Indications for cesarean section during pregnancy and childbirth. List of absolute and conditional indications for surgery. What are the main indications for a caesarean section?

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

Historical facts confirm that similar operations were carried out in ancient times, but now a caesarean section is very often a way to save the woman in labor. IN Lately the number of indications for cesarean section has increased significantly, since for many women natural vaginal birth is risky.

However, it is worth considering that performing a planned or emergency caesarean section may cause complications and consequences in the distant future. But at the time of the operation, preserving 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 Roman Emperor Gaius Julius Caesar. During the birth process, the mother of the future emperor died, and then his father, wanting to save the child’s life, cut open the stomach and pulled out the baby.

When is the operation performed?

Cesarean births can be elective, planned or emergency. At elective surgery appointed her exact date(often a week or two before the expected date of birth) and is carried out if there is normal readings in mother and fetus, as well as at the first signs of the onset labor activity.

A woman often learns about a planned caesarean section during pregnancy (sometimes in the very early stages). But even in this case, childbirth begins naturally and is completed abdominally.

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

• The fetus is alive and can continue to exist in the womb, but it is removed to preserve the life of the mother ahead of schedule;
• The woman must give written consent to the operation;
• IN bladder patients have a catheter installed, since cesarean section is performed only in conditions of an empty bladder;
• The woman in labor has no signs of infection;
• Surgery should only be performed in the operating room with the participation of an experienced obstetric surgeon.

Main indications

There are two large groups of factors that can lead to termination of pregnancy by cesarean section:

• Absolute indications for which there is no other way to manage labor;
• Relative indications under which a woman can give birth to a child naturally, and the decision to perform the operation is decided at a consultation.

In addition, there is a division of provoking factors into maternal and fetal. Emergency surgery may also be performed during childbirth or latest dates pregnancy.

Absolute readings

Indications for which cesarean section is performed in mandatory, includes an extensive list of maternal and fetal factors. These include:

Anatomical narrow pelvis

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

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

• Oxygen starvation of the fetus;
• Weak contractions;
• Child infection;
• Early rupture of the amniotic sac;
• Loss of the baby's umbilical cord or limbs.

An anatomical narrow pelvis also provokes the development of complications during the pushing period:

• Secondary weakness of pushing;
• Injuries to the pelvic joints and nerve endings;
• Oxygen starvation of a child;
• Birth injuries 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 a woman’s body only during pregnancy and is necessary for transporting blood, oxygen and nutrients from mother to baby. Normally, the placenta is located on the fundus of the uterus or the posterior or anterior organ of the organ. However, there are cases when the placenta forms in the lower segment of the uterus and overlaps internal os, making natural delivery impossible. Besides, similar 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 os. However, even incomplete presentation may cause sudden bleeding. Bleeding especially often begins during childbirth, when the internal os expands, causing gradual bleeding. In this case, a caesarean section is performed only when severe loss blood.

Threat or presence of uterine rupture

There are many reasons that can cause uterine rupture: improper management of labor, poor coordination ancestral forces, fruit size is too large. If the patient is not promptly provided medical assistance, the uterus may rupture, in which case both the woman and her child die.

Early placental abruption

Even if the placenta is attached right place, during pregnancy or during childbirth, it may begin to peel off. This process is accompanied by bleeding, the intensity of which depends on the degree of detachment. In moderate to severe cases, 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.

Failed scar

Sutures on the uterus can appear not only after abdominal delivery, but also after any other surgical manipulations on the internal genital organs. A scar that occurs during a complicated postoperative period is considered defective (the woman had a high fever, the skin sutures took too long to heal, or endometritis developed). The fullness of the scar can be determined only with the help of ultrasound.

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

Indications for surgery can be on the part of the mother, when childbirth poses a threat to her health, and on the part of the fetus, when for him the process of childbirth is a burden that 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 children's place) is located in the lower part of the uterus and covers the internal os (the entrance to the uterus from the vagina). This threatens severe bleeding, dangerous for both the life of the mother and the fetus. The operation is performed at 38 weeks of pregnancy or earlier if bleeding occurs.
• Premature detachment normally located placenta. Normally, the placenta separates from the wall of the uterus 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.
• Inconsistency of the uterine scar after an incision in a previous birth or other operations on the uterus.

  A uterine scar is considered invalid if, according to ultrasound, its thickness is less than 3 mm, its contours are uneven and there are inclusions connective tissue. If postoperative period after the first operation it was difficult (fever, inflammation of the uterus, prolonged healing of the suture on the skin), this also indicates the failure of the scar on the uterus.

