Indications for caesarean section. Caesarean section: indications and contraindications

Birth by caesarean section is the current way to bring a baby into the world today. Despite the fact that this practice has many disadvantages (for example, the low adaptability of the newborn to the external environment, a difficult recovery period for the mother), in some cases it is indispensable. We are talking about situations where, without surgical intervention, the mother and (or) her baby will inevitably die. We will talk about indications for caesarean section later.

Natural childbirth has always been and will be a priority: according to the idea of nature, only two should participate in the birth of a new life - a mother and a child. But doctors did not hesitate to intervene in the sacred sacrament, and figured out how to help a woman if, for some physiological reason, she cannot give birth on her own. It is authentically known that the practice of dissection of the anterior wall of the abdomen for obstetrics began to be mastered in the distant past. From the myths of ancient Greece, it is known that Asclepius and Dionysus were born artificially when their mothers died during childbirth. Up to the 16th c. this method of delivery was called a cesarean operation, and the term familiar to us appeared only in 1598.

You can often hear that this operation is called royal birth. Indeed, in Latin, "caesarea" translates as "royal", and "sectio" means "cut". Today, the concept has been somewhat distorted: some believe that with the help of a surgical scalpel, women who imagine themselves to be queens give birth - with complete anesthesia and without the slightest effort of their own. Despite the fact that the operation is resorted to mainly in the absence of the opportunity to give birth naturally, the question of whether it is possible to use a caesarean section without indications is asked by many women to doctors.

In some European countries, a woman decides on her own how she will give birth. In Russia, doctors insist on the need to perform a caesarean section solely on indications, but there is no official law that would prohibit the “abuse” of the surgical procedure in the absence of good reasons. Perhaps that is why some expectant mothers choose this particular method of delivery.

List of indications for caesarean section

The grounds for the operation are absolute and relative:

they talk about absolute indications if the life of a woman in labor and her child is at stake. In this case, doctors have no choice and there is only one way out - surgical intervention;
we are talking about relative indications when a woman can give birth to a baby herself, but the risk of developing certain complications still exists. Then the doctors weigh the pros and cons, and then make the final decision on the method of delivery.

There are also emergency situations for fetal or maternal reasons, when doctors quickly change the course of natural childbirth to an operative one.

Absolute indications for caesarean section

Many factors can be identified as indications for a planned caesarean section.

Too narrow pelvic bone.

With such an anatomical feature, the course of childbirth depends on how much the bone is narrowed. So, a degree exceeding 3 - 4 is dangerous with negative consequences for the woman in labor and the baby. A narrow pelvis is associated with such complications in childbirth:

fading of contractions;
premature rupture of amniotic fluid;
intrauterine infection of the fetus;
development of endometritis and chorioamnionitis;
oxygen starvation of the child in the womb.

Due to attempts in a woman in labor with a narrow pelvis, the following can occur:

uterine rupture;
trauma to the baby during childbirth;
damage to the joints of the pelvis;
the appearance of fistulas in the genitourinary and intestinal tract;
severe bleeding after childbirth.

Overlapping of the internal os by the placenta.

Usually, when the placenta is located in the uterus, in its back or front wall, no problems arise. When the child seat is attached too low, it completely covers the internal pharynx and, accordingly, excludes the exit of the child in a natural way. The same difficulties arise if there is an incomplete overlap, lateral or marginal. In this case, bleeding may begin during contractions, the intensity of which doctors cannot predict.

Premature detachment of a normally located placenta.

If the placenta exfoliates prematurely, bleeding begins, which can take various forms. With closed bleeding, blood accumulates between the wall of the uterus and the placenta without visible signs, with open bleeding, blood is released from the genital tract. Mixed bleeding is a combination of open and closed forms. The problem that threatens the life of the mother and child is solved with the help of an emergency caesarean section.

Rupture of the uterus.

In this dangerous situation, the answer to the question of why a caesarean is performed becomes obvious. Without surgery, both the mother and the child will die. The cause of uterine rupture can be a large fetus, the actions of an inexperienced obstetrician, an incorrect distribution of the force with which the expectant mother is pushing.

Improper suturing.

When an abnormal scar remains on the uterus after any surgical operation, a caesarean section is performed for obstetrics. About the features of the scar learn during ultrasound.

Two or more scars on the uterus.

Two or more operations on the uterus is a serious obstacle to having a baby naturally. With normal delivery, tears may appear at the site of postoperative scars. By the way, the number of operative births is also limited. Answering the question of how many times a cesarean can be done, doctors are unanimous - without a significant risk to health, women perform two cesarean sections in their entire lives. In isolated cases, if there are serious reasons, a third operation can be performed.

Ineffective treatment of convulsive seizures.

With late toxicosis, in some cases, convulsions occur, which put the woman into a coma. If the treatment of such a condition was unsuccessful, they resort to an emergency caesarean section within two hours, otherwise the woman in labor will die with the child.

Severe illness during pregnancy.

We list the cases in which a cesarean is performed:

heart disease;
diseases of the nervous system in an acute stage;
thyroid disease with severe course;
diseases associated with a violation of pressure;
diabetes;
eye surgery or severe myopia.

Anomalies in the development of the uterus and birth canal.

Due to the weak contractile activity of the uterus and the obstruction of the birth canal, the child is deprived of the opportunity to move forward, therefore, he needs outside help. This situation is most often due to the presence of tumors in the pelvic organs that overlap the birth canal.

late pregnancy.

With age, the muscles of the vagina become less elastic, which, with independent childbirth, is fraught with serious internal tears. This is one of those cases when you can do a caesarean, even if all the health indicators of the woman in labor are normal.

Relative indications for caesarean section

Narrow pelvis.

This reason for a caesarean section is found during natural childbirth, when the doctor sees that the circumference of the fetal head does not correspond to the size of the pelvic inlet. This happens if the baby is very large or labor activity is too weak.

Divergence of the pelvic bones.

Every expectant mother faces this phenomenon. The divergence of the pelvic bones is expressed by pain in the pubic region, swelling, changes in gait and clicking sounds during walking. But if the pelvic bones do not expand enough, and in addition to this, the woman has a physiologically narrow pelvis and a large fetus, a caesarean section is inevitable.

Weak labor activity.

When a woman in labor has little labor force, her fetal bladder is artificially pierced to stimulate the process. However, even if such a measure is not enough to activate natural delivery, a decision is made to perform a caesarean section. This is the only way out, otherwise the child will suffocate or be seriously injured in childbirth.

Postponed pregnancy.

The operation is indicated for unsuccessful induction of labor, weak contractions, the presence of gynecological problems in the pregnant woman and diseases in the acute stage.

Pregnancy after artificial insemination or prolonged infertility.

If a woman, after numerous unsuccessful attempts, manages to become pregnant and bear a child, she undergoes a complete diagnosis of indications so that doctors can make a verdict on the method of delivery. If a woman in labor has had abortions, cases of stillbirth or spontaneous termination of pregnancy in the past, she will have a caesarean section.

Hypoxia or intrauterine growth retardation.

In this case, the expectant mother will also have an operation. The question of how long a planned cesarean is done for such indications depends on how long the child has not received enough oxygen and whether this problem was solved with the help of drug treatment.

In addition, a woman in labor will certainly have an artificial delivery if at least one of the factors is present:

pubic varicose veins;
large fruit;
immature cervix;
multiple pregnancy.

Reasons for caesarean section dictated by the interests of the child

If the mother herself has no reason for surgical intervention, but the fetus has them, the delivery will be operative. Indications may be:

wrong position of the baby. If the baby is head down to the mother's pelvic bones, everything is in order. Any other position of the fetus is considered a deviation from the norm. This is especially dangerous for male babies: being in the wrong position and moving along the mother's birth canal, which has not yet been expanded, boys can pass the testicles, which will lead to infertility. Suffer from excessive pressure and the head of the child;
hypoxia. With a diagnosed oxygen deficiency, an immediate operation is indicated, otherwise the contractions will only aggravate the baby's well-being, and he may suffocate;
prolapse of the umbilical cord. With this pathology, the loops of the umbilical cord often wrap around the baby so much that he dies from suffocation. The situation will be corrected only by an emergency caesarean section, but, unfortunately, it is not always possible to save the child;
life of the fetus after the death of the mother. When the mother dies, the child's vital activity is preserved for some time, then the operation is done to save the baby.

Restrictions on caesarean section

Doctors, of course, always try to save both lives, but in some cases, circumstances do not turn out the way we would like, so doctors are forced to save a woman or a child. There are several situations in which you have to make a difficult choice:

severe prematurity;
intrauterine fetal death;
serious infection of the baby;
chorioamnionitis in combination with high temperature during childbirth;
prolonged labor (more than one day).

How is a cesarean performed?

The most optimal time to start the operation is the activation of labor. In this case, the contractile activity of the uterus will contribute to the manipulation of specialists and help the baby adapt to external irritating factors. At what time a planned caesarean section is done depends mainly on the decision of the doctor, but this does not happen before 37 weeks of pregnancy. Ideally, the expectant mother is admitted to the hospital at week 38 of an “interesting” position.

Almost all artificial delivery operations are accompanied by epidural anesthesia. At the same time, the analgesic effect extends to the lower part of the body so that mommy can attach the baby to the breast immediately after he is born. An emergency caesarean section is done under general anesthesia.

At the moment when the baby should be born, the doctor cuts the abdominal wall and uterus of the woman in labor to help him be born. After removing the child, the incisions are sutured with a continuous suture and staples are applied on top for reliability. They are removed 6-7 days after the operation, before sending the happy parents and the heir home.

How is a caesarean section done? Video

For many women, surgery with an incision becomes an inevitable ordeal, giving birth through the birth canal for which it is impossible or dangerous for her and her baby. Like any other surgical operation, caesarean section is performed only for medical reasons.

Indications for surgery may be on the part of the mother, when childbirth poses a threat to her health, and on the part of the fetus, when the process of childbirth is a burden for him, which can lead to birth trauma and fetal hypoxia. They can occur both during pregnancy and childbirth.

First, let us dwell on certain points, the presence of which presupposes such an operation in pregnant women.

