarean section

Women who persist in their desire to give birth on their own do not know the dangers of an emergency caesarean section.

The danger lies in the urgency of the operation. When planning a cesarean section, doctors and the woman have time to prepare - the gynecologist examines the pregnant woman and the fetus for possible complications.

The consequences of an emergency cesarean section are more severe than with a planned operation - the choice of anesthesia is more difficult, the postoperative period is more difficult, intestinal paresis is more often diagnosed, and the risk of adhesions increases.

Intraoperative

Complications that arise during the operation:

• sudden bleeding;
• complications from anesthesia - sudden allergic reaction;
• difficulty removing the baby;
• injury to internal organs.

Postoperative

• defeat spinal cord if carried out incorrectly;
• , provoked by blood loss;
• development of purulent-septic complications;
• soreness of the sutures;
• development of adhesive processes;
• difficulties associated with breastfeeding, impaired milk production;
• subsequent pregnancies must be planned; you cannot become pregnant within two years after a cesarean section;
• there is a high probability that the next birth will be performed by caesarean section;
• ban on vigorous physical activity for 6 months.

Video: emergency caesarean section indications

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

Caesarean section is one of the most common operations in obstetric practice, which is an emergency procedure that every obstetrician-gynecologist must know, and sometimes a caesarean section must be performed by a doctor of any specialty who is proficient in surgical techniques.

In modern obstetrics, caesarean section is of great importance, since in case of complicated pregnancy and childbirth it allows preserving the health and life of mother and child. However, every surgery may have serious adverse effects in the near term postoperative period[bleeding, infection, pulmonary embolism (PE), OM embolism, peritonitis], and during subsequent pregnancy (scar changes in the area of ​​the uterine incision, placenta previa, true placenta accreta). In the structure of indications for cesarean section, the first place is currently occupied by a scar on the uterus after a previous cesarean section. Despite the use of improved methods of cesarean section in obstetric practice, the use suture material high quality, complications of the operation in the mother continue to be recorded. Caesarean section can have an impact on the subsequent reproductive function of women (possible development of infertility, recurrent miscarriage, menstrual irregularities). In addition, during a cesarean section, it is not always possible to preserve the health of the child, especially in cases of severe miscarriage, postmaturity, infectious disease of the fetus, or severe hypoxia.

A doctor of any specialty must know the indications for cesarean section and be able to objectively assess the benefits of cesarean section for the mother and child, taking into account the possible adverse effects of the operation on health. female body and when emergency indications on the mother's side, perform a caesarean section.

Despite possible complications Caesarean section, the frequency of this operation throughout the world is steadily increasing, which causes reasonable concern for obstetricians in all countries. In Russia, the frequency of cesarean sections in 1995 was 10.2%, in 2005 - 17.9%, and in Moscow these figures were 15.4% and 19.2%, respectively (with fluctuations from 11. 3 to 28.6%). In the USA in 2003, 27.6% of operations were performed (in 2004 - 29.1%), in Canada in 2003 - 24%, in Italy - 32.9%, in France - 18%.

The increase in the frequency of cesarean sections in Russia and Moscow is combined with a decrease in perinatal mortality (PM): in Russia in 2001 it was 1.28%, and in 2005 - 1.02% (in Moscow this figure for the same period decreased from 1.08 to 0.79%). Of course, the PS indicator depends not only on the frequency of surgical delivery, but also on the optimization of the management of complicated pregnancy, childbirth, resuscitation and nursing of premature babies and children with extremely low body weight, as well as the treatment of children born with intrauterine diseases.

The increase in the frequency of cesarean sections in modern obstetrics is due to objective reasons.

· Increase in the number of primigravidas over 35 years of age.
· Intensive implementation of IVF (often repeated).
· Increased history of cesarean section.
· Increased incidence of cicatricial changes in the uterus after myomectomy performed through laparoscopic access.
· Expansion of indications for caesarean section in the interests of the fetus.

To a certain extent, more frequent caesarean sections are facilitated by the use of objective methods obtaining information about the condition of the fetus, in which overdiagnosis is possible (fetal cardiac monitoring, ultrasound, X-ray pelvimetry).

CLASSIFICATION OF CESAREAN SECTION OPERATIONS

Surgical access for caesarean section, as a rule, is laparotomic (abdominal, abdominal wall, possibly retroperitoneal) and vaginal. To extract a viable fetus, only laparotomy is performed, and for a non-viable fetus (from 17 to 22 weeks of gestation), both abdominal and vaginal access is possible. Vaginal caesarean section is currently practically not performed due to technical difficulties and frequent complications. Regardless of the access, a caesarean section performed before 17–22 weeks is called a minor caesarean section. A minor caesarean section is performed to early interruption pregnancy for medical reasons and, as a rule, currently in obstetric practice, abdominal access is more often used.

Depending on the location of the incision on the uterus, the following types of cesarean section are currently distinguished.

· Corporal caesarean section with an incision of the uterine body in the midline.
· Isthmicocorporeal with an incision of the uterus along the midline, partly in the lower segment and partly in the body of the uterus.
· In the lower segment of the uterus, a transverse incision is made with bladder detachment.
· In the lower segment of the uterus with a transverse incision without detachment of the bladder.

In addition to the above-described CS methods, it was proposed that in case of an infected uterus, dissect it in the lower segment with temporary isolation of the abdominal cavity (the parietal peritoneum after its transverse dissection is sutured to the upper sheet of the vesicouterine fold) or perform extraperitoneal CS (exposure of the lower segment of the uterus by detachment of the parietal peritoneum and vesicouterine fold after abduction of the right rectus abdominis muscle to the right). Currently, due to the high quality of antibacterial drugs and suture material, there is no need for these methods.

INDICATIONS FOR CESAREAN SECTION OPERATION

Indications for caesarean section are divided into absolute and relative. The lists of absolute indications differ from one author to another and are constantly changing, since many indications that were considered relative in the past are now considered absolute.

To standardize the indications for caesarean section, it is advisable to divide them into 3 main groups (the list includes indications associated with a high risk to the health and life of the mother and child).

· Indications for elective caesarean section during pregnancy.
- Complete placenta previa.
- Failure of the uterine scar (after cesarean section, myomectomy, uterine perforation, removal of a rudimentary horn, excision of the angle of the uterus during tubal pregnancy).
- Two or more scars on the uterus.
- Obstruction from the birth canal to the birth of a child (anatomically narrow pelvis of II or more degree of narrowing, deformation of the pelvic bones, tumors of the uterus, ovaries, pelvic organs).
- Severe symphysitis.
- Presumably large fetus (fetal body weight more than 4500 g).
- Severe cicatricial narrowing of the cervix and vagina.
- Presence in medical history plastic surgery on the cervix, vagina, suturing genitourinary and enterogenital fistulas, third degree perineal rupture.
- Breech presentation, with a fetal body weight of more than 3600–3800 g (depending on the size of the patient’s pelvis) or less than 2000 g, III degree extension of the head according to ultrasound, mixed breech presentation.
- In multiple pregnancies: breech presentation of the first fetus with twins in first-time mothers, triplets (or large quantity fruits), conjoined twins.
- Monochorionic, monoamniotic twins.
- Malignant neoplasm.
- Multiple uterine fibroids with the presence of large nodes, especially in the lower segment of the uterus, malnutrition of the nodes.
- Stable transverse position of the fetus.
- Severe forms of gestosis, eclampsia with ineffective therapy.
- III degree FGR, if its treatment is effective.
- High myopia with changes in the fundus.
- Acute genital herpes (rashes in the external genital area).
- History of kidney transplant.
- Death or disability of a child during a previous birth.
- IVF, especially repeated, in the presence of additional complications.

· Indications for emergency caesarean section during pregnancy.
- Any variant of placenta previa, bleeding.
- PONRP.
- Threatening, begun, accomplished uterine rupture along the scar.
- Acute fetal hypoxia.
- Extragenital diseases, deterioration of the pregnant woman’s condition.
- A state of agony or sudden death of a woman in the presence of a living fetus.