• Two or more scars on the uterus after incision surgery. It is believed that two or more cesareans increase the risk of uterine rupture along the scar during childbirth due to the weakness of the scar tissue. Therefore, the incision is made before labor begins.
• Anatomically narrow pelvis (the so-called anatomical limitation in the size of a woman’s pelvic ring, which makes it difficult for the fetal head to pass through this ring) II-IV degree of narrowing. Every woman has her pelvic size measured during pregnancy. Obstetricians have clear criteria normal sizes pelvis and narrow pelvis according to the degree of narrowing. Tumors and deformations 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 fruit is considered large when its weight is 4 kg or more.
• Severe symphysitis. Symphysitis or symphysiopathy is the separation of the pubic bones. In this case, severe difficulties and pain appear when walking.
• Multiple large uterine fibroids, malnutrition of myomatous nodes.
• Severe forms gestosis and lack of effect from treatment. Preeclampsia is a complication of pregnancy in which the function of vital organs, especially the vascular system and blood flow, is disrupted. Severe manifestations of gestosis are preeclampsia and eclampsia. In this case, microcirculation in the central nervous system is disrupted, which can lead to serious complications for both the mother and the fetus.
• Serious illnesses. Diseases of cardio-vascular system with symptoms of decompensation, disease 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 the stretching of the vaginal walls necessary for the passage of the fetus.
• Condition after plastic surgery on the cervix and vagina, after suturing genitourinary and enterogenital fistulas. A fistula is an unnatural connection between two adjacent hollow organs.
• Perineal rupture III degree in previous births. If during childbirth, in addition to the skin and muscles of the perineum, the sphincter (the muscle that locks the anus) and/or the rectal mucosa is torn, then this is a third-degree perineal rupture; a poorly sutured rupture can lead to incontinence of gases and feces.
• Pronounced dilatation of veins in the vaginal area. At spontaneous birth bleeding from such veins can become life-threatening.
• Transverse position of the fetus.
• Conjoined twins.
• 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 a narrowing of the pelvis. With a breech presentation, the risk of birth injury during birth of the fetal head increases.
• In Vitro Fertilization, artificial insemination in the presence of other complications from the mother and fetus.
• Chronic fetal hypoxia, fetal hypotrophy, refractory to drug therapy. In this case, the fetus receives an insufficient amount of oxygen and for it the process of childbirth is a burden that can lead to birth trauma.
• Primiparas over 30 years of age in combination with another pathology.
• Long-term infertility in combination with another pathology.
• Hemolytic disease of the fetus due to unprepared birth canal. When rhesus (less often - group) incompatibility of the blood of mother and fetus develops hemolytic disease fruit - destruction of red blood cells(erythrocytes). The fetus begins to suffer from a lack of oxygen and the harmful effects of red blood cell breakdown products.
• Diabetes if early delivery is necessary and the birth canal is unprepared.
• Post-term pregnancy with unprepared birth canal and in combination with other pathology. The process of childbirth is also a stress that can lead to birth injury to the fetus.
• Cancer of any location.
• Exacerbation of genital herpes. For genital herpes, the indication is the presence of blisters herpetic rashes on the external genitalia. If by the time of birth it is not possible to cure a woman of this disease, there is a risk of infection of the fetus (if the membranes rupture or the fetus passes through birth canal).

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

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

Indications for cesarean section during 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 induction of labor. When water breaks out before contractions begin, they try to induce them with the help of medications (prostaglandins, oxytocin), but this does not always lead to success.
• Anomalies of labor that are not amenable to drug therapy. If weakness or incoordination develops, labor is carried out drug therapy, which also does not always lead to success.
• Acute fetal hypoxia. When the heartbeat suddenly becomes rare and does not recover.
• Abruption of a normal or low-lying placenta. Normally, the placenta separates from the wall of the uterus after the baby is born. Sometimes this happens during labor, 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 promptly recognized by a doctor, since a delayed operation can lead to fetal death and removal of the uterus.
• Presentation or prolapse of umbilical cord loops. If the umbilical cord prolapses and the fetus is in cephalic presentation, if an incision is not made within the next few minutes, the child may die.
• Incorrect insertion of the fetal head. When the head is in an extended state (frontal, facial presentation), as well as a high, straight position of the head.

Sometimes a cesarean 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 create a real threat to the life of the fetus. And a caesarean section is always a last resort when all attempts to help a woman give birth on her own are futile.

In his book "Caesarean section: a safe option or a threat to the future?" renowned obstetrician Michel Oden analyzes absolute and relative. Relative ones most often depend on the doctors delivering the baby and the current situation in obstetrics. And their number is growing all the time...