Indications for caesarean section during pregnancy:

Placenta previa. When the placenta (baby place) is located in the lower part of the uterus and covers the internal os (the entrance to the uterus from the side of the vagina). This threatens with severe bleeding, dangerous both for the life of the mother and for the fetus. The operation is performed at 38 weeks of pregnancy or earlier if bleeding occurs.
Premature detachment of a normally located placenta. Normally, the placenta separates from the uterine wall after the baby is born. Sometimes this happens during pregnancy, then severe bleeding begins, which threatens the life of the mother and fetus and requires immediate surgery.
Failure of the scar on the uterus after an incision in a previous birth or other operations on the uterus.
A scar on the uterus is considered insolvent if, according to ultrasound, its thickness is less than 3 mm, the contours are uneven and there are inclusions of connective tissue. If the postoperative period after the first operation was difficult (fever, inflammation of the uterus, prolonged healing of the suture on the skin), this also indicates the insolvency of the scar on the uterus.
Two or more scars on the uterus after an incision operation. Two or more caesarean deliveries are thought to increase the risk of uterine rupture along the scar in childbirth due to the weakness of the scar tissue. Therefore, the incision is made before the onset of labor.
Anatomically narrow pelvis (the so-called anatomical limitation of the size of the pelvic ring of a woman, which makes it difficult for the fetal head to pass through this ring) II-IV degree of narrowing. Every woman has her pelvis measured during pregnancy. Obstetricians have clear criteria for the normal size of the pelvis and narrow pelvis according to the degree of narrowing. Tumors and deformities of the pelvic bones. They can serve as an obstacle to the birth of a child.
Malformations of the uterus and vagina. Tumors of the uterus, ovaries and other organs of the pelvic cavity, closing the birth canal.
Large fetus in combination with another pathology. A large fetus is considered when its mass is 4 kg or more.
Expressed symphysitis. Symphysitis or symphysiopathy - divergence of the pubic bones. In this case, there are pronounced difficulties and pain when walking.
Multiple uterine fibroids of large sizes, malnutrition of myomatous nodes.
Severe forms of preeclampsia and lack of effect from treatment. Preeclampsia is a complication of pregnancy, in which there is a disorder in the function of vital organs, especially the vascular system and blood flow. Severe manifestations of preeclampsia - pre-eclampsia and eclampsia. At the same time, microcirculation in the central nervous system is disturbed, which can lead to serious complications for both the mother and the fetus.
Severe illnesses. Diseases of the cardiovascular system with decompensation phenomena, diseases of the nervous system, diabetes mellitus, high myopia with changes in the fundus, etc.
Severe cicatricial narrowing of the cervix and vagina. May occur after previous operations or childbirth. This creates insurmountable obstacles to the opening of the cervix and stretching of the walls of the vagina, necessary for the passage of the fetus.
Condition after plastic surgery on the cervix and vagina, after suturing urogenital and enterogenital fistulas. A fistula is an unnatural communication between two adjacent hollow organs.
Rupture of the perineum III degree in previous births. If during childbirth, in addition to the skin and muscles of the perineum, the sphincter (the muscle that blocks the anus) and / or the rectal mucosa is torn, then this is a third-degree perineal rupture, a poorly sutured rupture can lead to gas and fecal incontinence.
Severe varicose veins in the vagina. In spontaneous childbirth, bleeding from such veins can become life-threatening.
Transverse position of the fetus.
Conjoined twin.
Breech presentation of the fetus (especially a boy) in combination with a fetal weight of more than 3600 g and less than 1500 g, as well as with narrowing of the pelvis. Breech presentation increases the risk of birth injury at birth of the fetal head.
In vitro fertilization, artificial insemination in the presence of other complications from the mother and fetus.
Chronic fetal hypoxia, fetal hypotrophy, resistant to drug therapy. In this case, the fetus receives an insufficient amount of oxygen and for him the process of childbirth is a load that can lead to birth trauma.
The age of primiparous older than 30 years in combination with another pathology.
Prolonged infertility in combination with other pathology.
Hemolytic disease of the fetus with the unpreparedness of the birth canal. With Rh (less often - group) incompatibility of the blood of the mother and fetus, hemolytic disease of the fetus develops - the destruction of red blood cells (erythrocytes). The fetus begins to suffer from a lack of oxygen and the harmful effects of the breakdown products of red blood cells.
Diabetes mellitus with the need for early delivery and unprepared birth canal.
Post-term pregnancy with unprepared birth canal and in combination with other pathologies. The process of childbirth is also a stress that can lead to birth trauma to the fetus.
Cancer of any localization.
Exacerbation of genital herpes. With genital herpes, the indication is the presence of vesicular herpetic eruptions on the external genitalia. If by the time of childbirth it is not possible to cure a woman of this disease, there is a risk of infection of the fetus (when the membranes rupture or the fetus passes through the birth canal).

In any case, doctors first try to solve the problem with conservative (i.e., non-surgical) methods. And they resort to surgical intervention only when their attempts did not lead to the proper result.

In addition to the above cases, there are also acute situations that require surgical delivery.

Indications for caesarean section in childbirth:

Clinically narrow pelvis. This is a discrepancy between the fetal head and the mother's pelvis.
Premature rupture of amniotic fluid and lack of effect from labor induction. When the waters are poured out before the start of contractions, they are tried to be induced with the help of medications (prostaglandins, oxytocin), but this does not always lead to success.
Anomalies of labor activity that are not amenable to drug therapy. With the development of weakness or discoordination and labor activity, drug therapy is carried out, which also does not always lead to success.
Acute fetal hypoxia. When the heartbeat suddenly becomes rare and does not recover.
Detachment of a normally or low-lying placenta. Normally, the placenta separates from the uterine wall after the baby is born. Sometimes this happens during contractions, then severe bleeding begins, which threatens the life of the mother and fetus and requires immediate surgery.
Threatening or incipient uterine rupture. It must be recognized by a doctor in a timely manner, since a late operation can lead to fetal death and removal of the uterus.
Presentation or prolapse of the umbilical cord. If an incision is not made during the prolapse of the umbilical cord and head presentation of the fetus within the next few minutes, the child may die.
Incorrect insertion of the fetal head. When the head is in an unbent state (frontal, facial presentation), as well as a high straight standing of the head.

Sometimes a caesarean section is performed for combined indications, which are a combination of several complications of pregnancy and childbirth, each of which individually does not serve as an indication for surgery, but together they pose a real threat to the life of the fetus. And always a caesarean section is an extreme measure, when all attempts to help a woman give birth on her own are futile.

Head of Department: Egorova A.T., professor, DMN

Student: *

Krasnoyarsk 2008

A caesarean section is an obstetric operation during which the fetus and placenta are removed from the uterus through an artificially created incision in its wall. The term "caesarean section" (sectiocaesarea) is a combination of two words: secare - to cut and caceelere - to dissect.

The removal of a child from the womb of a dead mother by cutting the abdominal wall and uterus was carried out in ancient times. However, centuries passed before the operation became the subject of scientific research. At the end of the 16th century, the monograph Francois Rousset was published, which for the first time described in detail the technique and indications for abdominal delivery. Until the end of the 19th century, caesarean sections were performed in isolated cases and almost always ended in the death of a woman, which was largely due to the erroneous tactics of leaving an unsewn uterine wound. In 1876, G. E. Rein and E. Roggo proposed removing the body of the uterus after removing the child, which led to a significant reduction in maternal mortality. Further improvement in the results of the operation was associated with the introduction into practice of a three-story uterine suture, first used by F. Kehrer in 1881 to close the uterine incision. Since that time, more frequent use of caesarean section in obstetric practice begins. The decrease in postoperative mortality has led to the emergence of repeated operations, as well as to the expansion of indications for abdominal delivery. At the same time, maternal and especially perinatal mortality remained high. Only since the mid-1950s, due to the widespread introduction into practice of antibacterial drugs, blood transfusion, and the success of anesthetic support for operations, the outcomes of cesarean section for mother and fetus have improved significantly.

In modern obstetrics, caesarean section is the most frequently performed delivery operation. Its frequency in recent years is 10-15% of the total number of births. There are reports of a higher caesarean section rate in some hospitals, especially abroad (up to 20% or more). The frequency of this operation is influenced by many factors: the profile and capacity of the obstetric institution, the nature of obstetric and extragenital pathology in hospitalized pregnant women and women in childbirth, the qualifications of doctors, etc. The increase in the frequency of caesarean section operations in recent years is associated with the expansion of indications for operative delivery in the interests of the fetus , which is important for reducing perinatal morbidity and mortality.

Indications for caesarean section. Allocate absolute and relative indications for caesarean section. The first absolute indications in the history of the development of abdominal delivery arose, which were such obstetric situations when it is impossible to extract the fetus through the natural birth canal even in a reduced form (i.e., after a fruit-destroying operation). In modern obstetrics, absolute indications also include indications in which another method of delivery through the natural birth canal is more dangerous for the mother than a caesarean section, not only in terms of life, but also in terms of disability. Thus, among the absolute indications, one can distinguish those that exclude vaginal delivery, and those in which caesarean section is the method of choice. The presence of absolute indications requires the indisputable performance of a caesarean section, relative indications need to be strongly substantiated.

The group of relative indications includes diseases and obstetric situations that adversely affect the condition of the mother and fetus if delivery is carried out through the natural birth canal.

Classification of indications for caesarean section

A. Absolute readings:

I. Pathology excluding vaginal delivery:

narrowing of the pelvis III and IV degrees, when the true obstetric conjugate is 7.5-8.0 cm or less;

a pelvis with a sharply reduced size and a changed shape due to fractures or other causes (oblique displacement, assimilation, spondylolisthesis factors, etc.);

pelvis with pronounced osteomyelitic changes;

bladder stones blocking the pelvis;

pelvic tumors, cervical fibroids, tumors of the ovaries, bladder, blocking the birth canal;

pronounced cicatricial narrowing of the cervix and vagina;

complete placenta previa.

II. Pathology in which caesarean section is the method of choice:

incomplete placenta previa in the presence of bleeding;

premature detachment of a normally located placenta in the absence of conditions for urgent delivery through the natural birth canal;

transverse and stable oblique position of the fetus;

inferiority of the scar on the uterus (scar on the uterus after corporal caesarean section, complicated postoperative period, fresh or very old scar, signs of thinning of the scar on the basis of ultrasound);

urogenital and enterogenital fistulas in the past and present;

clinical discrepancy between the size of the fetal head and the mother's pelvis;

eclampsia (if vaginal delivery is impossible in the next 2-3 hours);

pronounced varicose veins of the vagina and external genital organs;

threatening uterine rupture;

cancer of the cervix, vagina, vulva, rectum, bladder;

the state of agony or death of the mother with a living and viable fetus.

B. Relative readings:

anatomically narrow pelvis of II and II degrees of narrowing in combination with other unfavorable factors (breech presentation of the fetus, incorrect insertion of the head, large fetus, post-term pregnancy, history of stillbirth, etc.);

incorrect insertion of the head - anterior head, frontal, anterior view of the facial insertion, high straight standing of the sagittal suture;

congenital dislocation of the hip, ankylosis of the hip joint;

uterine scar after caesarean section or other operations with favorable healing in the presence of additional obstetric complications;

threatening or beginning fetal hypoxia;

anomalies of labor forces (weakness of labor activity, discoordinated labor activity) that are not amenable to conservative therapy or combined with other relative indications;

pelvic presentation of the fetus;

cases of incomplete placenta previa in the presence of other aggravating moments;

late preeclampsia of mild or moderate severity, requiring delivery in the absence of conditions for its delivery through the natural birth canal;

post-term pregnancy in the absence of readiness of the pregnant woman's body for childbirth or in combination with other obstetric complications;

the threat of the formation of a genitourinary or intestinal-genital fistula;

the age of the primiparous over 30 years in combination with other factors unfavorable for natural delivery;

burdened obstetric or gynecological history (stillbirth, miscarriage, prolonged infertility, etc.);

large fruit;

prolapse of the umbilical cord;

malformations of the uterus;

extragenital diseases requiring rapid delivery in the absence of conditions for its delivery through the natural birth canal.

