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].