Many women whose babies are about to be born will be offered a caesarean section. If we take it upon ourselves to analyze everything possible situations, the information will fill volumes. There are several ways to classify the causes of birth" the upper way"We will try to separate absolute and relative indications for surgery.

Absolute indications for cesarean section

Expectant mothers should be warned about some very specific, non-negotiable indications for surgery, although such situations are relatively rare.

This group of indications includes umbilical cord prolapse. Sometimes, when amniotic fluid is released - spontaneously or after artificial opening of the amniotic sac - a loop of the umbilical cord can fall through the cervix into the vagina and end up outside. At the same time, it can be compressed, and then blood stops flowing to the child. This is an undeniable indication for a cesarean section, except in cases where labor is already at the stage when the baby is about to be born. During full-term birth in a cephalic presentation, prolapse of umbilical cord loops occurs extremely rarely if the amniotic sac is not opened artificially. It occurs more often when premature birth or during childbirth in a leg presentation. For a few minutes before an emergency caesarean section, the woman should assume a position on all fours - this will reduce compression of the umbilical cord.

In the case of complete placenta previa, it is located in the cervix and prevents the delivery of the baby. Most clear symptoms This condition is the discharge of scarlet blood from the genital tract, which is not accompanied by pain and most often occurs at night at the end of pregnancy. The location of the placenta is reliably determined by ultrasound. Complete is diagnosed at the end of pregnancy. It is an absolute indication for caesarean section. If the placenta is low attached in the second trimester of pregnancy, it is very likely that it will rise to a safer position in the remaining weeks. It is wrong to talk about placenta previa in the middle of pregnancy.

Placental abruption can occur both before and during childbirth. This means that the placenta, or a significant part of it, separates from the wall of the uterus before the baby is born. In typical and obvious cases, sudden sharp pain in a stomach. This pain is constant and does not ease for a minute. Sometimes - but not always - the pain is accompanied by bleeding, and the woman may be in a state of shock. It is often unclear why placental abruption occurs unless the cause is obvious, such as trauma (from a car accident or domestic violence) or the development of preeclampsia. In the classical form, when bleeding occurs, obvious or hidden (if the outflow of blood is impossible), the usual measures emergency care are blood transfusion and immediate surgical delivery while the child is alive. In milder cases, when the placenta detaches from the edge, small area, painless bleeding usually occurs. Nowadays, such forms of placental abruption are diagnosed using ultrasound. In general, if the doctor suggests a cesarean section due to placental abruption, it is better not to discuss this indication. Premature placental abruption is one of the main causes of intrauterine fetal death.

Frontal presentation is the position of the fetal head when it is in the middle position between full flexion (usual " occipital presentation") and full extension ("facial presentation"). The diagnosis of frontal presentation can sometimes be made by palpation of the abdomen: the protruding part of the head, the back of the head, is located along the back of the fetus. Usually the diagnosis is made during childbirth during a vaginal examination: the obstetrician's fingers find brow ridges with the eye sockets, ears and even the nose of the child. With frontal presentation, the fetal head passes through the pelvis with its largest diameter (from the back of the head to the chin). If frontal presentation persists, the indications for cesarean section are absolute.

A transverse position of the fetus, also called a shoulder presentation, means that the baby lies horizontally, neither head nor buttocks down. If a woman is to repeated births, it is more likely that the baby will take a longitudinal position towards the end of pregnancy or at the very beginning of labor. If this does not happen, vaginal birth will not be possible. This is another absolute indication for caesarean section.

Relative indications for cesarean section

Cases when there are absolute indications for cesarean section are extremely rare. The more frequent relative indications depend largely on factors as varied as the personality, age and professional experience of the midwife and doctor; the country where the child is born, the protocols existing in this clinic and accepted standards; character, lifestyle, family environment and circle of friends of the expectant mother; latest research, published in reputable medical journals and featured in the media, data obtained from popular websites, etc. This is why caesarean section rates vary so much from obstetrician to obstetrician, clinic to clinic, and country to country.

The presence of a uterine scar (usually from a previous cesarean section) is an example of a relative and negotiable indication: frequency operative delivery for this reason, it increased and decreased at different periods in the history of childbirth. Today, widespread attention has been drawn to the dangers of unexplained stillbirth, although its absolute risk is very small. A history of cesarean section is so common situation and such a pressing problem that we will consider it separately.