Most of the indications for a caesarean section are due to concern for the health of both the mother and the fetus, that is, they are mixed. In some cases, indications can be distinguished taking into account the interests of the mother and the interests of the fetus. For example, bleeding with complete placenta previa and a non-viable fetus, any indication in the presence of a dead fetus, some extragenital diseases require a caesarean section in the interests of the mother. Indications due to the interests of the fetus include: threatening or beginning fetal hypoxia, hemolytic disease of the fetus, breech presentation, facial insertion of the head, multiple pregnancy. In modern obstetrics, there is a tendency to expand the indications for caesarean section in the interests of the fetus. The success of neonatology in nursing premature babies contributed to the emergence of indications for caesarean section in the interests of a premature fetus: breech presentation of the fetus in preterm birth, twins weighing less than 2500 g and the presence of a breech presentation of one of the fetuses.

Let us consider in more detail some of the most common indications for caesarean section.

narrow pelvis continues to be one of the most common reasons for caesarean section. Severe degrees of anatomical narrowing of the pelvis are rare and, being an absolute indication for caesarean section, do not present any difficulty in choosing the mode of delivery. The issue of performing a caesarean section for III and IV degrees of narrowing of the pelvis is usually decided in advance, and the operation is performed in a planned manner at the end of pregnancy. It is much more difficult to solve the question of the method of delivery at II and II degrees of constriction. In cases of combination with other unfavorable factors (large fetus, breech presentation of the fetus, post-term pregnancy, older nulliparous, etc.), caesarean section becomes the method of choice. However, it is not uncommon for the need to end childbirth by caesarean section only occurs during childbirth, when a clinical discrepancy between the size of the fetal head and the mother's pelvis is revealed. Delay in the operation in this case is dangerous with severe complications: rupture of the uterus, death of the fetus, the threat of the formation of urogenital fistulas. Thus, in the management of childbirth in a woman in labor with a narrow pelvis, the identification of a functional, clinically narrow pelvis is of decisive importance, and if it is present, immediate delivery by caesarean section. On the other hand, the occurrence of a clinically narrow pelvis during childbirth requires clarification of the cause, which in some cases makes it possible to identify fetal hydrocephalus and avoid unnecessary caesarean section by applying a fruit-destroying operation.

placenta previa is now often an indication for caesarean section. The absolute indication is complete placenta previa, in which other methods of delivery are not possible. Incomplete placenta previa is less dangerous, and in many cases, delivery through the natural birth canal is possible with it. Determining in the choice of method of delivery in case of incomplete placenta previa is the degree and intensity of bleeding. With significant bleeding (blood loss of more than 250 ml), regardless of the condition of the fetus, cesarean section becomes the operation of choice. Previously used operations for incomplete placenta previa, such as turning the fetus on a leg with incomplete opening of the uterine os according to Braxton Hicks, metreiriz, skin-head forceps, have completely lost their significance in modern obstetrics. The advantages of caesarean section over vaginal delivery methods for placenta previa are:

the possibility of its implementation during pregnancy and regardless of the period of childbirth;

caesarean section is a more aseptic method of delivery;

a great opportunity to save not only full-term, but also premature, but viable children;

placenta previa can be combined with its true increment, which requires expanding the scope of surgical treatment up to hysterectomy.

Premature detachment of a normally located placenta requires immediate delivery. In the absence of conditions for such through the natural birth canal, a caesarean section is indicated, regardless of the condition of the fetus. Late diagnosis and delayed surgery lead to life-threatening complications for the mother: uteroplacental apoplexy (Kuveler's uterus) and coagulopathic bleeding, which are the main causes of maternal mortality.

Naliga of the scar on the uterus after a caesarean section, uterine rupture or perforation, surgery for uterine malformation is often an indication for abdominal delivery. At the same time, the scar on the uterus does not fundamentally exclude the possibility of delivery through the natural birth canal. Repeated caesarean section is indicated in the following cases: 1) there are indications that caused the previous caesarean section; 2) the interval between caesarean section and real pregnancy is less than 1 year (a long break of more than 4 years is also considered unfavorable for the condition of the scar); 3) there were complications of the postoperative period, worsening the healing of the scar on the uterus; 4) two or more caesarean sections in history.

Abdominal delivery is certainly necessary in the presence of a clearly defective scar (according to palpation and ultrasound), as well as when there is a threat of uterine rupture along the scar during childbirth. In rare cases, when there was a corporal caesarean section in history, a planned caesarean section is indicated due to the significant risk of uterine rupture. In modern obstetrics, after an involuntary corporal caesarean section, as a rule, sterilization is performed.

Postponed uterine rupture is always an indication for a planned caesarean section, however, such operations are a rare exception, since suturing of uterine rupture is usually performed with sterilization.

With a history of conservative myomectomy, caesarean section is the operation of choice in cases where the incision of the uterus affected all its layers. The presence of a scar after perforation of the uterus during induced abortion usually does not require a planned caesarean section. The need for abdominal delivery arises in the event of signs of a threat of uterine rupture during childbirth.

High perinatal mortality in oblique and transverse positions of the fetus in cases of delivery through the natural birth canal, it determines the use of caesarean section as the method of choice for a live fetus. Abdominal delivery is performed in a planned manner with a full-term pregnancy. The classic external-internal rotation of the fetus with subsequent extraction is used only in exceptional cases. A caesarean section is necessary when the transverse position is neglected and the fetus is dead, if the production of a fruit-destroying operation is dangerous due to the possibility of uterine rupture.

Frontal insertion, anterior view of the anterior head and facial insertions, posterior view of the high erect position of the sagittal suture are indications for abdominal delivery in the presence of a full-term fetus. With other options for incorrect insertion of the head, the issue of caesarean section is resolved positively when combined with other complications of pregnancy and childbirth (large fetus, post-term pregnancy, narrow pelvis, weakness of labor, etc.). In cases where delivery is carried out through the natural birth canal, careful monitoring is necessary for signs of a discrepancy between the size of the fetal head and the mother's pelvis. The disproportion between the size of the fetal head and the size of the mother's pelvis with incorrect insertions of the head is also due to the fact that these insertions are often found in various forms of narrowing of the pelvis. Identification of signs of a clinically narrow pelvis requires immediate abdominal delivery.

Childbirth in breech presentation of the fetus are pathological. Even in the absence of most of the complications inherent in these births, during the period of exile, the fetus is always threatened by hypoxia and intranatal death due to compression of the umbilical cord and impaired uteroplacental circulation. One can hope for a favorable outcome of childbirth only under the most optimal conditions for the course of the birth act (average fetal size, normal pelvic size, timely discharge of amniotic fluid, good labor activity). When pelvic presentation is combined with other unfavorable factors (narrowing of the pelvis of I-II degree, older age of the primiparous, large fetus, delayed pregnancy, premature outflow of water, weakness of labor, presentation and prolapse of the umbilical cord, the presence of late gestosis, incomplete placenta previa, etc.), when delivery through the natural birth canal does not guarantee the birth of a live healthy child, breech presentation is one of the most important components of combined indications for caesarean section.

Currently fetal hypoxia occupies one of the leading places among the indications for caesarean section. Fetal hypoxia may be the main, the only indication for abdominal delivery or be one of the combined indications. In all cases when the mother's disease affects the condition of the fetus, when the first signs of fetal hypoxia appear and there are no conditions for urgent delivery through the natural birth canal, abdominal delivery should be performed. Fetal hypoxia can be a concomitant indication for caesarean section in many obstetric situations: with small narrowing of the pelvis, late gestosis, pelvic presentation of the fetus, etc. Especially unfavorable in terms of prognosis is fetal hypoxia with weakness of labor activity, postnatal pregnancy, in primiparous older age. In these cases, to an even greater extent, the choice of the method of delivery should be inclined in favor of caesarean section. The solution to the issue of abdominal delivery when signs of fetal hypoxia appear should not be late, so the main thing in this problem is the timely diagnosis of fetal disorders. When managing high-risk women in labor, it is necessary to conduct a comprehensive assessment of the fetal condition using cardiotocography, dopplerometry, amnioscopy, determining the nature of labor activity (external or internal hysterography), determining the COS of the fetus and the woman in labor, and studying the pH of amniotic fluid.

Combination of pregnancy and uterine fibroids occurs in less than 1% of cases, but at the same time, a complicated course of pregnancy and childbirth is observed in about 60%. The presence of uterine fibroids is often combined with complications that may require abdominal delivery: transverse and oblique positions of the fetus, placenta previa, weakness of labor, etc. In addition, the unfavorable (cervical-isthmus) location of the nodes creates an insurmountable obstacle to opening the cervix and advancing the fetus . Abdominal delivery may become necessary due to complications of fibroids (malnutrition or node necrosis), as well as other indications requiring surgical treatment of fibroids. Thus, the tactics of childbirth in a woman in labor with uterine myoma depends, on the one hand, on the size, topography, number and condition of myomatous nodes, on the other hand, on the characteristics of the course of the birth act.

Anomalies of labor activity are a common complication of childbirth. Their adverse effect on the condition of the fetus is well known. Therefore, the solution of the issue of abdominal delivery in case of ineffectiveness of conservative therapy, weak or discoordinated labor activity should not be late, since delayed delivery dramatically increases the incidence of neonatal asphyxia. With the ineffectiveness of labor-stimulating therapy, the role of caesarean section has increased significantly due to the fact that in recent years, in the interests of protecting the fetus, vacuum extraction of the fetus and extraction of the fetus by the pelvic end are not used. Weakness of labor activity is a frequent and essential component in combined indications for caesarean section with relative degrees of narrowing of the pelvis, in older primiparas, with breech presentation of the fetus, postmaturity, fetal hypoxia, posterior occipital insertion of the head, etc.

Late preeclampsia poses a danger to the mother and fetus due to the inevitable development of chronic hypoxia, chronic peripheral circulatory disorders and the development of degenerative changes in parenchymal organs, the threat of premature detachment of a normally located placenta. Timely termination of pregnancy in patients with late preeclampsia, with the ineffectiveness of its treatment, remains the leading component of measures to combat the severe consequences of this pathology. The absence of conditions for rapid vaginal delivery in cases where termination of pregnancy is indicated (with severe forms of preeclampsia, an increase in symptoms during treatment, a long course with treatment failure), is an indication for abdominal delivery. At the same time, it should be borne in mind that caesarean section is not an ideal method of delivery for patients with late preeclampsia. The usual blood loss during caesarean section of 800-1000 ml is undesirable for these patients due to their lack of circulating blood volume, hypoproteinemia, circulatory hypoxia, etc. The predisposition of pregnant women with late gestosis to the development of postpartum inflammatory diseases increases after operative delivery.

Thus, caesarean section in patients with late gestosis is used as a method of early delivery or as a component of resuscitation in severe forms of the disease.

Diseases of internal organs, surgical pathology, neuropsychiatric diseases require termination of pregnancy if the course of the disease sharply worsens during pregnancy and poses a threat to the woman's life. Caesarean section in these cases has advantages over vaginal delivery, as it can be performed at any time, quickly enough and regardless of the condition of the birth canal. Sometimes the choice of method of delivery is influenced by the possibility of sterilization. In case of extragenital diseases, a small caesarean section is often performed - abdominal delivery during pregnancy up to 28 weeks, when the fetus is not viable. The conclusion about the time and method of termination of pregnancy or the termination of labor in the abdominal way is developed by the obstetrician together with the doctor of the specialty to which the disease belongs.

Unconditional indications for delivery by caesarean section include: isolated or predominant mitral or aortic insufficiency, especially with low cardiac output and left ventricular function; mitral stenosis, occurring with repeated attacks of pulmonary edema or pulmonary edema that is not stopped by medications.