· Indications for emergency caesarean section during childbirth are the same as during pregnancy. In addition, a cesarean section may be necessary for the following complications of childbirth.
- Uncorrectable disorders of contractile activity of the uterus (weakness, incoordination).
- Clinically narrow pelvis.
- Prolapse of the umbilical cord or small parts of the fetus with cephalic presentation of the fetus.
- Threatened, started or completed uterine rupture.
- Leg presentation of the fetus.

If there are indicated indications for cesarean section, the doctor may decide to perform a vaginal delivery, but at the same time he bears moral and sometimes legal responsibility in the event of an unfavorable outcome for the mother and fetus.

If during pregnancy indications for a cesarean section are identified, it is preferable to carry out the operation as planned, since it has been proven that the frequency of complications for the mother and child is significantly less than with emergency intervention. However, regardless of the timing of the operation, it is not always possible to prevent health problems in the fetus, since its condition may change before the operation. The combination of prematurity or postmaturity with fetal hypoxia is especially unfavorable. An insufficient incision on the uterus can also cause injury to both the premature and post-term fetus (damage to the spinal cord and brain).

Caesarean section is also performed for combined indications, i.e. in the presence of a combination of several complications of pregnancy and childbirth, each of which individually is not considered a reason for a cesarean section, but together they are considered as a real threat to the life of the fetus in the case of vaginal delivery (post-term pregnancy, births in first-time mothers over the age of 30 years old, history of stillbirth or miscarriage, previous long-term infertility, large fetus, breech presentation, etc.).

When a woman in labor experiences these complications, a cesarean section is performed to prevent diseases in newborns and their death.

For this reason, in the reports of obstetric institutions, among the indications for cesarean section, the column “complicated obstetric history” was introduced (unfavorable outcome for the fetus or newborn during a previous birth, history of infertility, IVF, age of first-time mothers 35 years and older, recurrent miscarriage, etc. ).

When assessing the performance of an obstetric hospital or a doctor who performed a cesarean section, it is more advisable to take into account the combination of all factors complicating pregnancy and childbirth, highlighting the leading one.

CONTRAINDICATIONS TO CESAREAN SECTION OPERATION

A special role in the outcome of cesarean section for the mother and fetus is played by the determination of contraindications and conditions for surgical delivery. When performing a caesarean section, you should consider the following contraindications.
· Intrauterine death of the fetus or its anomaly incompatible with life.
Fetal hypoxia in the absence urgent indications to a caesarean section on the part of the mother and confidence in the birth of a live (single heartbeat) and viable child.

When vital important indications Maternal contraindications for caesarean section should not be taken into account.

CONDITIONS FOR THE OPERATION

· Live and viable fetus. In case of danger that threatens the life of a woman (bleeding with complete placenta previa, PONRP, uterine rupture, neglected transverse position of the fetus and other disorders), a caesarean section is also performed in case of a dead and non-viable fetus.
· The woman must give informed consent to the operation.

PREPARATION FOR CESAREAN SECTION OPERATION

During a planned operation, the day before, a woman should have a “light” lunch (thin soup, broth with white bread, porridge), and in the evening - sweet tea with crackers. A cleansing enema is prescribed the evening before and the morning of the operation (2 hours before the start).

In case of emergency surgery full stomach It is emptied through a probe and an enema is prescribed (in the absence of contraindications, such as bleeding, uterine rupture, etc.). The patient is given 30 ml of a 0.3 molar solution of sodium citrate to drink to prevent regurgitation of stomach contents into the respiratory tract (Mendelssohn syndrome). Before anesthesia, premedication is performed. A catheter is inserted into the bladder. On the operating table, it is necessary to listen to the fetal heartbeat.

When performing a caesarean section, it is necessary to remember the precautions of the operating team (the risk of infection with syphilis, AIDS, hepatitis B and C, other viral infection). In order to prevent the above diseases, it is recommended to wear a protective plastic mask and/or goggles, double gloves due to the danger of puncturing them with a needle during surgery. You can also use special “chain mail” gloves.

METHODS OF PAIN RELIEF

Pain relief depends on the qualifications of the anesthesiologist.

· Regional anesthesia is considered the method of choice for elective surgery. If rapid delivery is necessary, either spinal or combined spinal and epidural anesthesia is performed.

· If it is impossible to perform regional anesthesia, then general combined anesthesia (endotracheal anesthesia) is used. Before starting general combined anesthesia, prevention of aspiration of gastric contents is necessary: ​​30 ml of a 0.3 molar solution of sodium citrate orally, ranitidine 50 mg and metoclopramide 10 mg intravenously. After oxygenation, induction of anesthesia is carried out (sodium thiopental at a dose of 4–6 mg/kg body weight). For the purpose of muscle relaxation, suxamethonium chloride is administered intravenously at a dose of 1.5 mg/kg body weight and then tracheal intubation is performed. Mechanical ventilation is carried out in the mode of normal ventilation with dinitrogen oxide and oxygen in equal quantities, and after removing the fetus, dinitrogen oxide should be 2 times more oxygen. After restoration of adequate muscle tone, breathing and consciousness produce extubation.

· Local infiltration anesthesia is extremely rarely used as anesthesia for cesarean section.
During surgery, it is necessary to carefully monitor blood loss, adequately replacing it with the introduction of crystalloid solutions. In case of massive blood loss, transfusion of blood components in the form of fresh frozen plasma and less often red blood cells is prescribed under the control of Hb and Ht concentrations.

It is advisable to draw blood before a cesarean section. During plasmapheresis, red blood cells are returned to the bloodstream, and the plasma is stored and, if necessary, transfused during surgery (the patient receives her own fresh frozen plasma). Currently, in case of expected large blood loss (with placenta previa, true placenta rotation), it is advisable to use a device for intraoperative reinfusion of autologous blood, with which you can collect the blood lost during surgery, wash the red blood cells and introduce them into the bloodstream. Caesarean section in obstetric hospital performed in an operating room by a specialist who knows the technique of abdominal transection. Only for health reasons and the impossibility of transporting a pregnant woman or woman in labor can the operation be performed in an unsuitable room, but in compliance with the rules of asepsis and antiseptics.

During the operation, it is advisable to have a neonatologist who knows how to perform resuscitation, especially in cases of intrauterine fetal damage or prematurity.

ANESTHESIA FOR CESAREAN SECTION

Despite the general decrease in the level of metabolic syndrome, mortality, the cause of which is anesthesia, remains almost at the same level. In obstetric practice, among surgical interventions performed using anesthesia, the majority of deaths occur during cesarean section. Of these, in 73% of cases, the death of patients occurs due to difficulties associated with intubation, aspiration of gastric contents into the tracheobronchial tree, and the development of aspiration pulmonitis. Risk of death from general anesthesia several times higher than that with regional anesthesia.

Anesthesia can contribute to death for other reasons (cardiac pathology, preeclampsia and eclampsia, bleeding and coagulopathies, etc.).

When choosing an anesthesia method, you should take into account:
· presence of risk factors (maternal age, complicated obstetric and anesthesiological histories, preterm birth, placenta previa or PONRP, aortocaval compression syndrome, preeclampsia, gestational diabetes, concomitant extragenital pathology, obesity, complications of previous or current pregnancies);
· the severity of changes in the mother’s body associated with pregnancy;
· condition of the fetus;
· the nature of the upcoming operation (based on urgency they are divided into planned and emergency, the latter are urgent or urgent);
· professional training and experience of the anesthesiologist, availability of appropriate equipment for anesthesia and monitoring the condition of the mother and fetus;
· the patient's wishes.

To make the right decision and prefer one or another method of anesthesia, you need to know the advantages and disadvantages of each of them. For planned or urgent CS surgery, regional anesthesia (epidural or spinal) is safer.

OPERATIONAL TECHNIQUE

Despite the apparent technical simplicity of cesarean section, this operation is classified as complex surgical interventions (especially repeat cesarean section).

The most rational method of caesarean section is currently considered to be an operation in the lower segment of the uterus with a transverse incision. However, it is possible (extremely rarely) to make a longitudinal incision in the uterus along the midline.

During a caesarean section, 3 types of access are used through the anterior abdominal wall (see Fig. 141).

