Cesarean section. Types and conduct of operations. Indications and contraindications. Postoperative period.
Caesarean section is the operation, in which the uterus is surgically opened and the fetus is extracted from it with all its embryonic formations. This operation is known since ancient times. In the Roman Empire (the end of the 7th century BC), the burial of pregnant women was forbidden without first extracting the child by cesarean section.
The first historically reliable Cesarean section on a live woman was performed on April 211610 by Trautmann's surgeon from Wittenburg. In Russia, the first operation of cesarean section with a favorable outcome for the mother and fetus was performed by G. F. Erasmus in 1756.
In 1780 Daniil Samoilovich defended his first thesis devoted to cesarean section.
The introduction of aseptic and antiseptic rules did not improve the consequences of the operation because the death rate was due to bleeding or infectious complications due to the fact that the cesarean section ended without the closure of the uterine wound.
In 1876 GE Rain and independently of him E.Porro proposed a method of extracting a child with subsequent amputation of the uterus.
Since 1881 after F. Kehrer sewed a uterine incision with a three-story suture, a new stage begins. the formation of cesarean section. It began to be carried out not only in absolute, but also in relative indications. The search for rational surgical technique began, which led to the method of intraperitoneal retrovesical caesarean section, which is the main one at the present time.
The rate of cesarean section over the past 30 years has increased 10-fold and is 9-15%. The increase in the frequency of caesarean section operations was mainly due to repeated operations, as well as due to frequent use in pelvic presentations and intrauterine hypoxia of the fetus.
Types of caesarean section
There are abdominal cesarean section (sectio caesarea abdominalis) and vaginal cesarean section (sectio caesarea vaginalis). The latter is almost not met in modern conditions. There is also a small cesarean section, which is performed with a gestation period of up to 28 weeks.
The abdominal cesarean section can be performed by two methods:
intraperitoneal and outside of the abdominal.
The intra-abdominal method of cesarean section according to the type of incision on the uterus is divided into:
1. Caesarean section in the lower segment:
b) longitudinal section (ischemic coronary caesarean section).
2. Cesarean section classical (corporal) with a cut of the body of the uterus.
3. Cesarean section with subsequent amputation of the uterus (the Reino-Porro operation).
Indications for cesarean section
Indications for cesarean section are divided into absolute, relative, combined and those that are rarely found. Absolute indications are those complications of pregnancy and childbirth, in which the use of other methods of delivery poses a threat to the life of a woman. Caesarean section under such conditions is carried out without taking into account all necessary conditions and contraindications.
In a clinical situation, when the possibility of delivering through the natural birth can not be ruled out, but it is associated with a high risk of perinatal mortality, one speaks of relative indications for surgery.
The combined indications unite the aggregate of several pathological conditions, each of which, in isolation, is not an occasion for prompt intervention. To such indications, which are very rare, there is a cesarean section on a dying woman. In addition, the testimony is given to the cesarean section with the documents of the mother and the fetus.
I. Indications from the mother:
- Anatomically narrow basin of III and IV degree of soundness (vera <7см) и формы узкого таза, редко встречаются (косозмищенний, поперечнозвужений, воронкообразный, спондилолистичний, остеомалятичний, сужен екзостазамы и костными опухолями и др)
- Clinically narrow pelvis
- Central placenta previa
- Partial placenta previa with severe bleeding and lack of conditions for urgent delivery per vias naturalis;
- Premature detachment of the normally located placenta and the absence of conditions for urgent delivery per vias naturalis;
- Uterine rupture that is fraught or has begun
- Two or more scars on the uterus
- Rumen's inconsistency on the uterus;
- Scarring on the uterus after corporal caesarean section;
- Cicatricial changes in the cervix of the uterus and vagina;
- Anomalies of labor that can not be corrected
- Varicose varicose veins enlargement of the veins of the cervix, vagina and vulva;
- Malformations of the uterus and vagina;
- Condition after rupture of the third degree crotch and plastic operations on the perineum;
- Conditions after surgical treatment of urogenital and intestinal fistula;
- Tumors of pelvic organs that interfere with the birth of a child;
- Cervical cancer;
- Absence of effect from treatment of severe forms of gestosis and impossibility of urgent delivery;
- Traumatic injuries of the pelvis and spine;
- Extragenital pathology in the presence of a record corresponding to a specialist on the need to exclude the second period of labor according to methodological recommendations;
- Genital herpes are verified.
II. Indications from the fetus:
- Fetal hypoxia is confirmed by objective research methods in the absence of conditions for
urgent delivery per vias naturalis;
- Pelvic presentation of the fetus with a body weight of more than 3700g when combined with another obstetric pathology and a high degree of perinatal risk;
- Loss of pulsating umbilical loops
- Misalignment of the fetus after the outflow of amniotic fluid;
- High direct stance of the swept seam;
- Extensor insertion of the fetal head (frontal, front view of the facial)
- Infertility treatment with a high risk of perinatal pathology;
- In vitro fertilization;
- The state of agony or clinical death of a mother with a live fetus;
- Multiple pregnancy with pelvic presentation and fetus.