Indirect indications for caesarean section are the active phase of rheumatism and bacterial endocarditis. Contraindications to abdominal delivery are heart defects accompanied by grade III pulmonary hypertension, cardiomegaly, atrial fibrillation, and tricuspid valve defects, in the presence of which the outcome of caesarean section is unfavorable.

In the presence of hypertension in pregnant women or a woman in labor, delivery by caesarean section is used only when cerebral symptoms appear (impaired cerebral circulation) and there are no conditions for immediate delivery through the natural birth canal.

Abdominal delivery is indicated for pneumonia with cor pulmonale, since the increase in circulating blood volume characteristic of this disease further increases with each contraction due to blood flow from the uterus, which can lead to acute right ventricular failure. The question of the use of cesarean section may arise during the delivery of women who have undergone lung surgery with the removal of a large amount of lung tissue. However, in most cases, pregnancy and childbirth in women who have undergone lobectomy and pneumonectomy proceed safely.

Delivery of pregnant women with diabetes mellitus is usually carried out ahead of schedule at 35-37 weeks of gestation, when the fetus is quite viable and still slightly exposed to the toxic effects of acidosis. In the presence of diabetic retinopathy, preeclampsia, a large fetus, fetal hypoxia, a history of stillbirth, no effect from the treatment of diabetes mellitus, in primiparas, especially older ones, delivery is performed by caesarean section.

In the event of a woman's sudden death during childbirth, the fetus can be retrieved alive within minutes of the mother's death. The operation is performed only in cases where the fetus is viable. In this case, a corporal caesarean section is performed in compliance with the rules of asepsis.

Contraindications for caesarean section. Currently, most caesarean sections are performed on a set of relative indications, among which indications in the interests of saving the life of the child are of leading importance. In this regard, in many cases, a contraindication to caesarean section is the unfavorable condition of the fetus: ante- and intranatal fetal death, deep prematurity, fetal deformities, severe or prolonged fetal hypoxia, in which stillbirth or postnatal death cannot be excluded.

Another contraindication for abdominal delivery for relative indications is infection during childbirth. The high-risk group for the development of infectious complications includes women in labor who have a long anhydrous period (more than 12 hours), repeated vaginal examinations during childbirth (3 or more), and prolonged labor (over 24 hours). With the appearance of temperature, purulent discharge from the genital tract, changes in blood tests, indicating inflammation, the woman in labor is regarded as having a clinically pronounced infection in childbirth.

In modern conditions, the issue of the possibility of caesarean section in infected childbirth has been fundamentally positively resolved. During the operation, the need for adequate preventive and therapeutic measures aimed at blocking the infectious process comes to the fore. These include antibacterial and detoxification therapy; careful surgical technique with minimal tissue trauma, good hemostasis, correct suturing; in cases of severe infection, a hysterectomy is performed. During the operation, immediately after the removal of the child, large doses of broad-spectrum antibiotics (for example, Klaforan 2 g) can be applied intravenously. In addition, in the prevention of postoperative septic complications, competent management of the postoperative period is of paramount importance: timely correction of blood loss, water and electrolyte disorders, acid-base status, adequate antibiotic therapy, immunocorrection, etc.

Thus, when clarifying contraindications to caesarean section, it must be borne in mind that they matter only in cases where the operation is performed according to relative indications. Contraindications should also be considered if delivery by caesarean section is the method of choice. With vital indications for caesarean section in the interests of the mother, the presence of contraindications loses its significance.

Preparation for the operation. When preparing a pregnant woman for a planned caesarean section, a detailed examination is carried out, including the study of biochemical blood parameters, ECG, determination of the blood group and Rh factor, examination of smears for the presence of gonococci, determination of the degree of purity of the vagina, examination by a therapist and, according to indications, examination by other specialists, on the eve and on the day of surgery, an examination by an anesthesiologist is necessary. In addition, in preparation for a planned caesarean section, a comprehensive assessment of the fetal condition (ultrasound, amnioscopy, cardiotocography) is mandatory. In many cases, vaginal debridement is required prior to surgery. In the case of an emergency operation, it is necessary to collect a detailed history, including allergic and blood transfusion, conduct an objective examination of a pregnant woman or a woman in labor, and assess the condition of the fetus.

It should be remembered that in all cases when a caesarean section is performed according to relative indications, one of the main conditions for its implementation is a live and viable fetus. Another condition is to determine the optimal time of the operation, when surgical delivery will not be too hasty or, conversely, belated. To perform a caesarean section, the mother's consent to the operation must also be obtained.

Before the operation, a complex of hygienic measures is carried out: pubic and abdominal hair is shaved, a pregnant woman or a woman in labor is washed in the shower, the intestines and bladder are emptied.

Preoperative drug preparation is carried out for the following purposes: 1) achieving mental peace and eliminating fear (barbiturates, seduxen, relanium); 2) prevention of side effects of narcotic and anesthetics, elimination of unwanted neurovegetative reactions (atropine, metacin); 3) prevention and treatment of certain complications

pregnancy and childbirth (late preeclampsia, impaired blood clotting, bleeding, etc.); 4) prevention and treatment of fetal hypoxia.

A team of surgeons (an operator and 2 assistants), an operating nurse, an anesthetist, an anesthetist nurse, a midwife, and a neonatologist are involved in providing the operation.

On the operating table, it is necessary to release the urine with a catheter, no matter what the certainty that the bladder is empty. An indwelling rubber catheter can also be inserted into the bladder. The abdominal wall on a sufficient area is treated with an antiseptic solution. Good results are obtained by triple treatment of the abdominal wall with modern antiseptics - 0.5% solution of rokkal or degmicide, iodopyrone, etc.

Technique of caesarean section. Currently, the method of choice is intraperitoneal caesarean section with transverse incision in the lower segment of the uterus. This technique provides relatively little trauma to the myometrium and good peritonization of the wound, which creates favorable conditions for healing and the formation of a full-fledged scar.

The so-called classic(corporal) cesarean section, in which the body of the uterus is dissected longitudinally, is used in modern obstetrics only in rare, exceptional cases, for example, in the presence of uterine fibroids and the need for hysterectomy, during surgery on a deceased woman, with heavy bleeding. With a longitudinal dissection of the body of the uterus, a significant injury occurs to muscle fibers, blood vessels, and nerves, which prevents the formation of a full-fledged scar. The only advantage of this technique of caesarean section is the speed of opening the uterus and extracting the fetus.

The technique is also rarely performed. extraperitoneal caesarean section, in which the lower segment of the uterus is exposed paravesically or retrovesically without opening the peritoneum. This method of abdominal delivery is contraindicated in cases of suspected uterine rupture, premature detachment of a normally located placenta, placenta previa, varicose veins of the lower uterine segment, the presence of uterine fibroids, and the need for sterilization. The main indication for its implementation are infected childbirth. However, hopes for absolute elimination of infectious complications due to extraperitoneal access to the uterus did not come true, since the hematogenous and lymphogenous pathways play a significant role in the spread of infection.

In addition, the operation of extraperitoneal caesarean section is technically difficult, dangerous with serious complications (bleeding from the prevesical tissue, injury of the bladder, ureter) and in many cases is accompanied by a violation of the integrity of the peritoneum. Due to all the above features of extraperitoneal caesarean section, this technique has limited application.

Before proceeding to the description of the technique of caesarean section, it is necessary to dwell on the features of anatomy and topography of the uterus at the end of pregnancy. The uterus during full-term pregnancy fills the small pelvis, the abdominal cavity and rests with its bottom on the lower surface of the liver. In shape, the uterus is an ovoid rotated from left to right, i.e., the left rib and the left round uterine ligament are close to the anterior abdominal wall, and the right rib of the uterus is close to the posterolateral. The bottom of the uterus is covered in front by the omentum and the transverse colon, the anterior surface of the body of the uterus and the isthmus are free from intestinal loops and directly adjacent to the anterior abdominal wall. The peritoneum covering the uterus is closely connected with the muscle layer in the region of its bottom and body, in the region of the lower segment of the peritoneum it is mobile due to the underlying fiber. The upper edge of this easily separated, whitish peritoneum corresponds to the upper border of the lower uterine segment. The posterior wall of the bladder is separated from the lower segment of the uterus by a layer of loose fiber, the thickness of which increases downwards to 1 cm or more. The lower segment of the uterus in front and from the sides is directly adjacent to the walls of the pelvis, but access to it during abdominal dissection is limited by the bladder. The emptied bladder is usually located in the pelvic cavity. When full, the bubble rises into the abdominal cavity and is located anterior to the lower segment or, which is less common, remains in the small pelvis, protruding the anterior vaginal wall downward. During childbirth, even an empty bladder lies above the pubic joint, sometimes rising 5-6 cm above the pubis.

The topography of the lower segment of the uterus varies depending on the period of labor. At the end of pregnancy and at the beginning of the first period of childbirth, the lower segment is in the small pelvis. At the end of the I period and the beginning of the II period of labor, the lower segment of the uterus is entirely above the plane of the entrance to the small pelvis.

Thus, during abdominal dissection, it is necessary to clearly define the landmarks of the body of the uterus, the lower segment, the part of the bladder adjacent to it, and the vesicouterine fold, taking into account the asymmetry of the position of the uterus.

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

Let's take a closer look at the operation technique.

First moment. The transection can be performed in two ways: a median incision between the umbilicus and the pubis and a transverse suprapubic incision according to Pfannenstiel. 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, it rarely causes postoperative hernias.

When performing a transverse suprapubic incision, the skin and subcutaneous tissue are cut along the line of the natural suprapubic fold over a sufficient length (up to 16-18 cm). The aponeurosis is incised in the middle with a scalpel, and then peeled off with scissors in the transverse direction and cut in the form of an arc. After this, the edges of the aponeurosis are captured by Kocher's clamps, and the aponeurosis exfoliates from the rectus and oblique muscles of the abdomen down to both pubic bones and up to the umbilical ring. Along the white line of the abdomen, the aponeurosis is cut off with scissors or a scalpel. On both edges of the dissected aponeurosis, 3 ligatures or clamps are applied with picking up the edges of the napkins that cover the surgical field. In order to achieve better access, in some cases, a suprapubic incision is made in Czerny's modification, in which the aponeurotic legs of the rectus muscles are dissected in both directions by 2-3 cm.

The parietal peritoneum is dissected in the longitudinal direction from the umbilical ring to the upper edge of the bladder.

Second moment. After delimiting the abdominal cavity with napkins, the vesicouterine fold of the peritoneum is opened in the place of its greatest mobility with scissors, which then move under the peritoneum in each direction, and the fold is dissected in the transverse direction. The bladder is easily separated from the lower segment of the uterus with a tupfer and is displaced downwards. After that, the level of the incision of 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 opening of the fetal bladder. The index fingers of both hands are inserted into the incision, and the opening in the uterus is moved apart until the moment when the fingers feel that they have reached the extreme points of the head.