Fig.14-1. Methods of dissection of the anterior abdominal wall according to Pfannenstiel.

· Inferior midline incision.
· Pfannenstiel incision.
· Joel-Cohen incision.

The decision on choosing the method of laparotomy for caesarean section should be made strictly individually in each case, guided by the amount of access to the uterus, the urgency of the operation, the condition of the abdominal wall (the presence or absence of a scar on the anterior abdominal wall in the lower abdomen), and professional skills. During a cesarean section, it is advisable to use synthetic absorbable threads: vicryl, dexon, monocryl or chrome-plated catgut.

The option of dissection of the anterior abdominal wall does not depend on the incision on the uterus. With an inferomedian incision of the anterior abdominal wall, the uterine wall can be dissected in any way, and with a Pfannenstiel incision, an isthmicocorporeal or corporal cesarean section can be performed. However, with a corporal caesarean section, an inferomedian incision is more often made, with a transverse incision in the lower segment of the uterus with opening of the vesicouterine fold - Pfannenstiel dissection, with a transverse incision in the lower segment without opening the vesicouterine fold - the Joel-Cohen approach.

In the absence of sufficient surgical experience, the simplest method of opening the abdominal wall is considered to be an inferomedian incision.

Corporal caesarean section

It is advisable to perform a corporal caesarean section only according to strict indications.

· Pronounced adhesions and lack of access to the lower segment of the uterus.
· Severe varicose veins in the lower segment of the uterus.
· Failure of the longitudinal scar on the uterus after a previous corporal cesarean section.
· The need for subsequent removal of the uterus.
· Premature fetus and non-expanded lower segment of the uterus.
· Conjoined twins.
· Advanced transverse position of the fetus.
· Presence of a living fetus dying woman.
· The doctor lacks the skill to perform a caesarean section in the lower segment of the uterus.

Corporal caesarean section is usually performed with an opening of the anterior abdominal wall through an inferomedian incision. With an inferomedian incision, the surgeon uses a scalpel to dissect the skin and subcutaneous tissue to the aponeurosis along the midline of the abdomen from the pubis to the navel. Next, a small longitudinal incision is made in the aponeurosis with a scalpel, and then it is extended with scissors towards the pubis and navel (Fig. 141, a).

Opening the peritoneum should be done with greater caution, starting the incision closer to the navel, since during pregnancy the apex of the bladder may be located high. Then, under visual control, the peritoneal incision is extended downward, not reaching the bladder.

Particular care should be taken when opening the peritoneum during repeated transection, when adhesive disease due to the danger of injury to the intestines, bladder, omentum. After opening the peritoneum, the surgical wound is delimited from the abdominal cavity with sterile diapers.

During a corporal caesarean section, the body of the uterus should be dissected strictly along the midline, for which the uterus must be rotated somewhat around its axis so that the cut line is at the same distance from both round ligaments (usually the uterus is slightly rotated to the left by the end of pregnancy). An incision in the uterus is made at least 12 cm long in the direction from the vesicouterine fold to the fundus. A shorter incision leads to difficulties in removing the fetal head. You can first deepen it along the intended line of dissection of the uterus to the fetal membranes at a distance of 3–4 cm, and then, using scissors under the control of the inserted fingers, increase the length of the dissection. An incision into the body of the uterus is always accompanied by heavy bleeding, so this part of the operation should be carried out as quickly as possible. Next, the amniotic sac is opened either with the index fingers or with a scalpel. With a hand inserted into the uterine cavity, the presenting part is removed, and then the entire fetus. The umbilical cord is cut between the clamps and the baby is handed over to the midwife. To enhance the contractile activity of the uterus and accelerate the separation of the placenta, 5 units of oxytocin are injected more often intravenously or less frequently into the uterine muscle. To prevent infectious postpartum illness prescribe intravenous antibacterial medicine wide spectrum of action.

Mikulich clamps are applied to the bleeding edges of the wound. The placenta is removed by pulling the umbilical cord and a manual examination of the uterus is performed.

If there is any doubt that the placenta has been completely removed, check with a blunt curette internal walls uterus.

During a planned caesarean section, before the onset of labor, it is advisable to pass the internal os of the cervix with your index finger (after this it is necessary to change the glove).

The incision on the uterus is sutured with two-row separate sutures (vicryl, monocryl, chrome-plated catgut, polysorb and other synthetic materials). The technique of suturing the uterus and the suture material are of great importance.

Correct comparison of the edges of the wound is one of the conditions for the prevention of infectious complications of the operation, the strength of the scar, which is important for the prevention of uterine rupture during subsequent pregnancies and childbirth.

Departing 1 cm from the upper and lower corners of the wound, for the convenience of suturing the uterine incision, one knotted vicryl suture is placed through all layers, using them as “holds”. When these sutures are pulled, the wound on the uterus becomes clearly visible. Next, a suture is placed on the mucous membrane and muscle layer, capturing part of the muscles, and a suture is placed on the seromuscular upper layer, which can be continuous. There are opinions about the need for a 3rd layer [seroserous (peritonization)], but, as a rule, it is not currently applied. When suturing the edges of a uterine wound, their good comparison is important (Fig. 142).

Rice. 14-2. Scheme of corporal caesarean section. Application of a continuous 2-row suture on the uterus during corporal CS.

After the operation is completed, the uterine appendages, appendix and nearby abdominal organs should be examined.

After toileting the abdominal cavity and assessing the condition of the uterus, which should be dense and contracted, they begin to apply sutures to the abdominal wall.

Suturing the incision of the anterior abdominal wall with a lower median incision is carried out layer by layer: first, a continuous thin suture (Vicryl No. 2/0) is applied to the peritoneum with a synthetic thread (Vicryl No. 2/0) in the longitudinal direction (from bottom to top), then separate sutures are applied to the rectus abdominis muscles. When making a longitudinal incision in the abdominal wall, the aponeurosis is sutured with synthetic (Vicryl No. 0, Nuralon) or silk threads, using either separate sutures every 1–1.5 cm, or a continuous Reverden suture. If synthetic threads are not available, silk should be used. Separate thin synthetic sutures (3/0) are placed on the subcutaneous tissue, and staples or separate silk sutures are placed on the skin incision.

Isthmicocorporeal caesarean section

During an isthmicocorporal cesarean section, the vesicouterine fold is first opened in the transverse direction, and the bladder is bluntly moved down. The uterus is opened along the midline both in the lower segment (1 cm away from the bladder) and in the body of the uterus. The total length of the incision is 10–12 cm. The remaining stages of the operation do not differ from those for a corporal caesarean section.

Caesarean section in the lower segment of the uterus with a transverse incision with bladder detachment

In this operation, the anterior abdominal wall is often opened with a transverse suprapubic incision according to Pfannenstiel. With this incision, postoperative hernias rarely develop, it has a favorable cosmetic effect, and after surgery, patients get up earlier, which helps prevent thrombophlebitis and other complications.

An arched transverse incision 15–16 cm long is made along the suprapubic fold (Fig. 141, b). The skin and subcutaneous tissue are dissected. The exposed aponeurosis is dissected with an arcuate incision 3–4 cm above the skin incision (Fig. 143, see color insert, 144).

Rice. 14-3. Caesarean section in the lower segment of the uterus with bladder detachment. a - dissection of the aponeurosis;

Rice. 14-3. Caesarean section in the lower segment of the uterus with bladder detachment. b, c - detachment of the aponeurosis.

Rice. 14-4. Caesarean section in the lower segment of the uterus with bladder detachment: a - dissection of the aponeurosis;

Rice. 14-4. Caesarean section in the lower segment of the uterus with bladder abruption: b

Rice. 14-4. Caesarean section in the lower segment of the uterus with bladder detachment: c - aponeurosis detachment.

The dissected aponeurosis is peeled off from the rectus and oblique abdominal muscles down to the pubis and up to the umbilical ring.