Contraindications to delivery by caesarean section:
- Extragenital and genital infections;
- Duration of labor for more than 12 hours;
- The duration of the anhydrous period is more than 6 hours;
- Vaginal examinations (more than 3);
- Intrauterine fetal death.
Conditions for the operation:
- A living fruit;
- Lack of infection;
- Mother's consent to an operation.
Preparation for the operation depends on whether, in a planned manner, before the onset of labor, or in childbirth, it is carried out. It should be noted that in the delivery the lower segment of the uterus is well expressed, which facilitates the operation.
If the operation is carried out in a planned manner, then everything must be prepared beforehand for the blood transfusion for the woman and for the resuscitation of the child, which can be born asphyxia. On the eve of the operation, a light lunch (liquid soup, broth with white bread, porridge) is given, in the evening sweet tea. A cleansing enema is done in the evening and in the morning on the day of the operation (2 hours before the operation). Amniotomy is performed 1.5-2 hours before the operation. On the eve of surgery at night give a sleeping pill (luminal, phenobarbital (065), pipolfen or diphenhydramine 003-005 g).
In the case of an operation of caesarean section in an emergency before the operation with a full stomach, empty it through the probe and put an enema (in the absence of contraindications: bleeding, eclampsia, rupture of the uterus, etc.). In these cases, anesthesiologists should always remember the possibility of regurgitation of acidic contents of the stomach in the respiratory tract (Mendelssohn syndrome). Urine is excreted by a catheter on the operating table.
A suitable method of anesthesia is endotracheal anesthesia with nitrous oxide combined with neuroleptic and analgesic agents.
In modern obstetrics, a cesarean section is often used in a transverse section in the lower uterine segment, since this method produces the least amount of complications. When conducting cesarean section by this method, there is less blood loss, it is easier to spivvstavty the edges of the wound and sew them. But this is not always justified, especially in the presence of a large fetus, when it is difficult to remove and becomes the transition of the edges of the incision to the ribs of the uterus and the trauma of the uterine arteries.
Technique of operation in the lower segment by a cross section.
The incision of the anterior abdominal wall can be carried out by the lower median or upper median laparotomy or Pfannenstil. The first two autopsies are recommended in urgent cases. When the planned cesarean section is performed, access to Pfannenstil is possible.
Pregnant uterus is removed into the surgical wound. Several sterile wipes are introduced into the abdominal cavity, the outer end of which is attached with clips of external laundry. The uterine vesicular fold is dissected 2 cm above the bottom of the bladder and stupidly cut up and down. On the front wall of the uterus with a scalpel, a longitudinal incision is made 1-2 cm long, and then bluntly or with a scissors continue it to 12 cm. Through the wound, amniotic membranes are ripped, and the fetus is removed by hand passing the lower pole of the head. The umbilical cord is cut between two clips. The child is passed on to the midwife. If the latter itself did not separate, perform manual separation and removal of the afterbirth. After this, a control audit of the uterine cavity is performed with a curette and stitches are applied, starting from the edges of the wound layer by layer:
1) musculoskeletal sutures with an amount of 10-12 at a distance of 0.5-0.6 cm from each other;
2) muscular-serous with immersion in them of the seams of the first row;
3) catgut serrus-serous suture that connects both edges of the peritoneum.
From the abdominal cavity take away all the instruments, napkins, then layer by layer sew the wall
The main stages of the operation:
1. Opening of the anterior abdominal wall and peritoneum.
2. Opening of the lower segment of the uterus 2cm below the vesicle-uterine fold.
3. Removal of the fetus from the uterine cavity.
4. Remove the litter by hand and check the uterine cavity with a curette.
5. Suturing on the uterus.
6. Peritonization due to the vesicle-uterine fold.
7. Revision of the abdominal cavity.
Sewing the anterior abdominal wall.
The technique of classical (corporal) caesarean section.
In case of premature pregnancy, with the purpose of careful removal of a premature fetus, it is recommended that an istmic-corporal cesarean section be used in which, after cross-sectioning, viseplating and tapping with the help of mirrors of the vesicle-uterine fold, the uterus grows in the lower segment with a longitudinal incision, which then lasts up to 10-12 cm. The further actions of the surgeon and the method of stitching the wound of the uterus are similar to the previously performed operation.
Corporal cesarean incision is used less often in modern obstetrics. It is performed in the absence of access to the lower segment, or when the lower segment is not yet formed, with pronounced varicose veins in the lower segment, with presentation, low attachment or a complete detachment of the normally located placenta, and also in the presence of scar on the uterus after earlier conducted a corporal caesarean section.