Third moment. The surgeon's hand is inserted into the uterine cavity in such a way that its palmar surface rests against the fetal head. This hand turns the head with the back of the head or face forward and produces its extension or flexion, due to which the head is released from the uterus. If there is a breech presentation, then the child is removed by the anterior inguinal fold or leg. In the transverse position of the fetus, the hand inserted into the uterus finds the pedicle of the fetus, the fetus is turned onto the pedicle and then removed. In this case, the head is removed through the opening in the uterus by a technique identical to the Morisot-Levre technique during vaginal delivery. The umbilical cord is cut between clamps and the newborn is handed over to the midwife. 1 ml of methylergometrine is injected into the muscle of the uterus. With a light pull on the umbilical cord, the placenta is separated and the afterbirth is released. In case of difficulty, the placenta can be separated by hand. After the placenta is isolated, the walls of the uterus are checked with a large blunt curette, which ensures the removal of fragments of membranes, blood clots and improves uterine contraction.

Fourth moment. Two rows of muscular-muscular sutures are applied to the wound of the uterus. The marginal sutures are placed 1 cm lateral to the incision angle on the uninjured uterine wall to ensure reliable hemostasis. When applying the first row of sutures, the Yeltsov-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 needle is injected and punctured from the side of the mucous membrane, as a result of which the knots after tying are located from the side of the uterine cavity. The second layer of musculoskeletal sutures matches the entire thickness of the muscular layer of the uterus. Knotted catgut sutures are placed in such a way that they are located between the seams of the previous row.

At present, the method of suturing the muscle layer with a single-row continuous suture from a biologically inactive material (Vicryl, Dexon, Polysorb) has become widespread.

Peritonization is performed 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 by the bladder and does not coincide with the line of peritonization. Wipes are removed from the abdominal cavity, and the abdominal wall is sutured tightly in layers. A continuous catgut suture is applied to the peritoneum, starting from the upper corner of the wound. The rectus abdominis muscles are brought together with a continuous catgut suture, then interrupted sutures are placed on the aponeurosis and interrupted catgut sutures on the subcutaneous tissue. The skin wound is sutured with silk, lavsan or nylon with interrupted sutures.

In some cases, after an abdominal caesarean section, a supravaginal amputation or extirpation of the uterus is performed. The indications for a hysterectomy following a caesarean section are as follows:

uterine fibroids requiring surgical treatment, due to the size, topography of the nodes, the presence of complications;

uterine ruptures, excluding the possibility of suturing;

uteroplacental apoplexy (Kuveler's uterus);

true increment of the placenta;

atony of the uterus, if bilateral ligation of the uterine vessels does not lead to uterine contraction and stop bleeding;

in rare cases, massive infection of the uterus.

Management of the postoperative period. Immediately after the operation, an ice pack is placed on the lower abdomen, and painkillers are prescribed. After 6-10 hours, the patient should actively turn in bed, in the absence of contraindications, the patient should be raised in a day. In uninfected cases and in the absence of risk factors for the development of infectious complications, antibiotics may not be prescribed. If there is a potential or clinical infection, antibiotics are given during or immediately after surgery.

During a caesarean section, blood loss is usually 800-1000 ml, therefore, in the postoperative period, infusion therapy is required to correct hypovolemia, acidosis, disorders of central and peripheral hemodynamics, and electrolyte balance (hemodez, polydez, rheopolyglucin, electrolyte solutions , protein preparations). With insufficient involution of the uterus, reducing agents are prescribed, in some cases - uterine lavage, physiotherapy.

In the first hours of the postoperative period, especially careful monitoring of uterine tone and blood loss is required, since the possibility of developing hypotonic bleeding is not ruled out. It is important to monitor the timely emptying of the bladder; bladder catheterization is acceptable on the first day after the operation. For the prevention of intestinal paresis, a subcutaneous injection of 0.5 ml of a 1% prozerin solution is prescribed, by the end of 2 days - an enema with a hypertonic sodium chloride solution.

In the absence of contraindications, breastfeeding can be allowed on the 2-3rd day after the operation. With an uncomplicated course of the postoperative period, the puerperal is discharged on the 11-13th day after the operation. If the patient had complications of pregnancy, childbirth or the postoperative period, then after the operation she is prescribed therapy aimed at eliminating these complications and their consequences.

Complications in abdominal caesarean section. When the abdominal wall is cut, difficulties usually arise during repeated abdominal dissection due to the adhesive process. The bladder in women who had a history of caesarean section may be located higher than usual, so it is necessary to understand the topography well in order to avoid injury to the organ. Mog Bladder Wound is the most serious complication that can occur when opening the abdominal cavity with a Pfannenstiel incision. Significant difficulties can cause adhesions of the uterus with the parietal peritoneum, intestines, omentum.

A rare and very dangerous complication is amniotic fluid embolism. The occurrence of embolism contributes to the incision of the uterus through the placental site, low arterial and venous pressure as a result of blood loss, uterine atony. With the ineffectiveness of the therapy of this complication, a fatal outcome can occur.

After removing the child and placenta, the possibility of an onset should be foreseen. hypo- and atony of the uterus. Hypo- and atonic bleeding during caesarean section is more common with placenta previa and premature detachment of a normally located placenta.

With uterine hypotension, the following conservative measures are carried out: the introduction of contracting agents into the uterus, intravenous drip of oxytocin, which in most cases gives an effect.

With atonic bleeding, therapy does not help, and delay in using surgical methods to stop bleeding (bilateral ligation of the uterine vessels, hysterectomy) can lead to death from acute blood loss.

Despite the undoubted achievements of anesthesiology, complications of anesthesia are sometimes observed during cesarean section. Most often they occur during induction anesthesia (laryngospasm, vomiting, regurgitation and aspiration of vomit with the development Mendelssohn's syndrome).

Immediate and long-term results of caesarean section for mother and fetus. Due to the widespread introduction of medical advances into obstetric practice (hemotransfusiology, antibiotic therapy, new methods of anesthesia, treatment of thromboembolism, improvement in the technique of caesarean section), a decrease in maternal mortality has been noted in recent decades.

The structure of maternal mortality has changed significantly. Previously, septic complications were the most common cause, recently they have become extragenital diseases and obstetric pathology (severe forms of late gestosis, bleeding or placenta previa, premature detachment of a normally located placenta, uterine rupture), which required a caesarean section.

Complications of the postoperative period are observed in 10-40% of puerperas. The main group of postoperative complications are inflammatory processes of various localization. More frequent complications include infectious processes in the area of abdominal wall wounds (partial, complete divergence of sutures, infiltrates) and endometritis. Many factors contribute to their development: a long birth act, a long anhydrous period, blood loss, frequent vaginal examinations, the presence of chronic foci of infection, errors in performing the operation and maintaining the postoperative period. The most unfavorable in its consequences is chorioamnionitis in childbirth. Fever in childbirth, purulent discharge from the genital tract, characteristic changes in blood tests are contraindications for caesarean section, and if necessary, it should end with a hysterectomy. The most dangerous infectious complications are peritonitis and sepsis, late diagnosis and improper therapy of which can lead to death.

In the postoperative period, a frequent complication is thromboembolism, which can occur after a technically flawless operation and a smooth course of the postoperative period. Therefore, it is important to identify, using clinical and laboratory methods, predisposition to this disease and its early stages. Applied methods of prevention and treatment of thromboembolism can significantly reduce the number of deaths from this disease. These methods include the use of fibrinolytic agents, anticoagulants, bandaging the legs before surgery in the presence of varicose veins, controlled hemodilution, early rising after surgery, and gymnastics.

One of the most frequent postoperative complications is posthemorrhagic anemia. Correct assessment of blood loss, adequate replenishment are important to reduce the incidence of this complication.

Every year, the absolute number of puerperas delivered by caesarean section is progressively increasing. In this regard, a new obstetric problem has arisen - the management of pregnancy and childbirth in women with a scar on the uterus, who are at risk for uterine rupture. The main cause of uterine rupture after caesarean section is scar failure. With the help of histological and clinical methods, the factors negatively affecting the formation of a full-fledged scar were determined. These include postoperative infection, placenta previa to the scar, poor suturing technique, a small (less than 1 year) or, conversely, a long (more than 4 years) period of time after cesarean section, trophoblast germination in the scar area. A long interval between pregnancies leads to progressive sclerosis in the area of the scar, its demuscularization, observing its increasing inferiority. During repeated delivery by cesarean section, the question arises of sterilization to prevent uterine rupture in subsequent pregnancies, the risk of which increases sharply after repeated cesarean section.

Condition of the newborn after caesarean section is determined not so much by the surgery itself and the anesthetic benefit, but by the pathology of pregnancy and childbirth, which was an indication for abdominal delivery, the degree of full-term and maturity of the fetus. In cases of a combination of serious complications of pregnancy and childbirth with complications arising during surgery (difficult or traumatic extraction of the fetus) or anesthesia (hypoxia, hypercapnia, the use of high concentrations of narcotic drugs), and the insufficient effectiveness of resuscitation measures, the number of children with postnatal asphyxia and other diseases of the newborn period, which in the future may cause violations of the psychomotor development of children. Difficult removal of the child is a rather strong irritant and can cause such aspiration complications as asphyxia, lung atelectasis, bronchopneumonia, and intracranial hemorrhage. Naturally, traumatic injuries of the child are unacceptable technical errors of the caesarean section.

Thus, the perinatal morbidity and mortality of newborns extracted by caesarean section, only in rare cases, is directly related to the operation, the main reason is severe obstetric and extragenital pathology. The reserve in reducing the perinatal loss of children during caesarean section is the improvement, expansion of diagnostic capabilities for determining the condition of the fetus before surgery. Cesarean section has undoubted advantages in terms of fetal outcome over such methods of delivery as vacuum extraction of the fetus, obstetric forceps, extraction of the fetus by the pelvic end.

Caesarean section in modern obstetric practice In recent years, the interest of researchers in the problem of caesarean section has increased significantly. This is due, on the one hand, to a change in the obstetric strategy and the expansion of indications for operative delivery, on the other hand, to an increase in the number of pregnant women with a uterine scar, the management of childbirth in which requires special attention from specialists. Since dissertations are the most serious fundamental research, their analysis allows us to get an idea of the most important achievements and the current state of the problem of caesarean section.

In 1997, the number of papers on the problem of cesarean section increased compared to 1996: from 6 dissertations (2 for the degree of Doctor of Medical Sciences and 4 for the degree of Candidate of Medical Sciences) completed in 1996 to 10 (4 and 6, respectively), performed in 1997.

As a result of the completion of these studies, a coherent system was created aimed at optimizing the production of caesarean section, developed in detail by L.S. Logutova (Moscow Regional Research Institute of Obstetrics and Gynecology of the Ministry of Health of Russia), I.M. Mirov (Ryazan State Medical University), M.V. Rybin (Moscow Medical Academy named after I.M. Sechenov and City Clinical Hospital No. 7 of the Committee of Health of Moscow), S.M. Filonov (Scientific Center for Obstetrics, Gynecology and Perinatology of the Russian Academy of Medical Sciences).

Serious attention is paid to evaluating the effectiveness of the method of suturing the incision on the uterus using various suture materials. Dissertators studied the features of reparative processes in the operating room, depending on the method of suturing and the type of suture material used, as well as the pathomorphological features of scars on the uterus after cesarean section. L.S. Logutova presented an assessment of the effectiveness of a single-row musculoskeletal suture. The incision on the uterus is sutured with separate muscular-muscular sutures with an interval of 1-1.5 cm. In this case, the needle is injected and punctured, stepping back 0.3 cm from the edge of the incision (above the decidua). The suture captures almost the entire thickness of the myometrium. After control of hemostasis, in order to create tightness, an additional continuous suture is applied to the own fascia of the uterus. The author recommends using absorbable synthetic threads "kaproag" for suturing the uterus. The use of this technique helps to reduce the number of cases of endometritis in the postoperative period by 2 times and is the prevention of a generalized infection. The author proposed a modification of extraperitoneal caesarean section.