The separated aponeurosis is retracted towards the pubis and navel. The rectus abdominis muscles are separated with the fingers in the longitudinal direction. Considering that upper limit bladder (even empty) at the end of pregnancy (and especially during childbirth) 5–6 cm above the pubis, care should be taken when opening the parietal peritoneum, especially when re-entering the abdominal cavity. The peritoneum is opened longitudinally with a scalpel for 1–2 cm, and then with scissors it is cut up to the level of the navel and downwards not reaching the bladder 1–2 cm. Next, the uterus is exposed, and with scissors in the midline the vesicouterine fold is opened 2–3 cm above it attachment to the bladder and dissect it in the transverse direction, not reaching both round ligaments of the uterus by 1 cm. The apex of the bladder is bluntly separated (Fig. 145, 146, see color insert), displaced downwards and held with a mirror.

Rice. 14-5. Caesarean section in the lower segment of the uterus with bladder detachment. Bladder detachment.

Rice. 14-6. Caesarean section with a transverse incision in the lower segment of the uterus with bladder detachment. Bladder detachment.

Rice. 14-7. Caesarean section in the lower segment of the uterus with bladder detachment. Dissection of the lower segment of the uterus and widening of the wound using fingers.

At the level of the large segment of the head, carefully (so as not to injure the head), a small transverse incision is made in the lower segment of the uterus. The incision is expanded with the index fingers of both hands (according to Gusakov) (Fig. 147, 148, see color insert) to the extreme points of the periphery of the head, which corresponds to its largest diameter (10–12 cm).

Rice. 14-8. Caesarean section with a transverse incision in the lower segment of the uterus with bladder detachment.

Dissection of the lower segment of the uterus and widening of the wound using fingers.

Sometimes, if it is difficult to remove the head ( low position, its large size) it is possible to extend the wound on the uterus to the round ligaments, but this is fraught with significant bleeding. To prevent such a situation, it is recommended that instead of spreading the edges of the wound bluntly (with fingers), make an arcuate incision with curved blunt-tipped scissors in a slightly upward direction (Derfler incision).

If the fetal bladder is not opened during the dissection of the uterus, then it is opened with a scalpel, and the membranes are separated with the fingers.

Then the left hand is inserted into the uterine cavity, the fetal head is grabbed, carefully bent, and the back of the head is turned into the wound (Fig. 149, 1410, see color insert).

Rice. 14-9. Caesarean section in the lower segment of the uterus with bladder detachment. Removal of the fetal head.

Fig.Fig. 14-10. Caesarean section with a transverse incision in the lower segment of the uterus with bladder detachment. Removal of the fetal head.

The assistant presses lightly on the fundus of the uterus. By gently pulling with both hands, one and then the other shoulder is sequentially pulled out by the head, after which the fingers are inserted into the armpits and the fetus is removed. If it is difficult to remove the fetal head, instead of using your hand, you can place a spoon of forceps under the lower pole of the head and, lightly pressing on the fundus of the uterus, remove the head from the uterus. In a breech presentation, the fetus is removed by the inguinal fold or by the pedicle. In the case of a transverse position of the fetus, it is removed by the leg, and then the head is removed from the uterine cavity using a technique identical to the Morisot-Levre technique.

If an attempt to remove the head is unsuccessful, it is advisable to increase access to the uterus, dissecting it 2–3 cm towards the bottom [the incision resembles an inverted letter T (anchor incision)].

The umbilical cord is cut between the clamps and the baby is given to the midwife. After crossing the umbilical cord with for preventive purposes the mother is given an intravenous broad-spectrum antibacterial drug. To reduce blood loss during surgery, 5 units of oxytocin are injected intravenously, less often into the uterine muscle. The afterbirth is removed by pulling the umbilical cord. It is necessary to grasp the edges of the wound, especially in the area of ​​the corners, with Mikulicz clamps. Next, a manual inspection of the uterine walls is shown to exclude the presence of remnants of the placenta and fetal membranes, submucosal uterine fibroids, septum in the uterus and other pathological conditions.

If you are not sure about the patency of the cervical canal, you should go through it with your finger, and then change the glove.

Most obstetricians consider it preferable to apply a continuous single-row Reverden suture to the uterine incision (Fig. 14-11, see color insert), but separate sutures can be used at a distance of no more than 1 cm.

Rice. 14-11. Caesarean section with a transverse incision in the lower segment of the uterus with bladder detachment. Application of a continuous single-row suture according to Reverden.

Peritonization is carried out using the vesicouterine fold. At the end of peritonization, an inspection of the abdominal cavity is performed, during which it is necessary to pay attention to the condition of the uterine appendages, the posterior wall of the uterus, the appendix and other abdominal organs.

When suturing the Pfannenstiel approach, a continuous suture is placed on the peritoneal incision from top to bottom, on the rectus abdominis muscles - a continuous suture (Vicryl No. 3/0), on the transversely opened aponeurosis - separate sutures or a continuous suture according to Reverden (Vicryl No. 0), on the subcutaneous tissue - separate thin sutures, for the skin incision - either staples or an internal cosmetic suture.

Caesarean section in the lower segment of the uterus with a transverse incision without bladder detachment

In recent years, a variant of the CS, referred to as the Stark method, has gained popularity in Europe and in our country.

This method is also used in the American hospital MisgavLadach, which created a scheme (“Partitura”) for the work of the surgeon and assistants during a caesarean section before the stage of suturing the surgical wound (Table 142) and after the birth of the placenta (Table 143).

Table 14-2. Scheme of work of the surgeon and assistants during CS using the Stark method (before the stage of suturing the surgical wound)

Operation stage	Actions of the participants in the operation
	Surgeon	Assistants
Laparotomy according to Joel-Cohen	Transverse incision on the skin 15 cm long
	Transverse dissection of the fiber and aponeurosis (4–5 cm)
	Removal of subcutaneous fat tissue with fingers and scissors
	Opening the peritoneum with a finger and spreading it with the fingers in a transverse direction
		Introduction of wide mirror
Autopsy of the uterus	Elimination of possible rotation of the uterine body
	An incision on the uterus 3–4 cm long in the middle-upper part of the lower segment and widening of the wound according to Gusakov	Maintaining the uterus in the midline
Birth of the fetus	Inserting the palm into the uterine cavity and placing it at the base occipital bone fetal head
		Removing a mirror
	Removal of the fetal head with the occiput anteriorly into the incision on the uterus with maximum flexion of the head
	Pressing the hand through the abdomen onto the fundus of the uterus in a direction coinciding with the axis of the fetus
	Removal of the fetal body with continued pressure from the palm of the suprauterus
	Using the index fingers inserted into the armpits, the fetal body is removed	Applying clamps and cutting the umbilical cord
	Handing over the newborn to the midwife
Birth of placenta	By slowly pulling the umbilical cord, it promotes the birth of the placenta, and if there is difficulty, it manual release placenta and placenta discharge	Pulling on the umbilical cord

Table 14-3. Scheme of work of the surgeon and assistants during CS using the Stark method (after the birth of the placenta)

Operation stage	Actions of the participants in the operation
	Surgeon	I assistant	II assistant
Stitching the incision with a wrap		Introduction of the mirror
	To apply a suture to the incision of the uterus, it can be removed from the abdominal cavity or left in it	Separates the edges of the wound so that the surgeon can examine the angle of the wound	Dries the corner of the wound on the uterus by injecting a needle
	Applying long thread made of vicryl, stitches the contralateral angle of the wound, capturing the endometrium and the entire thickness of the myometrium
		Ties the thread into 4 knots
			Cuts off the short end of the thread
	Continues suturing with a continuous Reverden suture	Leads the thread	Dries the edges of the incision before injections
	The last injection and puncture in the area of ​​the ipsilateral corner of the wound on the uterus
		Ties the thread into 4 knots	Cuts off the ends of the thread
Toilet inspection		Removes a mirror
	Repositions the body of the uterus into the abdominal cavity
	Conducts an inspection of the uterus, uterine appendages and abdominal toilet using tuffers on forceps
	Receives a needle holder with a charged needle and tweezers from the operating nurse	Dries the corner of the wound on the aponeurosis opposite to the surgeon	Farabefar dilators open the angle of the wound on the aponeurosis opposite to the surgeon's
	Using a long vicryl thread, the contralateral angle of the aponeurosis is sutured	Ties the thread into 4 knots	Cuts off the short end of the thread
	Continues suturing the aponeurosis with a continuous suture according to Reverden	Leads the thread	Dries the edge of the incision before making injections, opens the wound, shows the edges of the aponeurosis along with the next needle injection
Suturing the anterior abdominal wall	The last injection and puncture in the area of ​​the ipsilateral angle of the wound aponeurosis		Reveals the angle of the wound from the surgeon's side
		Ties the thread into 4 knots
	Several separate thin sutures are placed on the subcutaneous tissue		Cuts off the ends of the thread
	The skin is sutured according to one of the following options:
	Continuous subcutaneous cosmetic suture	Leads the thread
	Metal brackets
	Application of 4 non-absorbable separate sutures on the skin and tissue according to Donati	Ties knots
End of operation	Apply an aseptic sticker to a stitched skin wound
	Conducts a vaginal examination of the vagina using tuffers	Spreads the patient's bent legs apart

When performing a cesarean section using the Stark method (in the lower segment of the uterus with a transverse incision without detachment of the bladder), an incision in the anterior abdominal wall is made using the Joel-Cohen method. This version of the CS has a number of advantages.

