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CESAREAN SECTION. PER TEMPUS POSTOPERATIVE

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Keywords
#cesarean section #laparotomy #hysterectomy #peritonitis #cardiac monitoring of fetus #ECF
Information about authors

Nurzhanov Khamit Nurzhanovich, Professor, Academic of the Academy of Sciences of clinical and fundamental medicine of the Republic of Kazakhstan. Obstetrician-gynecologist of the highest category. The gold doctor. Labor veteran. Honored worker of education and science of the Russian Federation. Member of the editorial Board of the Republican magazine "Densaulyk", member of the terminology Committee of the Ministry of Health of the Republic of Kazakhstan. Public figure. Professor of Department of Obstetrics-Gynecology

SUC on BL "Center of Perinatology and Pediatric Cardiac Surgery"

(050060, Republic of Kazakhstan, Almaty, 2a Basenova St., e-mail: beibars.ata@mail.ru);

Arystanova Ardak Nurlanovna, Intern student

"Kazakhstan-Russian Medical University"

(050000, Republic of Kazakhstan, Almaty, Abylai Khan str. 51/53, e-mail: ardakaristanova447@gmail.com);

Sakiyeva Ayim Muratovna, Intern student

"Kazakhstan-Russian Medical University"

(050000, Republic of Kazakhstan, Almaty, Abylai Khan str. 51/53, e-mail: ardakaristanova447@gmail.com).

Introduction

Caesarean section (caesarean section) is a surgical operation in which the fetus and the placenta are removed through an incision in the abdominal wall (laparotomy) and uterus (hysterotomy), and the integrity of the uterus and abdominal wall is restored [1].

History reference.

There are conflicting opinions about the origin of the name of the operation. According to one version, the operation got its name in honor of Guy Julius Caesar, which was extracted abdominally, for which he received the name Caesar [2].

In modern obstetrics, CS is of great importance, since with a complicated course of pregnancy and childbirth, it allows you to save the health and life of the mother and child. CS, like any surgical intervention, can have adverse consequences both in the immediate postoperative period (bleeding, infection, pulmonary embolism (pulmonary embolism), embolism, peritonitis), and in long periods of a woman's life. Despite the use of high-quality suture material, complications of the operation in the mother continue to be recorded. CS can affect the further reproductive function of women: it is possible to develop infertility, habitual miscarriage, menstrual irregularities, placenta previa, placenta accrete during subsequent pregnancy. CS cannot always maintain the health of the child, especially with deep miscarriage, prolongation, infectious disease of the fetus, severe hypoxia [2,3].

Despite the possible complications of CS, the frequency of this operation is constantly growing throughout the world, which causes reasonable alarm for obstetrician-gynecologists of all countries. CS is performed in cases when delivery through the natural birth canal is impossible or dangerous for the life of the mother or fetus.

Objective reasons for the increase in the number of surgical operations in modern obstetrics are:

  • Decrease in parity (most primiparas);
  • An increase in the number of primiparous older age 30-35 years;
  • History of C-section;
  • The desire to expand indications for CS in the interests of the fetus;
  • An increase in the number of pregnant women with repeated attempts at in vitro fertilization (IVF);
  • Cicatricial changes in the uterine wall after myomectomy;
  • Hyperdiagnosis using additional research methods (fetal CTG, ultrasound, X-ray pelvic geometry).

Classification.

Surgical access for CS is most often abdominal and extremely rare at short gestation - vaginal.

Abdominal cesarean section is usually used for delivery with a viable fetus. It is produced to terminate a pregnancy for medical reasons in a short time (17-22 weeks), and then it is called a small caesarean section.

Depending on the location of the incision on the uterus, currently distinguish:

  • Corporeal (classical) CS - a section along the midline in the body of the uterus;
  • Isthmic-corporal - a section along the midline of the uterus, partly in the lower segment, partly in the body of the uterus;
  • Bottom CS - a section along the midline in the bottom of the uterus with a transition from the front wall to the back;
  • In the lower segment of the uterus, a transverse section with the opening of the vesicoureteral fold;
  • In the lower segment of the uterus, a transverse section without opening the vesicoureteral fold.

The most rational method of CS in the whole world is considered to be a transverse incision in the lower segment of the uterus.

