Medical indications for a planned caesarean section. The absolute indications are

It's no secret that a caesarean section is an operation that ends a significant percentage of pregnancies. Some future mothers know in advance that their baby will be born by cesarean, others are preparing for natural childbirth, but problems arise in the process, and an operative outcome becomes the only possible one. A conscientious doctor will not prescribe a caesarean just like that; there must always be good reasons for such an outcome of pregnancy. In this article we will talk about indications and contraindications for caesarean section. Traditionally, indications for CS are divided into absolute and relative indications on the part of the mother and on the part of the fetus. Below are lists of indications for both planned and emergency caesarean sections.

Absolute indications for caesarean section

The decision on the need for a caesarean section in each case is made by the doctor. Despite the unpredictability of the birth process, in a number of situations it is known in advance what to give birth naturally a woman is not allowed, so a planned caesarean section is scheduled. Testimony from mother and child physically making natural childbirth impossible are called absolute.

Absolute indications for caesarean section on the mother's side:

1. Absolutely narrow pelvis - this is a narrowing of the pelvic bones of a woman, through which the child cannot physically pass during natural childbirth. Obstetricians refer to the size of the pelvis as either normal or narrowed. The anatomically narrow pelvis has an objectively reduced size, and natural delivery in such a situation is impossible. Absolutely narrow is the pelvis II-IV degree of narrowing. With III-IV degree, a caesarean section will be planned, and with II degree, the decision will most likely be made already during natural childbirth.

With a normal size of the pelvis or with I degree of narrowing normal delivery are possible, but if a woman is carrying a large child, there is a possibility that her pelvis will be clinically narrow. The dimensions of the pelvic ring in this case simply do not correspond to the dimensions of the fetal head.

Careful measurement of the true dimensions of the pelvis using ultrasound examination and X-ray pelvimetry (radiography of the pelvic bones) allows you to find out whether a woman can give birth herself or whether a planned caesarean section is required.

Even with the normal size of the pelvic ring, the baby may turn incorrectly during childbirth. If a vaginal examination reveals frontal or facial insertion of the head, this means that natural childbirth is not possible, since the head cannot pass through the pelvis with its largest size. This situation is an absolute indication for an emergency caesarean section.

1. Mechanical obstacles for natural delivery (uterine fibroids in the isthmus, ovarian tumors, deformities of the pelvic bones) are also an absolute indication for a planned caesarean section. This factor is usually diagnosed by ultrasound.
2. Threat of uterine rupture exists in women who have already undergone a caesarean section or have a history of any operations on the uterus. The doctor determines the probability of rupture according to the condition of the scar. If it has a thickness of less than 3 mm, uneven contours and inclusions connective tissue, the risk of uterine rupture along this suture is too great for a woman to give birth on her own. For reliability, the scar is examined both before and during childbirth. Additional factors in favor of caesarean are the presence of two or more caesarean sections in the past; severe postoperative period after a previous caesarean elevated temperature, inflammatory processes in the uterus; long healing of the seam on the skin; numerous natural childbirth, thinning the wall of the uterus.

Absolute indications for caesarean section on the part of the fetus:

1. placenta previa - an extremely dangerous situation, which, fortunately, is easy to diagnose during pregnancy with the help of ultrasound. The placenta previa is not attached to the back of the uterus, as it should be, but in its lower third and sometimes even directly above the cervix, thereby blocking the exit for the fetus. Placenta previa can cause severe bleeding that can put both mother and baby at risk. This anomaly, in the absence blood secretions, indicating placental abruption, becomes a diagnosis for a planned caesarean section only on later dates pregnancy. Earlier - there is no need to panic, the placenta can still rise to its normal position.
2. Premature placental abruption - separation of the placenta before the onset of labor or during their process is dangerous for both the woman (profuse blood loss) and the fetus (acute hypoxia). It is an absolute indication for an emergency caesarean section.
3. Cord prolapse can occur during childbirth with polyhydramnios, when a large amount of amniotic fluid is poured out (water is leaving), and the baby's head has not yet been inserted into the small pelvis. The prolapsed umbilical cord is squeezed between the pelvic wall and the head, which means that the blood flow between mother and child is disturbed. If the obstetrician diagnoses such a condition during a vaginal examination after the discharge of water, this is a reason for an emergency caesarean section.
4. Transverse position of the fetus becomes an absolute indication for caesarean section already during childbirth. In a natural way, a child can be born only if he is located with his head or buttocks down, i.e. has head or pelvic presentation. In the transverse position, children of multiparous women most often find themselves (due to weakening of the muscles of the uterus and abdominal wall), also factors contributing to the transverse position of the fetus are placenta previa and polyhydramnios. If the baby does not turn over during labor, even with the help of obstetric manipulations, doctors have no choice but to perform an emergency caesarean section.