· Quick fetal extraction.
· Significant reduction in operation time.
· Reduced blood loss.
· Reduced need for postoperative painkillers.
· Reducing the incidence of intestinal paresis, the frequency and severity of other postoperative complications.

In this modification of cesarean section, laparotomy is carried out by a superficial linear transverse incision of the skin 2–3 cm below the line connecting the anterior superior iliac spines (Fig. 141, c; 1412, see color insert).

Using a scalpel, the incision is deepened along the midline in the subcutaneous tissue and at the same time the aponeurosis is incised. Then the aponeurosis is dissected to the sides under the subcutaneous fat with the slightly open ends of straight scissors. The surgeon and assistant move the rectus abdominis muscles to the side by traction along the skin incision line. The peritoneum is opened with the index finger. In this case, there is no threat of injury to the bladder. An incision on the uterus up to 12 cm long is made along the vesicouterine fold without first opening it. Removal of the presenting part and placenta is carried out in the same way as with any other method of dissection of the uterus.

Rice. 14-12. Methods of dissection of the anterior abdominal wall: according to Joel-Cohen.

The uterine wound is sutured with a single-row continuous vicryl suture. The intervals between injections are 1–1.5 cm.

To prevent weakening of the thread tension, the Reverden overlap is used. Peritonization of the suture on the uterus is not performed. The peritoneum and muscles of the anterior abdominal wall do not need to be sutured. A continuous suture is placed on the aponeurosis with vicryl according to Reverden (vicryl No. 0), and separate thin sutures are placed on the subcutaneous tissue (vicryl No. 3). The skin is closed either with a subcutaneous cosmetic suture or staples are applied. An option is possible when separate sutures are placed on the skin incision with silk (3-4 sutures per incision), using coaptation of the wound edges according to Donati.

A repeat cesarean section is performed on the old scar with its excision.
Immediately after the operation, on the operating table, a vaginal examination should be performed, blood clots should be removed from the vagina and, if possible, from lower sections uterus, produce vaginal toilet, which contributes to a smoother course of the postpartum period.

COMPLICATIONS OF CESAREAN SECTION OPERATION

Complications are possible at all stages of the operation.

When transversely incising the skin, subcutaneous tissue and Pfannenstiel aponeurosis, one of the most common complications is bleeding from the vessels of the anterior abdominal wall, which in the postoperative period can lead to the formation of a subaponeurotic hematoma.

· One of the complications during a cesarean section, especially a repeated one, is injury neighboring organs: bladder, ureter, intestines.

· The most common complication of caesarean section is bleeding.
- It can occur during dissection of the uterus if the incision is extended to the lateral side and the vascular bundle is injured. A very serious complication is bleeding caused by hypotension or atony of the uterus, a violation of the blood coagulation system.
- To prevent large blood loss after a cesarean section, it is necessary to carefully monitor the condition of the postpartum woman during the day (skin color, pulse, blood pressure) and especially monitor the condition of the uterus, bloody discharge from the genital tract.
- If there is bleeding in the early postoperative period, you should try to stop the bleeding conservative means: external massage of the uterus, instrumental evacuation of the uterus, intravenous administration of uterotonic agents, infusion-transfusion therapy using fresh frozen plasma. If there is no effect, relaparotomy is indicated. It is advisable to begin the operation with bilateral ligation of the internal iliac artery. Lack of effect is considered an indication for hysterectomy. Good stopping results uterine bleeding obtained from embolization of the uterine arteries. During transfusion infusion therapy To restore blood loss and prevent (as well as treat) disseminated intravascular coagulation syndrome, it is effective to use fresh frozen plasma and, according to indications, red blood cell mass.

· An unfavorable consequence of abdominal delivery is purulent-septic complications, which can cause maternal mortality after surgery. Currently, death from infection should be considered as a result of the woman’s background condition (infection), errors during the operation, and insufficient surgical qualifications of the doctor. Postoperative infectious complications can manifest as endometritis, thrombophlebitis, and wound suppuration. Peritonitis is the most severe and life-threatening infection for a woman.

When performing a caesarean section on a planned basis, the frequency of postoperative complications is 2–3 times less than during an emergency operation, therefore it is necessary to strive, if there are indications, for the timely performance of planned caesarean section operations.

FEATURES OF POSTOPERATIVE MANAGEMENT

If the operation is performed using regional anesthesia, then the child is placed on the mother’s chest for 5–10 minutes immediately after primary processing. Contraindications to this are extreme prematurity and birth with asphyxia. After the end of the operation, cold is immediately prescribed to the lower abdomen for 2 hours. In the early postoperative period, intravenous administration of 5 units of oxytocin or dinoprost is indicated, especially for women at high risk of bleeding.

On the first day after surgery, infusion and transfusion therapy is carried out. Solutions are administered that improve the rheological properties of blood, giving preference to crystalloid solutions. The total amount of fluid administered is determined depending on the initial data, the volume of blood loss and diuresis. Uterotonic drugs are used, and, if indicated, painkillers, anticoagulants (not earlier than 8–12 hours after surgery) and antibacterial drugs.

Bladder and bowel functions should be closely monitored. To prevent intestinal paresis after infusion therapy, metoclopramide and neostigmine methyl sulfate are used 1–2 days after surgery, and then a cleansing enema is prescribed.

If there are no contraindications on the part of the mother and child, then breastfeeding can be allowed on the 1st–2nd day after surgery.

Toilet the postoperative wound daily with a 95% solution ethyl alcohol with application of an aseptic sticker. In order to determine the condition of the wound and possible inflammatory and other changes in the uterus in the postoperative period, an ultrasound is prescribed on the 5th day. Sutures or staples from the anterior abdominal wall are removed 6–7 days after the operation, and 7–8 days after the operation the postpartum woman can be discharged home under the supervision of a doctor at the antenatal clinic.

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Unfortunately, not in all cases pregnancy ends in physiological birth. There are a number of reasons why natural childbirth poses a serious threat to the health and even life of both the fetus and the woman in labor. In such cases, specialists prescribe a caesarean section for the woman. Let's talk about what it is, in what cases it is the only possible way to give birth to a child, and when it is contraindicated, what types there are, what anesthesia is used, etc.

What is a caesarean section

A Caesarean section is a method of delivery in which the baby is removed from the mother's body through an incision in the wall of the uterus. This is an abdominal operation, during which the doctor, using special medical instruments, makes an incision in the abdominal wall, then an incision in the uterine wall, and then delivers the child into the world. The history of caesarean section goes back a long way. They say that Caesar himself was the first to be born in this way... A couple of centuries ago, this operation was performed only on dead women in order to preserve the life of the child. A little later, caesarean sections began to be used for women who, during natural childbirth, encountered any complications that prevented the successful birth of a child. But if we take into account that at that time people had no idea about antibacterial drugs and antiseptics, then it becomes obvious that cesarean section in those days in the vast majority of cases led to the death of the woman in labor. Today, when medicine has developed so much that it is quite capable of curing the most various diseases and carry out the most complex operations, caesarean section has ceased to be a dangerous surgical intervention. Moreover, today it is becoming more and more popular. According to statistics, more than 15% of all pregnancies end in non-physiological birth. This can be attributed to the fact that many women opt for a cesarean section, falsely believing that this operation will be less painful than giving birth naturally. It is not right. By nature, a woman is given the opportunity to produce offspring in only one way, and if natural childbirth is not prohibited by an obstetrician, then preference should be given to it.