“Lack of progress in labor” is often cited as a reason for a first cesarean section. In most cases, the lack of progress in labor is due to the widespread misunderstanding of the physiology of labor in our time. It will take decades to once again understand that humans are mammals, and their key need for childbirth is peace and privacy. It will take decades to understand that a midwife is, first and foremost, a mother-like figure, someone who makes us feel safe and secure, who does not stare at us or criticize us. In the current climate, it would be dangerous to prioritize reducing the rate of caesarean sections. The immediate consequence of this will be an increase in the number dangerous interventions in vaginal births and an increase in the number of newborns requiring the help of pediatricians. For now, we must recognize that in the age of industrialization of childbirth, most caesarean sections are completely justified, and lack of progress in labor is the most common indication for surgery.

A discrepancy between the size of the pelvis and the fetal head simply means that the baby's head is too large to fit through the pelvic bones. This is a vague concept because the size of the baby's head and the mother's pelvis depends largely on the exact position of the head and how it "configures" during birth. In the case when a decision is made to perform a caesarean section during childbirth, it can be difficult to distinguish the discrepancy between the sizes of the pelvis and the fetal head from the “lack of progress in labor”: in the same circumstances, a woman can arbitrarily be given either the first or the second as the reason.

Fetal distress is also a vague concept because various specialists use different criteria to diagnose this condition. Fetal distress often occurs when labor is not progressing. As a result, it can be difficult to separate the two indications for cesarean section. Currently, labor induction is one of the main risk factors for the complex of complications that will subsequently be recorded in the birth history as weakness of labor, discrepancy between the sizes of the fetal head and the mother’s pelvis, or fetal distress.

• The best place and environment is where there is no one except an experienced midwife - maternally caring and silent, who tries not to attract attention and is not afraid to deliver a breech birth.
• The first stage of labor is diagnostic. If it passes easily and without problems, childbirth through natural means is possible. But if the first stage of labor is long and difficult, you should immediately perform a caesarean section before the moment comes when there is no turning back.
• Since the first stage of labor is diagnostic, it is very important not to try to artificially ease it, either with drugs or by immersion in water.
• After reaching the "point of no return" keywords become peace and solitude (privacy). The most important thing here is to make childbirth as easy and quick as possible. Even listening to your heartbeat can be a harmful, distracting activity. The main goal should be to create conditions for a powerful ejection reflex.
• In cases of purely breech presentation, you can act more boldly than with other types of breech presentation.

This tactic of managing breech birth can significantly reduce the overall incidence of cesarean section, since breech presentation in full-term pregnancies occurs in 3% of cases.

Nowadays, more and more caesarean sections are being performed in cases of twins. One of the reasons is that in 40% of cases, one child of twins is in a breech presentation, and in 8% of cases, both are present. Even more often, a caesarean section is prescribed in cases where one of the children is much larger than the other: this situation seems potentially dangerous for a child with a lower weight, especially if the children are of the same sex. The idea of ​​a planned caesarean section for twins can be daunting for those most concerned about the risk of having a premature baby. Also, situations occasionally arise when a second child has to be born via caesarean section after the first one has been born. naturally. The birth of a second child from twins is often considered riskier than the first. One of the reasons is the unhealthy turmoil that occurs every time in the delivery room immediately after the birth of the first child, at the very time when it is so important to maintain an atmosphere of reverence, according to at least, until the second baby and placenta are born. This is another modern trend associated with a widespread misunderstanding of the role of peace and solitude (privacy).

Nowadays, triplets are almost always born by caesarean section, although this practice has been questioned from time to time. Cases of spontaneous births of triplets have been described... including at home after a previous cesarean section!

There is also a trend towards an increase in the rate of caesarean sections among HIV-infected women. The goal is to reduce the risk of transmission of the virus from mother to child. This testimony is another example of how overnight in our age evidence-based medicine Routine practice may change. From 1994 to 1998, HIV-infected women in the United States underwent cesarean sections in approximately 20% of cases. In 1998, a study was published that showed that the risk of infection of the baby was significantly reduced if vaginal birth was avoided. After this, between 1998 and 2000, the rate of cesarean section in this situation increased to 50%. It is likely to increase further with the advent of new technology that protects the child from any contact with maternal blood.

The herpes virus can also be transmitted to a child during childbirth through vaginal transmission. More often herpetic infection is recurrent in nature. This means that the woman has already had exacerbations before pregnancy. In this case, there is almost no risk of infection, since the mother has time to form antibodies that penetrate the placenta (IgG), which can protect the child. The risk is more significant in those in rare cases when the mother’s primary infection occurred during pregnancy, when she only has time to form antibodies IgM class that do not pass through the placenta. In this case, a caesarean section reduces the risk of transmission of the virus.