Many obstetrician-gynecologists suggest that if there are indications for CS during pregnancy, it is preferable to carry out the operation in a planned manner, since it is proved that the number of complications for the mother and fetus is significantly less than those who underwent emergency interventions. But planned CS cannot prevent the negative impact of antenatal factors leading to the development of hypoxia or infection in the fetus, as well as a violation of the surgical technique of performing CS, can lead to trauma to the fetus during extraction. CS can also be performed on the basis of the testimony. These include a combination of postponed pregnancy and the unpreparedness of the birth canal, the age of the primiparous over 35 years and the large size of the fetus or previous prolonged infertility and pelvic presentation, etc.

Currently, the world is discussing the question of conducting CS at the request of a woman due to various motivations (fear of trauma to the child during childbirth, reluctance to experience pain during childbirth, changes in the anatomy and function of the genital organs after the spontaneous birth). Here it is necessary to explain to patients about the feasibility and benefits of natural childbirth, the doctor should make every effort to avoid delivering by CS at the request of the woman [4].

A special role in the outcome of CS for the mother and fetus is played by the determination of contraindications and conditions of operative delivery.

Contraindications:

1. Intrauterine death of the fetus or deformity incompatible with life;

2. Fetal hypoxia in the absence of urgent indications on the part of the mother, if there is no certainty in the birth of a living (single heartbeat) and a viable child.

With vital indications by the mother, the listed contraindications do not take into account.

Conditions for the CS:

1. A living and viable fetus. In the event of a threat to the life of a woman (bleeding during placenta previa, abruptio placentae, uterine rupture, neglected lateral position of the fetus, etc.), CS is also performed with a dead and nonviable fetus;

2. The consent of the patient to the operation. You must sign an informed consent for the operation [5].

Cesarean section technique.

CS is performed in an operating room by a specialist who knows the technique of abdominal gluttony in compliance with the rules of asepsis and antiseptics. During the operation, a neonatologist and, if necessary, a pediatric resuscitator should be present.

To produce CS, 4 methods of opening the anterior abdominal wall can be used (Figure 1):

  • Lower middle section, line a;
  • Lower-middle section with a detour;
  • Pfannenstiel section, line b;
  • Joel-Cohen section, line c [6].

Suturing of the uterine wound after cesarean section.

The technique of suturing the uterus and suture material (synthetic absorbable sutures: Vicryl, Dexon, Monocryl or Safil) is very important. Correct comparison of the edges of the wound is one of the conditions for the prevention of infectious complications, the strength of the scar, which prevents rheumatism during subsequent pregnancies and childbirth. Two or one-row muscle sutures are used. In many clinics, it is preferable to suture the incision in the uterus with double-row muscular to muscular of safil or vikryl sutures, while using both separate and continuous sutures.

Many obstetrician-gynecologists prefer to put a continuous single-row suture according to Reverden on the uterine incision. There is an opinion that a continuous suture causes myometrial ischemia, which in the future can lead to the development of scar failure. Therefore, individual seams are applied at a distance of no more than 1 cm [7,8,9].

Purpose

The main purpose of the study is to study the indications and features of delivery by cesarean section and the course of the postoperative period.

Materials and research methods

In 2018, caesarean sections were performed on 1507 women at the Perinatal Center and Pediatric Cardiac Surgery (050060, Republic of Kazakhstan, Almaty, Basenova St., 2a). As can be seen from Table 1, the largest number of women were operated on in August, only 150 women. For a more detailed analysis, we took the birth history of this month.

 

Results and their discussion

1. Over 1 year (Table 1) in the PC and PCS, they delivered under caesarean section (CS) of 1507 pregnant women, they performed surgery more often in the month of August, compared to other months.

2. The majority of women in childbirth were between the ages of 30 and more (64.7%), which indicates an increase in the number of deliveries at an older age. The ethnic composition was dominated by Kazakh women (77.3%). According to the type of activity, among the women permitted by CS, the majority were women who were engaged in household work (60.6%).

3. The overwhelming number of women in labor had a favorable heredity (91.3%), as well as a large number of them with registered marriage (92.0%).

4. A third (30.7%) of pregnant women operated on and had a history of infectious diseases.

5. About 2/3 (62.6%) of the observed women had a history of somatic diseases, 45% of them with urinary tract pathology. In addition, 70% of women in labor underwent various surgical interventions. One third (36.7%) of the operated pregnant women had various gynecological diseases.

6. In 1/4 (26.6%) of pregnant women who underwent surgery, menstrual function began early (from 11-12 years), as well as early (from 15-19 years) sexual life (23.3%). In the majority (80%) - menstrual function went well.