Most authors consider it preferable to apply a single-row suture to the uterus. M.V. Rybin presented the scientific rationale for a new method of abdominal delivery modified by Stark to reduce the frequency and severity of postoperative complications. The technique of the operation consists of the following 3 stages:

The first stage is a laparotomy according to the Joel-Kohen method.

The second stage is the incision of the uterus, the extraction of the fetus and placenta.

The third stage is the suturing of the wound of the uterus and the restoration of the integrity of the abdominal wall.

The wound of the uterus is sutured with a single-row continuous Vicryl suture. The intervals between injections are 1.5 cm. To prevent relaxation of the threads, an overlap according to Reverden is used. Peritonization of the suture on the uterus is not performed. The peritoneum and muscles of the anterior abdominal wall are not sutured, a continuous vicryl suture according to Reverden is applied to the aponeurosis. The skin and subcutaneous tissue are compared with separate silk sutures at large intervals (3-4 sutures per incision), using the Donati wound coaptation technique. In the postoperative period, the puerperal woman is allowed to get up after 6-8 hours. It is noted that caesarean section according to the Stark method helps to reduce the frequency of immediate and distant purulent-septic complications in puerperas. At the same time, a reduction in the time from the beginning of the operation to the extraction of the fetus was noted, which is of great importance in situations requiring emergency delivery, and helps to reduce the incidence of anesthetic depression in the newborn. The author notes that the use of a new modification of cesarean section is of great economic importance, due to a decrease in the frequency of complications, a reduction in the cost of operating time, a reduction in the duration of the operation, and a decrease in the need for suture material.

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CM. Filonov conducted a clinical assessment and a comparative analysis of the course of the postoperative period in patients, single-row or double-row sutures, while various synthetic sutures were used.

As a result of the studies performed, the advantages of applying a single-row (compared to a double-row) twisting muco-muscular suture using vicryl and PDS II when suturing the incision on the uterus were established. When suturing the uterus with a single-row suture, the duration of the operation is reduced by 7 minutes, in addition, a more favorable course of reparative processes is noted and the consumption of suture material is reduced by 2 times. In women with a single-row suture on the uterus, according to ultrasound data, edema in the area of the postoperative suture is observed 4 times less often than when applying a two-row suture, while there is a statistically significant decrease in edema by the 9th day, and with a two-row suture such dynamics is observed by the 9th day. days were not noted. Complicated course of the postoperative period when applying a single-row suture was noted in 8.1% of puerperas, a two-row one - in 19.1%.

THEM. Mirov presented the scientific rationale for the use of easy-to-perform modifications of caesarean section and tubal sterilization, which improve the rehabilitation of the operated patients. When discussing the technique of the operation, the author, unlike other researchers, adheres to the point of view of the expediency of applying a two-story suture to the uterine incision. At first, he recommends applying a continuous muco-muscular suture of the 1st floor, then knotted or U-shaped sutures of the second floor (a continuous suture is also possible).

The question of the possibility of performing myomectomy during pregnancy and childbirth has long been debatable. G.S. Shmakov (Scientific Center for Obstetrics, Gynecology and Perinatology of the Russian Academy of Medical Sciences) argued the expediency of active surgical tactics with the expansion of indications for myomectomy during cesarean section. He noted that the frequency of postoperative complications after myomectomy during caesarean section depends on surgical tactics, antibiotic prophylaxis and antibiotic therapy, as well as on the type of synthetic suture material used. Compliance with optimal conditions allows to reduce the number of postoperative intestinal paresis from 11.1% (in 1979) to isolated cases (in 1991-1995), and the number of purulent-inflammatory complications from 14.6 to 4.4% in isolated cases wound infection in recent years. The data of the histological study of fibroid nodes correspond to the data of ultrasound examination, which is evidence of the reliability of the echographic characteristics of the node architectonics in dystrophic and necrotic changes in the fibroid. The author believes that the intrauterine method of contraception is acceptable and safe and does not provoke recurrence of fibroids in women with a uterine scar after myomectomy. The introduction of the IUD after caesarean section should be carried out no earlier than 6 months after the operation.

Serious attention in the completed dissertations is given to the evaluation of various methods for examining puerperas after caesarean section. It is noted that modern methods of cytological examination (endometrial prints during caesarean section, aspirates from the uterine cavity in the postpartum period) are of great interest. A large place is occupied by studies on the assessment of the immune status of puerperas and the correction of its violations.

For this purpose, the phagocytic activity of monocytes and neutrophils, indicators of cellular immunity, phagocytic index, phagocytic number, the content of immunoglobulins of the main classes (A, M, G), leukocyte index of intoxication, HBT-test, autoflora of the skin were studied.

Yu.V. Trusov (Irkutsk State Institute for Postgraduate Medical Education) conducted a comprehensive assessment of the features of the immune status of women during full-term pregnancy and childbirth. For the first time, he tested the method of extracorporeal immunocorrection using autologous thymalin-bearing erythrocytes, which makes it possible to increase the effectiveness of complex therapy for endometritis after cesarean section and is a secondary specific prevention of the generalization of the infectious process. THEM. Mirov attaches great importance to the use of the developed scale for assessing the condition of puerperas after cesarean section and the algorithm for their examination, which improves the prediction and diagnosis of infectious complications.

In the diagnosis of postoperative diseases and the assessment of the state of postoperative sutures on the uterus, the ultrasound technique proved to be effective. L.S. Logutova proposes to use the method of biocontrast echoscopy, which differs from conventional ultrasound in additional contrasting of the uterine wall by introducing a rubber balloon filled with 70-90 ml of sterile liquid into its cavity. The study is carried out with a full bladder.

According to M.V. Rybin, transabdominal and transcervical echographic examination allows you to establish the rate of uterine involution after cesarean section. These methods expand the possibilities of diagnosing and predicting the outcome of purulent infectious diseases after caesarean section in order to timely prevent the development of complications.

One of the methods of treatment of complications during caesarean section is intraoperative blood reinfusion. E.S. Nunaeva (Scientific Center for Obstetrics, Gynecology and Perinatology of the Russian Academy of Medical Sciences), based on the results of laboratory and clinical studies, presented the advantages and possibilities of using intraoperative blood reinfusion by a hardware method during caesarean section, which allows preserving the ultrastructure and functional abilities of erythrocytes in 99.6% of cases. The influence of intraoperative blood reinfusion on clinical, biochemical, hemostasiological parameters of tissue oxygen supply during caesarean section was determined. The results obtained demonstrated the absence of coagulant activity in the reinfused erythrocyte suspension. Electron microscopic studies have shown that erythrocytes used for reinfusion during surgery and obtained by the method of hardware processing have normal structural and functional properties, which makes them capable of full functioning after reinfusion. For the first time, a decrease in the stabilization time of hemodynamic blood parameters and an improvement in the parameters of CBS and blood gases, volumetric oxygen transport, faster recovery of hemoglobin parameters, the number of erythrocytes and the volume of circulating blood in the early postoperative period were revealed. Intraoperative reinfusion of blood during caesarean section is indicated for blood loss of more than 700 ml in women at high risk of bleeding (placenta previa and abruption, varicose veins of the uterus, hemangioma of the pelvic organs, etc.), as well as when expanding the scope of surgical intervention (conservative myomectomy, supravaginal amputation and extirpation of the uterus). A tactic has been developed for conducting blood reinfusion by a hardware method during cesarean section. The designs of the new generation devices provide for a high-quality washing of erythrocytes with a large amount of solution, which makes the procedure safe in obstetrics. Of interest are works on the prevention of bacterial infection after caesarean section. The state of microbiocenosis of the vagina was studied. It was noted that in pregnant women with bacterial vaginosis and when opportunistic microorganisms in high titer (> 404 CFU / ml) are detected in the vaginal discharge, the risk of developing inflammatory complications increases by at least 2.3-2.7 times compared with state of normocenosis. One of the ways to prevent postoperative inflammatory complications was the development of management tactics for patients with impaired vaginal microbiocenosis. The need for prolonged antibiotic prophylaxis in order to prevent complications in the postoperative period is shown.

In order to reduce the frequency of infectious complications after caesarean section, a system for their prevention has been developed: 1) general preventive measures taken before surgery, in the intraoperative and postoperative periods; 2) individual preventive measures applied before surgery, also including pathogenetic therapy of the underlying disease, rehabilitation of foci of chronic infection, non-specific stimulation of immune system factors (UVR, laser blood irradiation, acupuncture). With a high degree of infectious risk, extraperitoneal caesarean section, aspiration and lavage drainage in the postoperative period, expansion of the scope of surgical intervention to extirpation of the uterus with fallopian tubes are indicated, if the operation is performed in the presence of endometritis.

Serious attention is paid to the development of principles of antibiotic therapy. It was noted that the prophylactic administration of antibiotics to women in labor with a high risk of developing infectious complications should be carried out selectively. With a clear threat of the development of inflammatory diseases, the most effective is the use of intrauterine-intramural antibiotic administration during cesarean section. This method provides antibiotic blockade of the entrance gate of infection of the uterus (endometrium, placental site, suture zone) and contributes to an uncomplicated postoperative period in 81.2% of the operated patients.

According to I.M. Mirov, in the prevention of postpartum infectious complications, a significant role belongs to the combination of drug therapy and non-drug effects, which helps to improve the rehabilitation of puerperas, reduce the massiveness and duration of the drug load. Among the non-drug methods of exposure for endometritis include:

carrying out sessions of hyperbaric oxygenation (HBO) in combination with the introduction of an antibiotic into the lymphatic channel, which is indicated for women with intestinal paresis;

the use of a modified UHF apparatus with directional exposure to near electromagnetic fields and with a significant predominance of the magnetic component for the treatment and prevention of endometritis after childbirth and cesarean section;

effective pain relief with a decrease in the daily dose of narcotic analgesics is successfully achieved through central electroanalgesia sessions after cesarean section;

the use of intraorganic exposure, prolonged washing of the uterus with cooled solutions of antiseptics with the addition of trypsin solution (at the beginning of the procedure) and drugs with an increased antibacterial effect (0.5% solution of horhexidine bigluconate, etc. at the final stage).

The study of delayed complications after caesarean section was carried out by T.N. Senchakova (Moscow Regional Research Institute of Obstetrics and Gynecology of the Ministry of Health of Russia). During the study, it was found that secondary suture failure after caesarean section, local or total panmetritis with abscessing of the pelvic tissue develop against the background of endometritis and indicate a generalization of the infection. The most significant risk factors for the development of delayed complications after caesarean section are exacerbation of chronic infectious processes during pregnancy, impaired contractile activity of the uterus during childbirth, low placenta, or technical errors during surgery. The effectiveness of the treatment of patients with delayed complications after caesarean section is determined by early diagnosis and active conservative surgical or surgical management. The author notes that the combination of hysteroscopy with active aspiration and lavage drainage of the uterine cavity allows you to quickly stop the inflammatory process in the uterine cavity, limit the possible generalization of infection in the absence of panmetritis, leads to secondary healing of sutures on the uterus or allows you to perform organ-preserving operations. Reliable prevention of delayed complications after caesarean section is an adequate assessment of the degree of infectious risk, compliance with modern surgical technologies, ultrasound monitoring of the course of the postoperative period, in the presence of signs of endometritis - early active tactics (hysteroscopy in combination with active aspiration of the contents of the uterine cavity). The use of this diagnostic system and active therapeutic tactics made it possible to preserve the uterus in 48.1% of patients with delayed complications after caesarean section.