Relative indications for caesarean section

The name "relative indications" speaks for itself: they include such conditions in which natural childbirth is physically possible, but has a theoretical risk to the health and even the life of the woman in labor and the baby.

Relative indications for caesarean section on the mother's side:

1. Extragenital pathologies – accompanying illnesses women not related to her gynecological health and pregnancy. The significant stress that a woman in labor experiences during childbirth can cause an exacerbation of existing pathologies that is dangerous for her health. Therefore, doctors attribute a number of diseases to relative indications for a caesarean section:

• cancer of any localization;
• cardiovascular diseases;
• diabetes;
• high myopia with a risk of retinal detachment;
• kidney disease;
• diseases nervous system and a number of others.

In addition, relative indications for caesarean section include diseases that can be transmitted from mother to child during its passage through the birth canal, for example, genital herpes.

1. Preeclampsia of pregnant women is an dangerous pathology that occurs in some women in the second half of pregnancy. With gestosis, the work of the kidneys, blood vessels and brain of the expectant mother is disrupted. This deviation is manifested by high blood pressure, the appearance of protein in the urine, swelling, headaches, flashing "flies" before the eyes, and sometimes convulsions. Preeclampsia in its severe forms (preeclampsia and eclampsia) is a medical indication for emergency caesarean section, because it causes fetal hypoxia.
2. Clinically narrow pelvis - this is a discrepancy between the size of the pelvic ring of a woman and the size of the presenting part of the child (head). In this case, the baby's head does not enter the birth canal with full disclosure of the cervix and the presence of active contractions. The danger of this pathological condition- at risk of uterine rupture, acute fetal hypoxia (which can even lead to his death). The size of the baby's head cannot be absolutely accurately determined before delivery, and in addition, incorrect insertion or distortion of the head is possible, so a clinically narrow pelvis is diagnosed already in the process of childbirth and is an indication for an emergency caesarean section.
3. Woman's age over 30 or 35 and first birth . The dangerous factor in this case is not the age, but the state of health of the woman in labor. It is logical that a 20-25-year-old primipara is likely to be healthier than one who is already 30-35 or more. However, not everything is so simple, and doctors know about it. Age over 35 can only be a relative indication for caesarean section. If a woman is healthy at 35, and the pregnancy is easy and safe, it is likely that she will be able to give birth naturally.
4. Persistent weakness of labor activity . If the natural childbirth that has already begun for some reason has subsided, there is no intensification of contractions or they have completely disappeared, and medical care does not bring results, doctors talk about the persistent weakness of labor activity. If the child suffers at the same time (devices show the presence of hypoxia), a caesarean section will appear to doctors as a more favorable outcome than waiting for the resumption of natural childbirth.
5. Scar on the uterus in itself is only a relative indication for caesarean section. But this is a risk factor for uterine rupture, which the obstetrician always pays attention to. Scars on the uterus are not always associated with a previous caesarean section, they may be the result of an artificial abortion or removal of fibroids. The condition of the scar must be monitored, especially after 36-37 weeks of pregnancy, and if it is complete, the woman has every chance of giving birth naturally.