Caesarean section: indications

Any medical procedure is carried out if there are indications for it. And even more so for abdominal surgery, which is a caesarean section. Doctors usually divide the indications for this operation into two types:

Absolute.

Relative.

Let's take a closer look at each of these two types.

Absolute indications for caesarean section

Absolute (vital) indications include such conditions (both of the woman and the fetus) in which the management of childbirth naturally is completely excluded. Absolute indications for cesarean section include:

Anatomical narrowing of the pelvis to 2-4 degrees. With this pathology, the fetus will not be able to safely pass through the mother’s birth canal. This indication always leads to a planned operation, because throughout the entire period of pregnancy, the pregnant woman’s pelvis is measured, and ultrasound diagnostics determines the size of the fetal head - the most voluminous part of the body. If the fetal head is larger than is possible for safe birth, then the doctor prescribes a caesarean section.

Uterine rupture (both threatened and in progress). Rupture of the uterine wall in most cases occurs for two reasons: the second pregnancy after cesarean, which occurred earlier than two years after the operation, and abdominal interventions, as a result of which an incomplete scar was formed on the uterine wall.

Eclampsia in pregnancy. This condition is also called late toxicosis or gestosis in pregnant women. An extremely dangerous condition in which a woman’s arterial pressure to critical levels, and laboratory tests detect protein in the urine.

Placenta previa. Normally, the placenta is attached either to the anterior wall of the uterus or to the posterior, which is much more common. If the placenta is not attached correctly, then the birth of a child naturally is impossible, because the placenta will block the birth canal.

Placental abruption. Under normal circumstances, placental abruption begins after the baby is born, in last stage childbirth In some cases, detachment occurs earlier than it should have happened. In such cases, emergency surgery is prescribed. This pathology can be suspected by the presence of brown vaginal discharge.

Pronounced varicose veins of a woman in labor. During natural childbirth, the condition of the veins will suffer, which can ultimately lead to thrombosis.

The presence of formations that close the birth canal. This includes myomatous nodes large sizes, ovarian cysts and others.

Deformation of the bone tissue of the pelvic bones due to mechanical damage or any disease.

Serious renal and/or liver failure.

Presence of a woman in labor serious illnesses, such as diabetes, heart defects.

Incorrect stable position of the fetus in the uterine cavity. Towards the end of pregnancy, the fetus takes its final position. Normally, the child lies with his head down, and his face “looks” at his mother’s stomach. But when the fetus has taken a transverse position, is in a full or leg breech position, or has turned its face “outward,” the doctor prescribes a cesarean section.

Sudden death women with a living fetus.

Relative indications for caesarean section

Relative indications for cesarean section include cases where there is a risk that physiological labor will have a negative impact on the health of the mother and/or child. There is a generally accepted list of relative indications, but in any case, the choice in favor of natural birth or cesarean remains with the specialist.

Relative indications can be:

Narrowing of the pelvis of 1-2 degrees.

Pregnancy, the duration of which is more than 42 weeks, subject to the absence of the onset of labor and an immature cervix.

The weight of the fetus is more than 4.3 kg.

The presence of chronic diseases in a woman in labor.

Herpetic infection. Caesarean section will help prevent the baby from becoming infected.

Eye diseases. For example, myopia with serious damage to the fundus.

First birth at 30 years of age or older.

History of infertility.

Multiple births.

Eco pregnancy.

The conclusion about the advisability of a cesarean section is made by the specialist who examined the pregnant woman and made conclusions about the state of her body, studied the medical history and assessed the risk/benefit ratio of physiological delivery.

Contraindications to caesarean section

Also, like many types of abdominal surgical interventions, cesarean section has its own contraindications, which include:

A fetus that has died in the uterine cavity.

Defects in the development of the fetus that are incompatible with life.

Severe diseases of the mother in labor of an infectious nature (colpitis, endocervicitis, endometritis and chorioamnionitis during childbirth).

If the fetus has entered the birth canal with its head.

Carrying out fruit preparation operations (cervical incisions, metreiriz, head-cutaneous forceps according to Ivanov).

After unsuccessful attempts at surgical delivery (extraction by the pelvic end, vacuum extraction, obstetric forceps).

If there are absolute indications for a cesarean section, even if there are contraindications to surgery, doctors have to operate on the pregnant woman.

Planned and emergency caesarean section

The operation is divided into two types: elective caesarean section and emergency caesarean section.

During a planned operation, the indications for its implementation are determined during pregnancy. The decision that a woman will not give birth on her own is made on the basis various studies, which includes various laboratory tests, ultrasound diagnostics, as well as consultations narrow specialists, most often - an ophthalmologist, surgeon, endocrinologist, phlebologist, hematologist or other doctors who deal with the diseases and health problems that have been diagnosed in the pregnant woman.

An emergency caesarean section is performed in cases where during pregnancy (at later) conditions of the fetus or woman have arisen that pose a threat to their health and/or life. An emergency caesarean section can also be performed during childbirth under the following conditions:

Lack of effect from labor stimulation in the next 2-4 hours with untimely rupture of amniotic fluid and weakness of labor;

Intrauterine fetal hypoxia during childbirth.

Anesthesia for caesarean section

The times when operations were performed without anesthesia are long gone. Today medicine offers a large selection of anesthetic drugs and types of anesthesia. When performing a caesarean section, the following types of anesthesia are used:

General anesthesia (intravenous, endotracheal and mask anesthesia)

Regional type: epidural and spinal anesthesia.

Local anesthesia with novocaine.

General anesthesia for caesarean section

The general type is classical anesthesia. That is, a person is immersed in deep dream and doesn't feel anything. Today, this method of labor pain relief is practically not used, but in some cases it still remains the only possible option. For example, in case of emergency caesarean section, when you cannot hesitate for a minute, and also if there are contraindications to the use of regional anesthesia.

Epidural and spinal anesthesia for caesarean section

Regional anesthesia includes epidural and spinal anesthesia. Both types of anesthesia are similar in their mechanism of action on the body: loss of sensitivity occurs in only a certain part of the body, while the consciousness of the woman in labor remains clear. Regional anesthesia is performed by inserting a needle into bottom part spine. If we compare the effects of general anesthesia and regional anesthesia on a woman’s body, then the latter will have a clear advantage. If only because the recovery period after its use will be much shorter than with general anesthesia. Plus, the mother is constantly conscious and has the opportunity to look at him immediately after removing the baby from the uterine cavity.

Difference between epidural and spinal anesthesia

During spinal anesthesia, an anesthetic is injected into the spinal space, resulting in a blockade of the nearby spinal cord. With epidural anesthesia, an anesthetic is injected into the epidural space, and leads to a blockade of the nerves exiting the spinal cord. Hence, the onset of the analgesic effect with spinal anesthesia occurs after 5-10 minutes, and with epidural anesthesia - after 20-30 minutes. Therefore, during an emergency caesarean section, spinal anesthesia is used. Both types of anesthesia lead to a decrease in blood pressure, while after spinal anesthesia this occurs sharply, and with epidural anesthesia it occurs gradually and is less pronounced. Side effects can develop from both types of anesthesia.

Local anesthesia for caesarean section without immobilization

Local anesthesia is carried out by layer-by-layer injection of a novocaine solution followed by dissection of the abdominal wall, subcutaneous tissue, abdominal wall muscle, aponeurosis, parietal peritoneum, vesicouterine fold of the peritoneum and uterus. The woman is conscious, there is no immobilization (the patient feels her legs), no side effects as with other types of anesthesia. During the operation, the woman must be emotionally and mentally healthy.

Additionally, the woman may be given nitrous oxide and oxygen. It is rarely used in modern medical institutions; preference is given to epidural or spinal anesthesia.