What about frail babies, especially premature babies, and those called “small for gestational age”? There is so much conflicting data published that any doctor can always find an article to support his point of view.

What about “special children” born as a result of long-term infertility treatment using the latest methods artificial insemination? What about other “special” children born shortly after unexplained intrauterine fetal death in a previous pregnancy?

In the future, if we do not return to understanding the key needs of a woman in childbirth, it may be easier and quicker to consider the remaining reasons for deciding to have a natural birth than to try to analyze the thousand and one possible indications for cesarean section.

Comment on the article "A thousand and one indications for caesarean section"

A planned caesarean section is considered when indications for it are established during pregnancy. Who is better to have a caesarean section? Caesarean section - liberation from original sin? In Moscow, about 15 percent of births end in caesarean section...

Discussion

The third CS was done at the Planning Center upon referral and free of charge. The referral was issued at the district consultation office, because third CS - presentation, ingrowth (was questionable). I came to them for a consultation and immediately after the consultation received a referral for hospitalization. I stayed with them for more than 2 months (according to compulsory medical insurance) waiting for PCS, but an ECS happened.

I had a caesarean section at MONIIAG for free, I was very pleased with the quality of the operation. Now I’m carrying my second one, the doctors say the stitch is very good, they even predict an EP this time. The stitch did not bother me during the entire pregnancy, and I will give birth soon. But I won’t guess. My sister-in-law almost at the same time as me had a CS done in Kulakova (her baby is 4 months younger), I was surprised that despite the considerable cost, they saved on absorbable threads for the external suture??, these braces are not fatal, of course, but unpleasant. I didn’t even think that nowadays there are maternity hospitals where stitches are removed. She was kept under care in Kulakova, but labor began spontaneously at night, it was a planned caesarean section, according to her, the doctors took a long time to get ready, about 4 hours after the start of contractions she was waiting for the operation. She had a planned pregnancy due to a stroke during pregnancy, so it was undesirable to sit through contractions in this situation.
Also, another friend recommends Sevastopolskaya, she gave birth to 2 children there, with her a difficult situation, something with blood incoagulability, says that they helped her very well there. Naturally, not free.
I personally didn’t have any indications for a c-section, the baby just didn’t want to come out, stimulation didn’t help, I lay there for a long time with contractions, weak genus Well, we decided to have an emergency Caesarean section. Such a story. I gave birth to the doctor Ketino Nodarovna (I don’t remember her last name, she is Georgian). Here's the story.

contract and caesarean "optional". I am looking for a doctor with whom I can agree on a planned caesarean section. My daughter-in-law is indicated for a caesarean section, do I need to enter into an agreement for paid services? My friend just gave birth. from the indications for cesarean - 36 years, first birth...

Discussion

The doctors persuaded me to have a natural birth. But the gynecologist who conducted the consultation recommended a CS. Since the old-timer is all that.
When I came to sign the contract, I said that I was ready for the CS. The doctor said, well, if a woman wants to be cut, we will cut her. It’s basically easier for them, as I understand it.
I'm very pleased that COP. Because afterwards I had problems when passing additional tests after giving birth, it turned out that I had some kind of bacteria there, completely safe for women and children over 3 months, but maybe big problems for newborns .. Like, an analysis is done for it, for example, as planned in America, but here we don’t, something like this.
In general, everything is fine with the child, and I am very glad that it was a CS. But I really gave birth late, at almost 40.

This is a surgical operation during which the anterior abdominal wall of the woman in labor is first incised, then the wall of her uterus, after which the fetus is removed through these incisions.

Caesarean section in modern obstetrics

In modern obstetrics, caesarean section is the most frequently performed operation. Its frequency in last years reaches 10-20% of total number childbirth

Indications for caesarean section

A caesarean section is performed only in situations where vaginal birth is fraught with serious danger to the life and health of the fetus or the woman herself.

There are absolute and relative indications for surgery

Absolute readings to a cesarean section are clinical situations in which vaginal delivery poses a danger to the woman’s life.

To the group relative readings diseases and obstetric situations that adversely affect the condition of the mother and fetus are included if childbirth is carried out naturally.

As you can see, most indications for cesarean section are due to concerns for the health of both mother and child. In one case, already at the very beginning of pregnancy, during examination, a woman is found to have the prerequisites that she may not be able to give birth on her own (for example, a strong narrowing of the pelvis, or a scar on the uterus from a previous operation). In another, indications for delivery by cesarean section appear as the gestational age increases (for example, the fetus has established a transverse position in the uterus or placenta previa has been determined by ultrasound). The doctor warns the pregnant woman about this fact immediately, explaining to her the reason. In both of these cases, the woman is prepared for a caesarean section. in a planned manner, that is, upon admission to maternity ward They begin to prepare her not for childbirth, but for surgery.