Relative indications for a planned caesarean section on the part of the child:

1. Breech presentation of the fetus allows a woman to give birth herself, but still it is considered pathological. Natural birth with breech presentation carries the risk of fetal hypoxia and birth trauma. The situation is aggravated if the child is large (more than 3.6 kg), and the mother is the owner of an anatomically narrowed pelvis.
2. large fruit (more than 4 kg) is an indication for caesarean section only if there are other relative indications.
3. Identified chronic or acute fetal hypoxia (oxygen starvation) can serve as a good enough reason for operative delivery. The causes of hypoxia can be different: chronic hypoxia usually caused by gestosis of pregnant women and leads to a delay in the development of the fetus; acute hypoxia may occur during prolonged or, on the contrary, too fast and active labor, with placental abruption or prolapse of the umbilical cord. For diagnostics oxygen starvation, an extremely life-threatening child, is used:

• listening with an obstetric stethoscope,
• Doppler ultrasound (study of blood circulation between the fetus, placenta and uterus),
• cardiotocography (registration of the heartbeat and fetal movements using a special apparatus),
• amnioscopy (examination of amniotic fluid using an optical device).

If hypoxia is detected, and the treatment does not bring results, a decision is made on the need for a caesarean section to preserve the health of the child.

Each of the relative indications separately cannot serve as a reason for prescribing a caesarean section, however, when deciding on the outcome of a pregnancy, the doctor weighs all the pros and cons of each option. If the operation seems to the doctor as a safer way of delivery for the health of the woman and the child, the choice will be made in her favor, taking into account only relative indications. In addition, there are so-called combined indications for caesarean section. They are a combination of factors, each of which is not in itself an indication for caesarean section, but together they turn into real threat life and health in natural childbirth. For example, this is a post-term pregnancy and identified hypoxia; large fetus and breech presentation; over 35 years of age and a serious illness.

Conditions for a caesarean section

A caesarean section can only be performed if a number of conditions are met. These include:

• fetal viability;
• the consent of the woman or her legal representatives(relatives) for surgery;
• availability of an operating room equipped with all necessary instruments and a qualified surgeon;
• no infections.

Contraindications for caesarean section

Like any operation, caesarean section has a number of possible contraindications. However, they are not absolute, since the reasons for the operation are usually quite good. Surgical delivery is undesirable in the following cases:

• the possibility of purulent-septic complications in a woman in the postoperative period;
• intrauterine fetal death;
• the presence of deformities and malformations in the fetus that are incompatible with life;
• deep prematurity of the fetus (respectively, its non-viability outside the uterus);
• prolonged severe fetal hypoxia, when it is no longer possible to deny the possibility of stillbirth or death of the newborn.

With the probability of fetal death, the choice of the method of delivery is aimed primarily at preserving the life and health of the woman. The operation, especially in the presence of risk factors, can cause infectious and septic complications (inflammation of the uterus or appendages, purulent peritonitis - acute inflammation in the peritoneum), as the dead fetus becomes a focus of infection.

Doctors identify the following risk factors for the development of purulent-septic complications:

1. A variety of immunodeficiency states (HIV, weakened immunity after taking potent medicines and etc.).
2. The presence of an infectious disease in a woman in acute or chronic form(inflammatory processes in the appendages, caries, chronic pyelonephritis, cholecystitis, upper respiratory infections, etc.).
3. Gynecological diseases and complications of pregnancy that worsen blood microcirculation (gestosis of pregnant women, anemia, hypotension and hypertension, etc.).
4. The duration of labor is more than 12 hours or the anhydrous period (after the discharge of amniotic fluid) is more than 6 hours.
5. Significant blood loss, not replenished in a timely manner.
6. High frequency of vaginal (especially instrumental) studies.
7. The presence of a corporal incision on the uterus (across the muscle fibers).
8. Unfavorable infectious environment in the hospital.

However, in the presence of absolute indications for caesarean section, even with acute infectious process, threatening septic complications, the woman should still be operated on. Until recently, in such a situation, only one option was possible - fetal extraction with simultaneous removal of the uterus in order to avoid purulent peritonitis. However, now there is a more favorable technique that allows you to save the uterus - caesarean section with temporary isolation abdominal cavity(extraperitoneal caesarean section).

Myths about caesarean section

AT modern medicine Unfortunately, there has been a dangerous trend towards an increase in the number of caesarean sections. This is especially true for developed, prosperous countries. Some women really dream of a caesarean as an easy way to deliver. The reason for this attitude is ignorance or misunderstanding of what a caesarean section is. Let's dispel popular myths about this operation:

1. It is painless, unlike natural childbirth . Not true. A caesarean section is an operation during which several layers of tissue are cut. Yes, general anesthesia or epidural anesthesia “turn off” the pain during the operation (by the way, not always completely). But after recovering from anesthesia pain in the suture area can make the postoperative period, especially its first days, completely unbearable. But you need to get up to go to the shower and toilet, and take care of the baby - feed, take him in your arms. Some women experience pain for several months.