Preparing for a caesarean section

During a planned caesarean section, the lesions of a pregnant woman are sanitized more thoroughly chronic infection and carry out a mandatory bacteriological examination at 36-37 weeks of pregnancy.

In the hospital on the eve of the operation, the pregnant woman is given a light lunch (thin soup or broth with white bread, porridge), and only sweet tea for dinner. In the evening, a cleansing enema is given, then it is repeated in the morning 2-3 hours before the operation. The evening before the operation, they take sleeping pills - phenobarbital and antihistamine. Before surgery, the genital area should be sanitized with a chlorhexidine solution.

If an emergency caesarean section is required, then before the operation the stomach is washed through a tube and a cleansing enema is performed. A pregnant woman is given to drink 30 ml of a 0.3 molar solution of sodium citrate to prevent regurgitation of stomach contents into the respiratory tract (Mendelssohn syndrome). Before anesthesia, premedication is performed and the bladder is catheterized.

Immediately before the operation, you need to listen to the fetal heartbeat, determine the location of the presenting part - if the head enters the birth canal, then a cesarean section becomes impractical.

Caesarean section: progress of the operation

When the anesthesia begins to take effect, the doctor will begin the operation itself. The surface of the abdominal wall is treated with a special antiseptic, after which the specialist makes two incisions. The first incision is a dissection of the abdominal wall (epidermis, subcutaneous tissue, aponeurosis and abdominal muscles). It is this incision, or rather a seam on the skin, that will remind a woman of her childbirth throughout her life. The second incision is a direct dissection of the uterine wall. After the wall of the uterus is cut and the doctor has full access to its cavity, he will use a special aspirator to suck out all the amniotic fluid from the uterus and then remove the baby.

Then a careful examination of those organs that are visible to the doctor is carried out, the baby's place (placenta) is taken out and the incisions are sutured one by one in layers. Interestingly, the entire operation takes no more than 15 minutes.

What types of incisions are there for a caesarean section?

Depending on individual clinical picture Women in labor use two types of incisions:

Vertical type (lower middle section).

Transverse type (Pfannenstiel incision and Joel-Cohen incision).

Transverse incisions are most often used.

A transverse Pfannenstiel incision is made in the area just above the pubis along the suprapubic fold, 15-16 cm long. The incision of the abdominal wall has an arcuate shape with excision of a skin flap. With this incision, a cesarean section is performed with the opening of the vesicouterine fold.

The Joel-Cohen transverse incision is made 2-3 cm below the line connecting the anterosuperior iliac spines, up to 12 cm long. The incision of the abdominal wall has a straight shape. With this incision, a cesarean section is performed without opening the vesicouterine fold (using the Stark method).

The Joel-Cohen transverse incision has advantages over the Pfannenstiel incision, namely:

There is no threat of injury to the bladder;

Easier and faster way to perform;

Quick fetal extraction;

Less blood loss;

Less traumatic;

Less painful sensations in the postoperative period;

Less risk of developing postoperative complications.

The main disadvantage of the Joel-Cohen incision compared to the Pfannenstiel incision is that, from a cosmetic standpoint, it is more visible and harder to hide under underwear.

Vertical incisions are practically not used, only in rare cases, which include:

The presence of a pronounced adhesive process in the lower part of the uterus.

The inability of the doctor to fully access the lower uterine segment.

Following a cesarean section is a myomectomy (removal of the uterus).

Transverse position of the baby in the uterine cavity.

The presence of complete placenta previa, which extends into the area of ​​the anterior wall of the uterus.

A living child in a dying/dead mother.

Postoperative period

What happens to the mother after a caesarean section?

Immediately after the doctor finishes stitching, a heating pad with ice is placed on the woman's lower abdomen, which is a means of preventing uterine bleeding. Cold improves uterine contractions, which is necessary to prevent unpleasant consequences in future. With a cold on her stomach, a woman lies in the delivery room for 2 hours, after which she is transferred to a special ward intensive care, where she will stay for another day. During these days the woman in labor will be monitored medical staff: monitor blood pressure, evaluate bladder function, take pulse measurements, and also monitor vaginal discharge.

After the operation, the woman is prescribed painkillers and antibiotics, as well as uterotonics, the action of which is aimed at improving the activity of uterine contractions and reducing blood loss in the postpartum period (oxytocin or dinoprost). During the first 24 hours after cesarean section, infusion and transfusion therapy with crystalloid solutions (saline solution, Ringer-Lock solution, and 5% glucose) is carried out to replenish the circulating blood volume (CBV) and improve rheological properties blood. The amount of fluid administered depends on the amount of blood loss and diuresis. 8–12 hours after surgery, anticoagulants may be prescribed according to indications.

1-2 days after cesarean section, in order to prevent intestinal paresis, metoclopramide and a cleansing enema are prescribed.

You can get out of bed 6 hours after a cesarean section.

What happens to the child

Today, joint childbirth is actively practiced. The accompanying person can be the child's father or any other close person. Before entering the maternity ward, he will have to undergo fluorography and visit a therapist. Immediately after removal from the uterine cavity, the child is not given to the mother, as happens during natural childbirth. First, the umbilical cord is cut, then he is examined by a neonatologist (a specialist in newborn babies), the nasal passages are cleared of mucus, and the child’s height is measured and weighed. After all this, he is handed over to the father or another person accompanying the woman in labor, who will care for him for at least six hours after the operation, until the mother can physically look after him.

Rehabilitation after caesarean section

In most cases rehabilitation period after a cesarean section it is no more difficult than after a physiological birth.

Diet after caesarean section

After the operation, you should not eat anything fatty, fried, smoked, or salty for 24 hours. It is generally recommended to abstain from food for the first 12 hours. Afterwards you can eat porridge with water, fat-free broths, boiled turkey, beef or chicken. On the third day, you can introduce other dishes into your diet. The main thing is to avoid foods that irritate the gastric mucosa. It is also important to remember that there are some foods that you should not eat while breastfeeding.

Suture care after caesarean section

The main thing after a cesarean section is to monitor the suture. On the first day after surgery, an aseptic sticker is used. Usually 4-5 days after the operation, the woman in labor is given ultrasound diagnostics, which evaluates the condition of the seam. If all is well, then after another day or two the new mother goes home. At home, you will also need to monitor the seam to prevent it from coming apart. Typically, the external suture on the abdominal wall is made with threads that dissolve on their own, so there is no need to remove them. Otherwise, sutures or staples are removed on the day of discharge (on days 5-6).

The seam needs to be processed special means, which the doctor recommends, usually a solution of brilliant green or potassium permanganate. For six months, you should not engage in sports that put stress on your abdominal muscles.

Consequences after caesarean section

Surprisingly, those pregnant women who undergo this operation without indications rarely think about its consequences, while women who really cannot give birth on their own are very worried. Fortunately, medicine today makes it possible to reduce the risk of unpleasant consequences of surgery, but some may still manifest themselves. Common consequences include:

Malfunctions in the mother's gastrointestinal tract.

Longer recovery period compared to EP.

Subsequent births most often occur by cesarean section.

Pain in the suture area can remain noticeable for one and a half months.

Caesarean section: complications and their treatment

Although a cesarean section is not considered a very serious and complex operation from a surgical point of view, sometimes a woman in labor may experience some complications. Complications are usually divided into three types:

Complications of internal organs.

Complications of sutures (both external and internal).

Complications that occurred as a result of the use of anesthesia.

Complications from internal organs

Complications from internal organs include large blood loss, the formation of adhesions, endometritis and thrombophlebitis. The most severe and life-threatening complication for a woman is peritonitis.

Blood loss during childbirth and postpartum hemorrhage

A large volume of blood lost during surgery is more common than other complications. Incision of soft tissues leads to disruption blood vessels. For comparison: with ER, a woman in labor loses approximately 0.25 liters of blood, while with cesarean this volume can increase up to 4 times and amount to 1 liter. Most often, severe bleeding is accompanied by pathologies of the placenta.

How to treat

The body cannot replace such a volume of lost blood on its own. Therefore, in this case, in the first hours after the intervention, the woman in labor is given special blood-substituting drugs (administered intravenously, through a catheter and dropper).