7. Only in 1/5 (18.7%) of women this was the first pregnancy, and the rest were pregnant again, among which 24% of patients had a burdened obstetric history.

8. The overwhelming majority (78%) of pregnant women received birth through “self-treatment”, the rest - by ambulance and only 2% - in the direction of women's consultation.

9. Only half (49.4%) of the pregnant women who were operated were shown planned CS, while the rest were operated on urgently!

10. Basically (98%), operations of CS, according to the technique and duration, were performed according to the generally accepted method, with analgesia, in many cases (91.3%) by spinal anesthesia. In most cases (70%), a continuous single-row suture was applied to the uterus after the incision, and the rest had a double-row suture with vicryl, and, as a rule (95.3%), a cosmetic intradermal suture was applied to the skin.

11. Complications of the operation in the form of hypotonic bleeding were noted only in 1 operated woman in labor.

12. At the end of the surgical intervention, in 100% of the operated joints, the sutures healed by “primary intention”, in almost all (93.3%) the postoperative scar was consistent.

13. The main part of women in labor who underwent surgery of the CS (81.2%) were in a hospital lasting from 4 to 9 days. 7.4% of the women spent more than 13 days, mainly due to problems with children. All examined women in labor, as well as their children were discharged in good condition under the supervision of doctors of the antenatal clinic and local pediatricians of the clinic.

 

Conclusion

According to the indicators of this study, in 149 out of 150 women who underwent cesarean section, the postoperative period was uneventful, and all women in labor, as a result, were safely discharged. But it is worth since at birth, the child must swallow a lot of beneficial bacteria contained in the birth canal. These bacteria create the very basis for the formation of a healthy microbiome. This is a big drawback of the operation, since after the first section of the uterus, without certain indicators, further labor through the vagina is contraindicated. It is also important to remember that any extraneous intervention in the human body, whether it is the operation itself or anesthesia, carries undesirable characteristics. Nature herself came up with the best method of delivery, let’s not argue with her for no good reason!

A WHO spokeswoman, Dr. Marlin Temmerman, says: “Women who have cesarean have a higher risk of bleeding. Also, do not forget about the scars that have remained from previous births that have passed through surgical intervention. Serious complications can occur. And even in some developed countries, where cesarean is often done, a higher level of maternal mortality is registered in comparison with other developed countries. Of course, this operation is not the main cause of death among women in childbirth, but the link certainly exists.”

Conclusions

From year to year, the rate of delivery by Caesarean section around the world tends to increase. At the same time, there is a risk that this phenomenon may persist. Based on our study, more than half of the operated women underwent surgery urgently, and not in a planned manner. That is, interventions, according to certain indications, were forced. This explains to us the importance of planning a pregnancy before it occurs and the careful management of the pregnancy by the doctor and the woman herself. There is also a category of women who have chosen this method of childbirth on their own, because of their fear of the coming torment. In this case, the doctor must explain that there are different methods of relaxation and pain relief during childbirth, as well as invaluable support can be provided by a spouse or partner.

In this regard, it is necessary to develop new ways to reduce the number of operative delivery methods, just as carefully consider the indications for it in each case.

 

References

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2. Radzinsky V.E. Obstetrics. Moscow, publishing group “GEOTAR-Media”; 2008. P. 26-59 (in Russ.).

3. Savelyeva G.M. Obstetrics. Moscow, publishing group “GEOTAR-Media”; 2011. P. 23-45 (in Russ.).

4. Krasnopolsky V.I., Savelyeva G.M. Obstetrics. M.: Medicine; 2000. P. 686-705 (in Russ.).

5. Savelyeva G.M., Karaganova E.Ya., Kurtser M.A. et al. Obstetrics and gynecology. M.: Medicine, 2007 No. 2. P. 3-8 (in Russ.).

6. Grebenkin B.E., Zaplatina V.S., Trouble Yu.V. Cesarean section in modern conditions: obstetrics and gynecology. 2009 No. 2. P. 141-200 (in Russ.).

7. Allen V.M., Basket T.F., O’Connel C.M. Obstetrics and Gynecology. 2010 Jul. Vol.32 # 7. P. 633-641.

8. Clazka A., Farber M.K., Sviggum H., Camann W. Anesthesia. Analgesia. 2013 Nov. Vol. 117 # 5. P. 1187-1189.

9. Kellez D.S. Placenta accreta and percreta. Leydig Journal Of Pathology. 2013. Vol.6. P. 181-197.

 

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