The study of peritonitis after caesarean section is devoted to the study of E.D. Khadzhieva (St. Petersburg Academy of Postgraduate Education) . The main reason for the development of peritonitis after caesarean section is progressive metroendometritis, metrophlebitis with the formation of obvious suture failure in 83.5% of patients and latent suture failure in 14.7%. The main factors determining the development of the disease are virulent pathogens (more often anaerobes), massive blood loss (in 22.2%), errors in surgical technique (in 25%), poor sanitation of the uterus during surgery with incomplete removal of placental tissue (in 25.6 %), fetal membranes (in 22.8% of patients).

Early (and during the first 3 days) and later (on the 4-7th day after surgery) the onset of peritonitis has 2 variants of the course: with a clinical picture of intestinal paresis (in 70.5% of patients) and without intestinal paresis (in 29.5 % of patients). Peritonitis after caesarean section, occurring without intestinal paresis, presents known diagnostic difficulties (in 11.7% of patients). The clinical picture in this variant of the course does not correspond to the nature of diffuse peritonitis, inflammatory changes in the pelvic organs and abdominal cavity, which is obviously associated with a decrease in the body's immune reactivity in response to the development of infection. In 63.9% of patients, peritonitis occurs when infected with gram-negative microflora, pathogenic staphylococcus, streptococcus. Non-spore-forming anaerobes - Bacteroides, Peptococcus, Peptostreptococcus - were identified in all examined patients. With peritonitis that developed after caesarean section, a deficiency of the T-system of immunity is expressed, which is manifested by lymphopenia, a decrease in the relative content of T-lymphocytes. Violation in the cellular link of immunity and a change in the nonspecific resistance of the organism contribute to the formation of a state of prolonged immunosuppression, against which the emergence of new and activation of chronic foci of infection is possible. During the course of the disease, patients have pronounced changes in hemostasis, corresponding to phases I-II of DIC with a simultaneous violation of the anticoagulant link. Persistent hypercoagulability with a decrease in fibrinolysis, observed in some patients, allows them to be attributed to the group of puerperas with thromboembolic complications. For prevention, the appointment of heparin and tocopherol acetate is effective.

Thus, as a result of the analysis of dissertations devoted to the problem of caesarean section, there is an increase in the interest of researchers in this important problem. New interesting data have been obtained on the issues of optimizing this operation, improving the technique of suturing the uterine incision, methods of diagnosing, treating and predicting the outcome of purulent-infectious diseases that developed after caesarean section.

However, despite the great contribution made to the development of the problem of caesarean section in obstetric practice, many of its aspects are not fully understood. This applies to the study of the frequency of caesarean sections in various regions of the country in comparison with maternal and perinatal mortality rates. It is of undoubted interest and of great practical importance to determine the optimal proportion of surgery among all methods of delivery. It is necessary to revise the relative indications for caesarean section, to develop tactics for the management of labor in women with a scar on the uterus after surgery, and to determine the optimal frequency of childbirth through the natural birth canal. The issues of rehabilitation of puerperas after caesarean section, in particular, puerperas who underwent purulent-inflammatory complications in the postoperative period, need to be further developed. Little attention is paid to the study of the physiology and pathology of newborns born by abdominal delivery. It is necessary to further develop rational tactics for managing this contingent of newborns in the early and late neonatal period.

The most serious achievement of modern obstetric art is the caesarean section - an operation that allows even in the most difficult cases to save the life of the child and mother.

Historical facts confirm that such operations were carried out in antiquity, but now a cesarean section very often acts as a way to save the woman in labor. Recently, the number of indications for caesarean section has increased significantly, since for many women, vaginal delivery is risky.

However, it should be borne in mind that a planned or emergency caesarean section may cause complications and consequences in the distant future. But at the time of the operation, saving the life of the child and mother plays an important role.

The name of the operation comes from the legend about the birth of the emperor of the Roman Empire Gaius Julius Caesar. In the process of childbirth, the mother of the future emperor died, and then his father, wanting to save the life of the child, cut open his stomach and pulled out the baby.

When is the operation performed?

Births by cesarean can be planned, scheduled and emergency. During a planned operation, its exact date is assigned (often a week or two before the expected date of birth) and is carried out if there are normal indications in the mother and fetus, as well as at the first signs of the onset of labor.

A woman learns about a planned caesarean section, often even during pregnancy (sometimes even at the very beginning). But even in this case, childbirth begins to be carried out in a natural way, and is completed abdominally.

There are a number of factors that are necessary indications for a caesarean section:

The fetus is alive, and can continue to exist in the womb, but to save the life of the mother, it is removed ahead of time;
The woman must give written consent to the operation;
A catheter is placed in the patient's bladder, since cesarean is performed only in conditions of an empty bladder;
The mother has no signs of infection;
Surgical intervention should be carried out only in the operating room with the participation of an experienced obstetrician-surgeon.

Main indications

There are two large groups of factors that can lead to the completion of a pregnancy by cesarean:

Absolute indications for which there is no other way of conducting labor;
Relative indications under which a woman can give birth to a child in a natural way, and the decision to perform the operation is decided at the council.

In addition, there is a division of provoking factors into maternal and fetal. An emergency operation may also be performed during childbirth or in the last stages of pregnancy.

Absolute readings

Indications for which a caesarean section is mandatory include an extensive list of maternal and fetal factors. These include:

Anatomical narrow pelvis

There are two groups of narrowing of the pelvis. The first includes a flat, transversely narrowed, flat rachitic and generally evenly narrowed pelvis. The second includes the oblique and oblique pelvis, as well as the pelvis deformed under the influence of tumors, fractures or other external factors.

If a woman has a narrow pelvis of grade 3 or 4 (the size of the conjugate is less than 9 centimeters), complications may occur before the process of labor:

Oxygen starvation of the fetus;
Weak contractions;
child infection;
Early rupture of the amniotic sac;
Prolapse of the loops of the umbilical cord or limbs of the child.

The anatomical narrow pelvis also provokes the development of complications of the pressing period:

Secondary weakness of attempts;
Injuries of the joints of the pelvis and nerve endings;
Oxygen starvation of the child;
Birth trauma and uterine rupture;
Necrosis of internal tissues with subsequent formation of fistulas;
With an anatomically narrow pelvis, childbirth in the third period can provoke bleeding.

Complete placenta previa

The placenta is formed in the body of a woman only during pregnancy and is necessary for transporting blood, oxygen and nutrients from mother to baby. Normally, the placenta is located at the bottom of the uterus or the back or front machine of the organ. However, there are times when the placenta forms in the lower segment of the uterus and covers the internal os, making natural delivery impossible. In addition, such a pathology can cause complications during pregnancy in the form of bleeding, the intensity and duration of which cannot be determined.

Incomplete placenta previa

This pathology can be lateral or marginal, that is, the placenta covers only part of the internal pharynx. However, even an incomplete presentation can cause sudden bleeding. Especially often, bleeding begins already during childbirth, when the internal pharynx expands, provoking a gradual one. The operation of caesarean section in this case is carried out only with a strong loss of blood.

The threat or presence of uterine rupture

There are many reasons that can cause uterine rupture: improper delivery, poor coordination of labor forces, too large a fetus. If the patient is not provided with medical assistance in a timely manner, the uterus may rupture, in which case both the woman and her child die.

Early placental abruption

Even if the placenta is attached in the right place, during pregnancy or during childbirth, it may begin to flake off. This process is accompanied by bleeding, the intensity of which depends on the degree of detachment. In moderate and severe cases, an emergency abdominal delivery is performed to save the mother and child.

Scars on the uterus (two or more)

If a woman has previously given birth at least twice by caesarean section, natural childbirth is no longer possible in the future, since in this case the risk of uterine rupture along the scar increases significantly.

Insolvent scar

Stitches on the uterus can appear not only after abdominal delivery, but also after any other surgical procedures on the internal genital organs. A scar that arose during a complicated postoperative period is considered defective (the woman had a high temperature, the skin sutures healed too long or endometritis developed). It is possible to determine the usefulness of the scar only with the help of ultrasound.

Cesarean section(lat. caesarea "royal" and sectio "incision") - childbirth with the help of abdominal surgery, in which the newborn is removed through an incision in the abdominal wall of the uterus. Previously, caesarean section was performed only for medical reasons, but now more and more often the operation is performed at the request of the woman in labor.

A bit of history of caesarean section

The first reliable caesarean section on a living woman was performed in 1610 by the surgeon Trautmann ( I. Trautmann) from Wittenberg. The baby was retrieved alive, but the mother died 4 weeks later (cause of death not related to surgery). In Russia, the first caesarean section was performed in 1756 by I. Erasmus. One of the first caesarean sections in Russia was practiced by the surgeon E. Kh. Ikavits.

In 2000, Mexican Ines Ramirez Perez performed a caesarean section on herself.

Before, during and after surgery

Before the operation, the pubis is shaved and a catheter is inserted into the bladder in order to avoid problems with the kidneys later. After anesthesia, the woman is placed on the operating table and the upper part of the body is fenced off with a screen.

During the operation, the doctor makes two incisions: the first incision is in the abdominal wall (skin, fat and connective tissues), the second is in the uterus. (The abdominal muscles are not cut; they are pulled apart, allowing them to heal more easily.) Both cuts can be vertical or horizontal (transverse), or one can be vertical and the other horizontal. For example, the skin incision may be horizontal, while the uterus is vertical. It is important for subsequent births to know which uterine incision was previously, so you need to ask your doctor and write it down for yourself.

There are two types of skin incisions for caesarean section. The transverse incision (or bikini incision) is used more frequently; it is done horizontally just above the pubic bone. A midline incision is made vertically between the umbilicus and the pubic bone. This incision allows for rapid removal of the fetus in emergency situations and may be preferable in some other cases (eg maternal obesity).

There are three types of uterine incisions. The classic incision is made vertically at the top of the uterus. Currently, it is rarely done, except in cases of threatened fetal life, placenta previa, and the transverse position of the fetus. After a classic incision, vaginal delivery is usually not recommended.

The most commonly practiced now is the lower transverse incision of the uterus. It is associated with less blood loss and less risk of postpartum infection, but is more time consuming than a classic incision. Subsequent births can occur through the natural birth canal, since this incision heals well and leaves a strong scar.

A vertical incision of the lower uterine segment is performed only when the lower part of the uterus is underdeveloped or too thin for a transverse incision (as in some preterm births).

To control bleeding from the incisions, the doctor bandages or cauterizes the ends of the cut blood vessels. Then the doctor sucks amniotic fluid from the uterus, removes the baby, quickly shows it to the woman in labor and hands it over to the nurse. The doctor then manually separates and removes the placenta. At this point, you may feel some pressure. The nurse cleans the baby's mouth and nose to remove fluid and mucus, as with vaginal delivery. The child is dried, evaluated on the Apgar scale, examined and given the necessary medical attention.