Certainly, psychological aspect The “rejection” of cesarean sections by expectant mothers is understandable. Few people feel a “craving” for surgical interventions in the affairs of their own body. But cesarean section is an everyday reality (judge for yourself: on average, 1 out of 6-8 pregnant women give birth this way). Therefore, the doctor always tries to explain all the pros and cons of the upcoming operation and reassure the woman.

But sometimes, when there seemed to be no signs of danger throughout the entire pregnancy and the woman began to give birth on her own, emergency situations(for example, the threat of uterine rupture or oxygen starvation of the fetus, persistent weakness of labor) and labor ends in urgent indications operation of caesarean section.

What clinical situations are considered a contraindication for a caesarean section?

1. Intrauterine fetal death (death of the fetus before birth).
2. Deep prematurity of the fetus.
3. Fetal deformities.
4. Prolonged oxygen starvation of the fetus, in which there is no confidence in the birth of a living child.
5. Infectious and inflammatory diseases mother.

What conditions are considered most favorable for the operation?

1. The optimal time for the operation is considered to be the beginning of labor, since in this case the uterus contracts well and the risk of bleeding is reduced; in addition, in the postpartum period, discharge from the uterus will receive sufficient outflow through the slightly open cervix.
2. It is better if the amniotic fluid is intact or no more than 12 hours should pass after its release.
3. Viable fetus (this condition is not always feasible: sometimes, if the mother’s life is in danger, the operation is performed on a non-viable fetus).

How does a woman prepare for a planned caesarean section?

When preparing a pregnant woman, a detailed examination is carried out, including a study of blood counts, electrocardiography, examination of vaginal smears, examination by a therapist and an anesthesiologist.

In addition, it is necessary to carry out comprehensive assessment condition of the fetus (ultrasound examination, cardiotocography).

The night before the operation, the pregnant woman is given a cleansing enema, which is repeated on the morning of the operation. At night, as a rule, sedatives are prescribed.

What are the methods of pain relief for a caesarean section?

Endotracheal anesthesia - This general anesthesia With artificial ventilation lungs; is currently the main method of pain relief for caesarean section. It is performed by an anesthesiologist and monitors the woman’s condition throughout the operation.

Operation stages

An incision of the skin and subcutaneous fat is made along the lower fold of the abdomen in the transverse direction.

The incision on the uterus is made carefully (so as not to damage the fetus) in the lower uterine segment (the thinnest and most distended place on the uterus). The incision is initially made small, also in the transverse direction. Then the surgeon, using his index fingers, carefully stretches the incision to 10-12 cm.

The next and most crucial moment is the extraction of the fetus. The surgeon carefully inserts his hand into the uterine cavity and brings out the fetal head, and then removes the entire baby. Afterwards the umbilical cord is cut and the baby is transferred pediatrician and a nurse.

The placenta with membranes (afterbirth) is removed from the uterus, the uterine incision is carefully sutured, the surgeon checks the condition of the abdominal cavity and gradually sutures its wall.

Which unpleasant moments possible after surgery?

There may be unpleasant sensations during recovery from anesthesia (and even then not for everyone). This may include nausea, dizziness, and headaches. In addition, the surgical wound can also be a source pain at first time. The doctor usually prescribes medications that reduce or eliminate pain (taking into account the effect of the medications on the newborn if the mother is breastfeeding).

Troubles can also include the need bed rest at first (1-2 days, on the 3rd day after surgery you are allowed to walk), the need to urinate through a catheter inserted into the bladder (not for long), a larger than usual number of prescribed medications and tests, constipation and some hygienic restrictions - wet toilet instead of a full shower (before the stitches are removed).

What is the difference postpartum period for women after caesarean section?

Mainly because it will take longer for a woman to feel like she did before pregnancy, as well as the sensations and problems associated with the post-operative scar.

These patients require more rest and help with household chores and with the baby, especially in the first week after discharge, so it is helpful to think about this in advance and ask family members for help. For discharge of special pain in the area postoperative suture must not be.

The incision area may be tender for a few weeks after surgery, but this will gradually subside. After discharge, you can take a shower and you should not be afraid to wash the seam (followed by treating it with brilliant green).

During the healing process of the suture, a tingling sensation, skin tightening or itching may occur. These are normal sensations that are part of the healing process and will gradually disappear.