2. It's even better for the baby - he does not need to pass through the tight birth canal, risking birth trauma. Absolute delusion. Babies born by caesarean section are traumatized by default. Neurologists always refer them to the risk group for speech disorders and other developmental delays. Nature created the mechanism of natural childbirth for a reason. A sharp change in the process of pressure acting on the child during the operation, the effect of anesthesia, the baby's passivity in the birth process, less contact with the mother due to restrictions after cesarean, a high probability of artificial feeding - all this cannot but affect the child's adaptation to the environment. It is more difficult for him to learn to scream, breathe, suck. There is no way to talk about any advantages of a caesarean section for a baby (unless, of course, we are talking about saving life and health).

3. At 30 or 35, health is no longer good enough to give birth on your own, especially for the first time. . This is not true. Age is only a relative indication for caesarean section, which cannot be decisive. The doctor must take into account the state of health of a particular patient, and not her passport age.

4. After caesarean - always caesarean . The presence of a scar on the uterus from a previous delivery operation also refers to relative indications for caesarean section. Modern diagnostics allows you to establish the viability of the scar and predict the possibility of natural childbirth.

As you can see, a caesarean section is not something to strive for at any cost. However, if there are indications for surgery, there is no need to panic. The method of delivery is undoubtedly important, but it is even more important that the mother and the newborn baby are alive and well. This is what should be the priority goal of the doctor who prescribes you a caesarean section or gives you the go-ahead for natural childbirth. We wish you good health and a happy meeting with your baby soon!

The pinnacle of modern obstetrics is the completion of childbirth and the birth of a child through surgical intervention - a caesarean section.

Historians have established that the origin of this operation has a direct connection with the times of antiquity, but only now this type of childbirth is often a salvation, both for the woman in labor and for the child.

A significant number of indications for caesarean section today is due to the high risk of resolution from the burden of the expectant mother by the vaginal route.

Of course, abdominal delivery, like other interventions of surgeons, hides a huge number of possible complications/consequences, however, their occurrence is extremely rare, and the scales are tipped in the direction of the birth of a live child and the saved life of the mother, and not potential complications.

The history of the name of the operation is overgrown with a huge number of legends and myths. The most significant is the story of the birth of Gaius Julius Caesar, the autocrat of the Roman Empire. The death of Caesar's mother during childbirth caused his father to cut the woman's womb with a sword and extract his son. Hence the saying: "Caesar's is Caesar's."

Conditions for the operation

A caesarean section can be elective, scheduled, or emergency. They talk about a planned delivery operation when it is performed 6 to 15 days before the date of the expected birth with existing maternal and / or fetal indications and the absence of the first manifestations of labor activity (see).

A planned operation means that the indications for it are known in advance, often in the first weeks and even days of bearing the unborn baby. The need for an emergency emergency section arises due to urgent, immediate, approximately within one to two hours of delivery and is mainly indicated in the process independent childbirth. They talk about a planned caesarean section when labor has just begun or amniotic fluid has poured out prematurely, but there are relative indications for surgery. That is, a woman is allowed into childbirth, but according to the plan of childbirth, they end up with an operation.

So, the necessary factors for surgical method delivery:

• the presence of a living fetus capable of existing outside the womb (considered a relative condition, since under some circumstances the operation is done in the interests of a woman in order to save her life);
• written consent of the woman in labor for a caesarean section;
• an empty bladder (it is desirable to install an indwelling catheter);
• there are no signs of infection during childbirth (also a very conditional indication);
• the presence of an experienced obstetrician-surgeon and operating room.

What are the indications for surgery?

All the reasons that lead to abdominal delivery can be divided into two subgroups.

• Absolute indications literally force the doctor to give birth to a woman by surgery, that is, one cannot do without surgery.
• They talk about relative indications when the situation is analyzed by a council of doctors and a conclusion is approved on one or another way to complete the birth. That is, a woman can give birth on her own, but the likely risks for her, as well as the baby, are taken into account.