After removing the baby and placenta, the doctor inspects the uterus and begins recovery. The incisions of the uterus and abdominal wall are sutured with dissolvable surgical suture. The skin is connected with dissolvable or insoluble thread, clips or staples, which are removed before discharge from the hospital.

Sewing usually takes about 30-45 minutes. A bandage is applied over the incisions. Pitocin is then given intravenously to contract the uterus. If the operation was performed under local anesthesia, by this time you will feel sick and nausea will appear. There may also be trembling all over the body. It is not entirely clear where such a reaction comes from, but everything passes in about an hour. They can give medicines, from which the woman in labor will doze off or fall asleep for the entire period. You need to ask in advance about these medicines. You can opt out of them if you wish. Warm blankets will help reduce shivering. If general anesthesia was used, the woman in labor will be unconscious for another hour or more after the operation.

If the partner of the woman in labor is in the operating room and the baby is in good condition, he will be able to hold the baby, and then both will be able to see and touch him. Otherwise, the baby will be transferred to the neonatal ward and happy parents will see him later. If the baby is breathing well and generally healthy, they may be brought to the recovery room to be held, nursed, and breastfed. Nurses will closely monitor the child for hours or days, especially if there are problems with breathing, maintaining body temperature, or other problems are suspected.

In the recovery room, a nurse will check your blood pressure, the condition of your sutures, the tightness of your uterus, and the flow of lochia to the lining. The woman in labor will be observed until the anesthesia wears off (two to four hours).

If the woman in labor was given spinal anesthesia, a spinal headache may appear when lifting the head. In this case, she will be advised to lie down for 8-12 hours or a blood filling will be made. If the operation was performed under general anesthesia, the throat and neck may hurt for several days due to the tube introduced there through which anesthesia was applied.

Indications for caesarean section

A caesarean section may be necessary in any of the following cases:

Craniopelvic disproportion

The baby's head is too big and the mother's pelvis is too narrow, or a combination of both. Craniopelvic disproportion is rarely diagnosed (although it may be suspected) before the onset of labor, because even in the case of a large head of a child and a relatively small pelvis of the mother, the head contracts slightly and the pelvic joint moves apart during childbirth. If enough time has passed and the contractions were strong, but there is no progress in labor, a diagnosis of craniopelvic disproportion may be made. Sometimes it is difficult to distinguish this case from an unfortunate fetal articulation.

Bad presentation or articulation

The child is located in the uterus, unsuccessfully for childbirth through natural routes. Examples include transverse fetal position (the baby lies horizontally), some types of breech presentation (full or foot), face and frontal presentation, stable posterior presentation, or asynclitism (the baby's head is turned so that it does not enter the pelvic inlet). Read more in the article on difficult presentations.

Lack of progress (or prolonged labor)

Contractions are not strong enough or there is no progress in dilating the cervix and descent of the fetus even after trying to relax the uterus or stimulate stronger contractions. Such a diagnosis cannot be made before the onset of the active phase of labor (after 5 centimeters of dilation), since the normal latent phase often drags on for a very long time.

Fetal disease

Specific changes in the fetal pulse, detected by listening or using electronic monitoring devices, may indicate problems with the child. These changes indicate that the baby conserves oxygen when the supply is limited (for example, when the umbilical cord is squashed or blood flow to the placenta is reduced. Follow-up tests - glans stimulation or a blood test - will show if the baby is well compensated or has begun to suffer from a lack of oxygen. If the baby is no longer able to cope with the lack of oxygen, a caesarean section is necessary.

The main danger of oxygen deficiency is that it (lack) can cause brain damage (cerebral palsy, mental retardation, epilepsy). Although brain damage can occur during childbirth, numerous studies show that it is more likely to occur even before labor begins, during pregnancy. Brain damage is not detectable while the fetus is in the protective environment of the uterus. This may only appear after the onset of labor, when fetal pulse disturbances are observed due to stress, or after the birth of the child, when signs of neurological disorders appear. A caesarean section can neither prevent nor cure disorders that have already occurred, although it can save such babies from the birth stress for which they are not ready.

Cord prolapse

When the umbilical cord descends into the cervix before the baby, the baby's body can pinch the umbilical cord, drastically reducing oxygen supply, and an immediate caesarean section is needed.

placenta previa

The placenta covers (in whole or in part) the cervix. When the cervix dilates, the placenta separates from the uterine wall, causing the mother to bleed painlessly and depriving the baby of oxygen. Placenta previa occurs approximately once in 200 pregnancies. This is a condition where the placenta is implanted (at least partially) to the cervix. The most characteristic symptom is vaginal bleeding, most often after seven months of pregnancy. Bleeding, usually intermittent, is not accompanied by pain. Treatment may include bed rest, ongoing medical supervision of the mother and fetus, and caesarean section.

Placental abruption

The placenta separates prematurely from the uterine wall. This can cause vaginal bleeding or occult bleeding and constant abdominal pain. Detachment reduces the supply of oxygen to the fetus and, depending on the degree of detachment, a caesarean section may be required. Detachment occurs most often during the third trimester or during childbirth. Although it sometimes happens for no apparent reason, women with high blood pressure or those who smoke and drink heavily are more at risk. If there is little bleeding, contractions continue, and the fetal heart rate remains normal, doctors usually allow labor to continue normally. Otherwise, a caesarean section is performed.

Threat of uterine rupture

This situation occurs either during repeated births, if the first ones were performed using a caesarean section, or after other abdominal operations on the uterus, after which a scar remained. With normal healing of the uterine wall with muscle tissue, uterine rupture does not threaten. But it happens that the scar on the uterus turns out to be insolvent, that is, it has a threat of rupture.

The failure of the scar is determined by ultrasound data (the thickness of the scar is less than 3 mm, its contours are uneven and there are inclusions of connective tissue). The failure of the scar on the uterus can also be indicated by the complicated course of the postoperative period after the first operation: fever, inflammation of the uterus, prolonged healing of the suture on the skin.

A caesarean section is also done after two or more previous caesarean sections, because this situation also increases the risk of uterine rupture along the scar in childbirth. Multiple births in history, which led to thinning of the uterine wall, can also create a threat of uterine rupture.

Of course, in each case, the condition of the scar is checked by ultrasound individually and repeatedly during pregnancy. So the doctor knows in advance about the insolvency of the scar on the uterus, and can prescribe a planned cesarean.

Mechanical obstacles

It is also possible to determine in advance such an indication for caesarean section as mechanical obstacles that interfere with childbirth through the natural birth canal. This may be, for example, uterine fibroids located in the isthmus, ovarian tumors, etc. Most often, this obstacle is determined by ultrasound, and on its basis, the doctor prescribes a planned caesarean. The same applies to tumors and deformities of the pelvic bones, which will also prevent the child from passing through the birth canal.

mother's illness

If the expectant mother has diabetes, diseased kidneys, bronchial asthma, hypertension, preeclampsia (toxicosis), heart or other serious illness, if the child cannot bear the stress of labor and childbirth through natural means. The presence of herpes in or near the vagina is also an indication for a caesarean section, as the baby can get an infection while passing through the birth canal. Also, an indication for surgery is often the maternal myopia of more than 5 diopters and the risk of retinal detachment, which leads to blindness. In this case, to exclude attempts, a caesarean section is used.

Multiple pregnancy

The likelihood of a caesarean section for twins (or more twins) is higher due to potential complications such as toxemia, prematurity, breech presentation, and cord prolapse.

Repeated caesarean section

A new caesarean section may be performed because the reasons for the first caesarean section persist, or because the doctor or patient prefers a caesarean section to a vaginal delivery. Also, an indication may be the poor condition of the postoperative scar on the uterus after a previous caesarean section.

In subsequent births, vaginal delivery is possible and even recommended in recent times if there is no medical indication. If this new approach is adopted, the repeat caesarean section rate will decrease.

Relative contraindications to caesarean section on the part of the mother

Maternal illnesses not related to pregnancy, in which the burden of natural childbirth threatens the life and health of the mother.

Such diseases include any cardiovascular pathology, kidney disease, high myopia with changes in the fundus, diseases of the nervous system, diabetes mellitus, cancer of any localization, and some other diseases.

In addition, indications for caesarean section are exacerbations in the mother of chronic diseases of the genital tract (for example, genital herpes), when the disease can be transmitted to the child during natural childbirth.

Complications of pregnancy

Relative indications for caesarean section are some complications of pregnancy, which can endanger the life of the child or the mother herself during natural childbirth.

First of all, it is preeclampsia - a late complication of pregnancy, in which there is a disorder in the function of vital organs, especially the vascular system and blood flow.

Severe manifestations of preeclampsia - preeclampsia and eclampsia. At the same time, microcirculation in the central nervous system is disturbed, which can lead to serious complications for both the mother and the fetus.

Persistent weakness of labor activity

A relative indication for caesarean section is the persistent weakness of labor activity, when labor that has begun normally for some reason subsides, or goes for a long time without noticeable progress, and medical intervention does not bring success. If at the same time the devices show that the condition of the fetus is deteriorating (for example, due to hypoxia), then operative delivery is possible.

Clinically narrow maternal pelvis

The situation when the size of the woman's pelvis does not correspond to the size of the presenting part of the child is also a relative indication for caesarean section.

You can often hear that for a nulliparous woman, age over 35 is also an indication for a caesarean section. This is not entirely true. A relative indication may be considered to be over 35 years of age in combination with pathology.

This means that in a situation where a younger woman can try to risk giving birth herself, a woman after 35 years is better not to do this. The point is simply that after the age of 35, the general health of a woman is usually worse than in her first youth. However, everything is decided individually, and age itself is not an obstacle to natural childbirth.

Advantages of a caesarean section

in the presence of absolute indications, caesarean section contributes to the preservation of the life and health of the mother and child;
there is no risk of perineal and cervical ruptures;
there is no stretching of the vagina, after which there may be problems with sexual life;
there is no risk of hemorrhoids;
absence of a painful period of contractions.

Disadvantages of a caesarean section

anesthesia is a serious test for the mother's body;
the newborn also inevitably receives a dose of anesthesia;
a long rehabilitation period, accompanied by severe pain;
the risk of infection in the abdominal cavity;
the child has an increased risk of complications of the respiratory system;
if the estimated date of birth is incorrectly determined (for example, with a large fetus), a premature cesarean section is possible, that is, the birth of a premature baby;
difficulties with the formation of lactation;
if it is necessary to prescribe antibiotics to the mother, the first application to the breast is possible 3-5 days after the operation.

In addition to these shortcomings, according to doctors, passage through the birth canal provides a smoother transition for the child to atmospheric pressure, gives impetus to the start of spontaneous breathing, and also contributes to the population of the sterile intestine of the newborn with bacteria necessary for normal operation, which is the best prevention of dysbacteriosis.

And in conclusion, it should be noted that those girls who, by their own admission, decided on a caesarean section solely out of fear of giving birth on their own, subsequently regretted their decision. Firstly, the rehabilitation period (which lasts about a week) is extremely painful, even going to the toilet is a big problem. Secondly, after the operation, in any case, an ugly scar remains. Even if the seam is very neat, it does not add attractiveness. And thirdly, the need to stay longer in the hospital after the birth of the baby also does not please anyone.