For several months after surgery, a feeling of numbness in the skin in the scar area may persist. If you experience severe pain, redness of the scar, or brownish, yellow or bloody discharge from the suture, you should consult a doctor.

Complications after cesarean section and their treatment

Peritonitis after cesarean section occurs in 4.6 - 7% of cases. Mortality from peritonitis and sepsis after cesarean section is 26 - 45%. The development of peritonitis causes infection of the abdominal cavity (from complications of cesarean section - chorioamnionitis, endometritis, suture suppuration, acute inflammatory processes in the appendages, infections penetrated by hematogenous or lymphogenous route - with paratonsillar abscess, with soft tan abscess, pyelonephritis).

Risk factors for the development of sepsis and peritonitis are similar in clinical features and management tactics:

• spicy infectious diseases during pregnancy
• chronic infectious diseases and existing foci of chronic infection.
• All vaginosis (nonspecific) and specific colpitis.
• Age: under 16 and over 35 years old.
• A long period without water (more than 12 hours), that is, an untimely cesarean section.
• Frequent vaginal examinations (more than 4).
• Peritonitis after chorioamnionitis or endometritis during childbirth

Therapy program and treatment

Diagnosis is always late, as is treatment. Developed tactics of surgical treatment (with removal of the uterus, since this is the primary source of peritonitis). The operation is most often performed on days 9-15; operations are rarely performed on days 4-6. Severity should be assessed by the progression of symptoms.

Treatment

1. Surgical intervention. The sooner it starts surgery Once the diagnosis of peritonitis is made, the fewer organ disorders will be observed after surgery. Removal of an organ as a source of infection (uterus with peritonitis after cesarean section) is etiologically targeted. The uterus and tubes are removed, the ovary is usually left if it is not in them inflammatory phenomena. Hysterectomy is more often performed than amputation. The lower segment is close to the cervix, therefore supravaginal hysterectomy is performed with removal fallopian tubes with revision of the abdominal organs.
2. Antibiotic therapy: cephalosporins and antibiotics acting on gram-negative microorganisms - gentamicin in maximum doses, preferably intravenously. Metronidazole drugs - metragil intravenously (acts on gram-negative flora, fungal flora). The spectrum of sensitivity of microorganisms to antibiotics must be done.
3. Treatment and relief intoxication syndrome. Infusion therapy with drugs that have detoxification properties: rheopolyglucin, lactasol, colloidal solutions. The administration of solutions improves the patient's condition. Also prescribed are drugs that increase the oncotic pressure of the blood - plasma, aminokrovin, protein preparations, amino acid solutions. The amount of liquid is 4-5 liters. Therapy is carried out under the control of diuresis.
4. Restoration of intestinal motility: all infusion therapy with crystalloid solutions and antibiotics improve motility. They also use drugs that stimulate intestinal motility (cleansing, hypertensive enemas), antiemetics, prozerin subcutaneously, intravenously; oxybarotherapy). The first 3 days should be a constant activation of intestinal motility.
5. Antianemic therapy - fractional blood transfusion (preferably warm donor blood), antianemic drugs.
6. Stimulation of immunity - the use of immunomodulators - timolin, complex, vitamins, ultraviolet radiation of the blood, laser irradiation blood.
7. Care and fight against physical inactivity are important, parenteral nutrition, then complete enteral nutrition - high-calorie, fortified - dried apricots, cottage cheese, raisins, dairy products. The fight against physical inactivity involves breathing exercises, early turning in bed, massage

Childbirth using a cesarean section is the current way of bringing a child into the world today. Despite the fact that this practice has many disadvantages (for example, low adaptability of the newborn to external environment, heavy recovery period for the mother), in some cases it is irreplaceable. We are talking about situations where, without surgical intervention the mother and/or her baby will inevitably die. We'll talk about indications for caesarean section later.

Natural childbirth has always been and will be a priority: according to nature’s plan, only two people should participate in the birth of a new life - mother and 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 reliably known that the practice of dissecting the anterior wall of the abdomen for obstetrics began to be mastered in the distant past. From myths Ancient Greece It is known that Asclepius and Dionysus were born artificially when their mothers died during childbirth. Up to the 16th century. This method of delivery was called a Caesarean operation, and the term we are familiar with appeared only in 1598.

You can often hear this operation called a 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 surgery is resorted to mainly when it is not possible to give birth naturally, many women ask doctors whether it is possible to use a cesarean section without indications.

In some European countries, a woman independently decides how she will give birth. In Russia, doctors insist on the need to perform a caesarean section only when indicated, but there is no official law that would prohibit “abuse” of the surgical procedure in the absence of compelling reasons. This may be why some expectant mothers choose this particular method of delivery.