The anterior abdominal wall is cut through the white line of the abdomen layer by layer. Incision begin above the pubis, lead to the navel. The front surface of the uterus is fenced off from the abdominal cavity with napkins so that amniotic fluid does not enter it. On the front wall of the uterus, a longitudinal incision is made about 12 cm long and through it the fruit is extracted by the leg or head, which is grasped by hand.
The umbilical cord is divided between two clamps. The child is passed on to the midwife. After that, the litter is removed, the uterine cavity is checked with a hand or curette, and the lining of the uterus is ligated (musculoskeletal, serous-muscular and serous-serous sutures). Remove all instruments and napkins and sew up the layer of the stomach.
With the outflow of amniotic fluid (more than 10-12 hours), after numerous vaginal examinations and when a threat of infection or its manifestations is present, it is advisable to perform extrasperitoneal cesarean section according to Morozov's method or cesarean section with temporary confinement of the abdominal cavity according to Smith.
The technique of the operation on Smith.
Anterior abdominal wall opening is performed according to Pfannenstiel (transverse incision) or the lower median laparotomy is performed. The peritoneum extends 2 cm above the bottom of the bladder. The bladder-uterine fold is dissected 1-2 cm above the bladder, its leaves are separated down and up, that the lower segment of the uterus (at a height of 5-6 cm) was fired. The edges of the vesicle-uterine fold are sutured to the parietal peritoneum from above and from below, and the bladder along with the fixed fold of the peritoneum is pulled downward. A semilunar incision is performed to dissect the uterine cavity. Then the operation is performed as a normal cesarean section.
Technique of the operation of a hemispheric cesarean section.
Laparatomy according to the Pfänenstil technique with a 14-15 cm incision. Further stratify the rectus abdominis muscles, and the pyramidal scissors are dissected. Muscles (especially led) push apart the side and separate from the peredeshervennoy fiber, a triangle is exposed: outside - the right side of the uterus, from the inside - a lateral vesicular fold, from above - a fold of the parietal peritoneum. Next, exfoliate the fiber in the region of the triangle, separate and move to the right the bladder until the lower segment of the uterus is exposed. In the lower segment a transverse incision is made 3-4 cm long, bluntly expands to the size of the head. Fetus is removed by the head or by the legs with pelvic presentation. Isolate litter, check the integrity of the bladder, ureters, sew up the walls of the uterus, layer-by-layer wound the wound of the anterior abdominal wall.
The Reino-Porro operation is a cesarean section with a supra-vaginal amputation of the uterus. In 1876 GE Raine experimentally substantiated, and E.Porro performed a cesarean section in conjunction with the removal of the uterus (the operation had to prevent the development of postpartum infectious disease). Currently, this operation is very rarely performed.
The indications for it are:
- Infection of the uterine cavity;
- Complete atresia of the sexual apparatus (impossibility of draining lochnyches)
- Cases of uterine cancer;
- Atonic bleeding, which can not be stopped by conventional methods;
- True increment of the placenta;
- Myoma of the uterus.
Management of the postoperative period:
• At the end of the operation, immediately apply cold and weight to the lower abdomen for 2 hours;
• to prevent hypotension in the early postoperative period, intravenous injection of 1 ml (5 U of oxytocin or 002% - 1 ml of methylergometrine per 400 ml of 5% glucose solution for 30-40 minutes;
• With the preventive purpose, the administration of broad-spectrum antibiotics is recommended after
in the postoperative period, closely monitor the function of the bladder and intestines (catheterization every 6 hours, normalization of the potassium level, proserin)
with the purpose of prophylaxis of thromboembolic complications, bandaging of lower limbs and application of anticoagulants according to indications are shown;
to rise to the patient it is resolved at the end of the first day, to go on the second day; Breastfeeding in the absence of contraindications after a few hours; an extract from the maternity ward is carried out 11-12 days after the operation;
after discharge from the hospital, all women with a scar on the uterus should be on dispensary in the women's consultation;
during the first year from the operation, contraception is mandatory: in uncomplicated operation and postoperative period, and in the normal menstrual cycle, the use of intrauterine contraceptives is indicated; in other cases, preference should be given to synthetic progestins;
the time of the onset of subsequent pregnancy is decided by taking into account the assessment of postoperative uterine scar, but not earlier than 2 years from the time of surgery;
Ultrasound in normal course of subsequent pregnancy should be carried out at least 3 times (when taken on the register, in the period of 24-28 weeks of pregnancy and the period of 34-37 weeks);
planned hospitalization for preparation for delivery is indicated in the period of 36-37 weeks of gestation; the delivery of women with operated uterus should be performed in 38-39 weeks of pregnancy;