If the bleeding does not stop, use: external massage of the uterus, instrumental evacuation of the uterus, uterotonic agents, infusion-transfusion therapy with fresh frozen plasma. If there is no effect from conservative treatment, surgical intervention is used to ligate the internal iliac artery or embolize the uterine arteries.

Formation of adhesions

The second most common complication of cesarean section is the formation of adhesions. Adhesions are films or ropes formed from connective tissues. They connect the internal organs of the peritoneum and are a protective mechanism of the body that prevents the development and spread of the inflammatory process. In principle, adhesions do not interfere with a person, but it happens that too many of them form and then they somewhat complicate the functioning of the internal organs. The formation of minor adhesions accompanies any surgical intervention, but they do not make themselves felt in any way. unpleasant symptoms. But as a result of cesarean delivery, adhesions often form on the uterine tubes, which can subsequently trigger the development of an ectopic pregnancy.

How to treat

The only method effective treatment adhesions are laparoscopy. But even after it, the development of adhesive formations is also possible. Therefore, it is easier to prevent this problem.

Prevention is special gymnastics, as well as physiotherapeutic procedures. The doctor who performed the operation will definitely tell you about this.

Endometritis

The development of endometritis is also a serious complication of cesarean section. The essence of the pathology is the development of the inflammatory process directly in the uterus itself.

It can be caused by pathogenic microbes that get into it. Endometritis manifests itself in the form of chills, loss of strength, loss of appetite, an increase in body temperature up to 39 degrees, as well as pain in the lower abdomen and vaginal discharge with purulent impurities. But it may not show up at all. Therefore, even if a young mother is not bothered by such symptoms, before being discharged from the maternity hospital, she must donate blood to detect inflammatory processes in the body (regular OAC).

How to treat

Treatment of endometritis is carried out only with antibacterial drugs. Today, almost all women in labor who have undergone a cesarean section are prescribed antibiotics immediately after the operation to prevent the development of this disease.

Thrombophlebitis

A serious complication that can occur after childbirth is deep venous thrombophlebitis. Blood clots form in the internal veins of the lower extremities, pelvis or uterus. Having come off, they can enter the heart or lung through the bloodstream, and there clog the blood vessels and stop the flow of blood. This can lead to disastrous consequences. Symptoms of thrombophlebitis are manifested by increased body temperature, chills, pain in the limb or abdomen, increased heart rate, and Shchetkin-Blumberg's symptom.

How to treat

Anticoagulants are used, which are administered intravenously or in tablets, depending on the severity of the condition.

Peritonitis

A serious complication after a cesarean section can be fatal. The development of peritonitis is provoked by infection of the abdominal cavity as a result of chorioamnionitis, endometritis, inflammatory processes in the appendages, suppuration of the suture, etc.

How to treat

A surgical intervention is required to remove the source of infection (the uterus and tubes, the ovaries are usually left behind). In addition, antibacterial, antitoxic, antianemic therapy, restoration of intestinal motility and stimulation of the immune system are required.

Complications from sutures

Complications of sutures can manifest themselves both immediately after a cesarean section, and after some time. Most often, women experience suture dehiscence and inflammation.

Treatment is prescribed by a doctor, it can be either local (antiseptic ointments, creams) or with the use of antibiotics (if suppuration has begun and the inflammatory process has spread to neighboring tissues). The divergence of the external seam is eliminated by applying a new one.

Complications from the use of anesthesia

Complications from the anesthesia used occur in every sixth woman who has undergone a cesarean section. General anesthesia can cause:

Problems with the mother's heart and blood vessels.

Damage to the throat as a result of the insertion of a tube (tracheal) into it.

Suppression of nervous, muscular and respiratory activity in a newborn.

Aspiration is the penetration of stomach contents into the respiratory system of a woman in labor, which is fraught with serious consequences.

Regional anesthesia, both spinal and epidural, often reduces a woman's blood pressure to critical levels. The activity of a newborn may be somewhat suppressed as a result of the effect of an anesthetic drug on his body. Some women note that after such anesthesia during a cesarean section, they began to have severe headaches and back pain.

Complications from the use of anesthesia require symptomatic treatment.

Caesarean section: pros and cons

Pros for a woman in labor

Absence of pain, which is inevitable during physiological childbirth.

Elimination of the perineal incision, which is often used for EP. An incision in the perineum can cause uterine prolapse.

Disadvantages for a woman in labor

Long recovery period.

High risk of developing inflammatory processes in the body.

Possible problems with breastfeeding, since after the operation the woman is prescribed antibiotics, so you cannot feed the baby for the first day.

Possible complications of subsequent pregnancies.

Aesthetic minus in the form of a seam on the stomach.

Pros for a newborn

There is no risk of the child receiving birth injuries.

There is a low probability of developing hypoxia, since during a cesarean section the child almost never experiences oxygen starvation.

Cons for a newborn

There is a high probability of developing neurological complications. Experts say that Caesarean babies, due to the fact that they were deprived of the opportunity to pass through the mother’s birth canal, are more vulnerable than children born naturally.

There may be increased intracranial pressure and headaches in the future.

According to a study by American doctors, the likelihood of developing obesity in adulthood is high compared to children born through the birth canal. According to researchers, during a cesarean section there is a possibility of bacteria entering the baby's intestines, which over time changes the metabolic rate in the body, which leads to excessive hunger and overeating.

It is rare, but it happens that a surgeon may accidentally damage the uterine wall during an incision. soft fabrics child.

Breastfeeding after caesarean section

If you use regional anesthesia, you can put your baby to your breast for 5-10 minutes immediately after surgery to stimulate breast milk production.

It is believed that to establish a complete natural feeding after a cesarean section it is somewhat more difficult than after a physiological birth. This is due to the fact that in most cases, to prevent complications, women in labor are prescribed antibacterial drugs that are incompatible with breastfeeding (BF). In addition, after surgery, a woman is not always able to constantly be near the newborn and feed him. Therefore, the baby is often fed formula for the first few days. Most children, after formula, are reluctant to take the breast and mothers, due to their fatigue and general not quite normal state of health, give up and stop trying to establish breastfeeding. But this is not always justified. Having a strong desire to breastfeed your child, you need to show some persistence: do not offer the child formula even if he flatly refuses to take the breast, feed through pain (which will certainly manifest itself the first time after the start of breastfeeding). After a cesarean section, full-fledged breast milk may come later than usually happens after a natural birth. Therefore, it is necessary to actively feed the baby and express during the first days after birth, so that lactation will gradually increase. Hot drinks and warm showers are recommended. Read more recommendations on how to increase your breast milk supply on our website.

A woman rarely thinks about what the scar will look like after surgery before the baby is born. After birth, the woman in labor begins to worry about how ugly he looks. It is worth saying that during a planned caesarean section, the incision is most often made transversely, in the lowest segment of the abdomen. Such a scar can be hidden without problems under underwear. It looks neat, like a long strip of scar tissue. An emergency caesarean section is most often performed through a vertical incision in the abdomen, so the scar remains visible and wide. If the appearance of the scar confuses a woman, it can be further corrected using laser resurfacing, microdermabrasion, plastic excision and chemical peeling. The first three methods are the most effective. Plastic excision can almost completely remove a scar, but the procedure is quite expensive and has many contraindications.

What does a cesarean section scar look like?

Caesarean scar with horizontal Joel-Cohen incision

Caesarean scar with horizontal Pfannenstiel incision

Cesarean scar with vertical incision

Pregnancy after caesarean section

Obstetricians say that repeat pregnancy after cesarean section should not be earlier than 2-3 years after the operation. This is due to the fact that a regular scar must form on the uterus, otherwise a repeat pregnancy can provoke its divergence. It is in 2-3 years that the scar becomes scarred and you can plan for the next child. But before conceiving, it is important to visit a doctor and undergo an ultrasound to assess the condition of the suture. After surgery, special attention should be paid to the issue of contraception, since abortion is no less dangerous than early pregnancy.

Subsequent deliveries after a cesarean section are not always performed by surgery; natural births are also possible. Everything will depend on the indications and contraindications for cesarean section.