List of indications for caesarean section

The grounds for carrying out an 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;
• about relative indications we're talking about, when a woman can give birth to a baby herself, but the risk of developing certain complications still exists. Then doctors weigh the pros and cons, after which they make a final decision on the method of delivery.

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

Absolute indications for caesarean section

Many factors can be identified as indications for elective caesarean.

Too narrow pelvic bone.

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

As a result of pushing, a woman in labor with a narrow pelvis may experience:

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

Covering the internal os with the placenta.

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

Premature abruption of a normally located placenta.

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

Uterine rupture.

In this dangerous situation, the answer to the question of why a cesarean section is performed becomes obvious. Without surgical intervention, both mother and child will die. The cause of uterine rupture can be a large fetus, the actions of an inexperienced obstetrician, or improper distribution of the force with which the expectant mother pushes.

Incorrect suturing.

When after any surgery An irregular scar remains on the uterus, and a caesarean section is performed for delivery. The characteristics of the scar are learned during an ultrasound.

Two or more scars on the uterus.

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

Unsuccessful treatment of seizures.

With late toxicosis, in some cases convulsions occur, which drive the woman into coma. If therapy for this condition is unsuccessful, an emergency caesarean section is performed within two hours, otherwise the woman in labor will die along with the child.

Serious illnesses during pregnancy.

We list in which cases a caesarean section is performed:

• heart disease;
• diseases of the nervous system in an acute stage;
• diseases thyroid gland with severe course;
• diseases associated with blood pressure disorders;
• 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 obstruction of the birth canal, the child is deprived of the opportunity to move forward, and therefore needs outside help. This situation is most often caused by the presence of tumors in the pelvic organs blocking the birth canal.

Late pregnancy.

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

Relative indications for caesarean section

• Narrow pelvis.

This reason for performing a cesarean section is discovered 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 is too weak.

• Divergence of the pelvic bones.

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

• Weak labor.

When a woman in labor has little labor power, her amniotic sac is artificially punctured to stimulate the process. However, if even such a measure is not enough to activate natural delivery, a decision is made to perform a cesarean section. This the only way out, otherwise the child will suffocate or get serious injury in childbirth.

• Post-term pregnancy.

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

• Pregnancy after artificial insemination or long-term infertility.

If a woman, after numerous unsuccessful attempts manages to get pregnant and carry a child, she passes full diagnostics indications so that doctors can make a verdict on the method of delivery. If the woman has a history of abortion, stillbirth, or miscarriage, she will have a caesarean section.

• Hypoxia or intrauterine growth retardation.

In this case, the expectant mother will also have to undergo surgery. The question of how long a planned cesarean section is performed for such indications depends on how long the child did not receive sufficient oxygen and whether this problem was solved with the help of drug treatment.

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

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

Reasons for cesarean section dictated by the interests of the child

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

• incorrect position of the baby. If the baby is positioned head down towards pelvic bones moms - everything is fine. 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 that is not yet dilated, boys can crush the testicles, which will lead to infertility. The baby's head will also suffer from excessive pressure;
• hypoxia. If oxygen deficiency is diagnosed, immediate surgery is indicated, otherwise contractions will only worsen the baby’s well-being, and he may suffocate;
• umbilical cord prolapse. With this pathology, the loops of the umbilical cord often wrap around the baby so tightly that he dies from suffocation. Only an emergency caesarean section will correct the situation, 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 continues for some time, then an operation is performed to save the baby.

Restrictions on performing a caesarean section

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

• 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 to do a caesarean section

The most optimal time to begin the operation - intensification of labor. In this case, the contractile activity of the uterus will facilitate the manipulations of specialists and will help the baby adapt to external conditions. irritating factors. At what stage a planned caesarean section is performed depends mainly on the doctor’s decision, but this does not occur earlier than 37 weeks of pregnancy. Ideally expectant mother admitted to the hospital at 38 weeks of an “interesting” situation.

Almost all artificial birth operations are accompanied by epidural anesthesia. In this case, the analgesic effect extends to bottom part body so that the mother can attach the baby to the breast immediately after his birth. An emergency caesarean section is performed under general anesthesia.

At the moment when the baby is about to be born, the doctor cuts the abdominal wall and uterus of the woman in labor to help him be born. After the baby is removed, the incisions are sutured using a continuous suture and staples are placed on top for security. They are removed 6–7 days after the operation, before sending the happy parents and heir home.

How is a caesarean section performed? Video