In addition, there are factors that lead to forced surgery during pregnancy or directly in the process of childbirth. Another gradation of indications for operative delivery is their division into maternal and fetal factors.

Abdominal delivery: absolute indications

Factors on the part of the mother, in the presence of which it is impossible to do without a caesarean section, include:

Anatomically narrow pelvis (the degree of narrowing is taken into account, that is, 3-4, in which the true conjugate is 9 cm or less)

The narrow pelvis is divided into 2 groups according to the shape of the narrowing.

• The first group includes: a transversely narrowed pelvis, a flat pelvis (a simple flat pelvis, flat rachitic and a pelvis with a decrease in the wide part of the cavity), and, of course, a generally uniformly narrowed pelvis. These are quite common forms of pelvic narrowing.
• The second group (rare forms) includes oblique pelvis, oblique pelvis, pelvic deformity due to bone exostoses, bone tumors or fractures, kyphotic pelvis, funnel-shaped pelvis and other types of narrow pelvises.

An anatomically narrow pelvis with grade 3 or 4 can complicate the course of childbirth. During contractions, almost 40% of women in labor experience:

• weakness uterine contractions ()
• early outpouring of water
• possible prolapse of the umbilical cord or arms / legs of the fetus
• development of chorioamnionitis, endometritis and infection of the unborn baby
• as well as intrauterine fetal hypoxia

During the straining period, the following complications may occur:

• secondary weakness of attempts
• intrauterine hypoxia of the child
• uterine rupture
• tissue necrosis with the formation of genitourinary fistulas, intestinal fistulas
• trauma of the pelvic joints and nerve plexuses
• and if childbirth reaches the third stage, then subsequent and / or postpartum hemorrhage cannot be avoided.

Complete placenta previa

As you know, the placenta is the organ that communicates between the organisms of the mother and child. In a normal pregnancy, the placenta is located either in the fundus of the uterus, or along the anterior or back wall. If the placenta is in lower segment of the fetus, and completely covers the internal pharynx, it becomes clear that the exit of the child from the mother's womb in a natural way becomes impossible. Moreover, placenta previa is potential threat not only for the unborn baby, but also for his mother during the entire period of pregnancy, because bleeding can open at any moment, the intensity and duration of which cannot be predicted.

Case Study: I have been observed by a woman of 38 years from the very beginning of pregnancy. Pregnancy was not the first, but very desirable. Despite the absence of any aggravating circumstances in her history, her placenta formed in the lower third of the uterus and blocked the internal os (full presentation). The woman was on sick leave for almost the entire pregnancy, under the supervision of doctors, she did not have a single bleeding. She successfully reached 37 weeks and was admitted to the pathology ward to prepare for a planned caesarean. Well, as usual, for some reason (or maybe fortunately) she began to bleed in the hospital and on the day off. Of course, we immediately went for an immediate cesarean, there was no time to lose. Like this planned operation turned into an emergency - the child was born healthy and with normal weight.

Incomplete placenta previa with severe bleeding

An incomplete placenta previa is said to occur when the latter only partially covers the internal os. Distinguish marginal presentation and lateral.

• With the marginal location of the placenta, it only slightly affects the internal pharynx
• Whereas with the side it overlaps by half or 2/3 of the diameter.

Incomplete placenta previa also threatens with sudden bleeding, the massiveness of which is difficult to predict. The peculiarity of this localization of the placenta is interesting in that spotting often appears during contractions, because it is at this time that the internal pharynx opens, and the placenta gradually exfoliates. The indication for urgent surgery with incomplete presentation is massive blood loss, which poses a danger to the life and health of the mother and child.

Premature detachment of a normally located placenta

Both during the period of expectation of the child, and during contractions (usually). The danger of this condition also lies in the occurrence of bleeding, which is external (that is, visible) - there are bloody discharges from the vagina, internal or hidden (blood accumulates between the placenta and the uterine wall, forming a retroplacental hematoma, and mixed (there is both visible and latent bleeding) Depending on the area of ​​placental abruption, there are 3 degrees of severity.In moderate and, of course, severe degrees, it is necessary to deliver the woman in labor as soon as possible, otherwise you can lose not only the baby, but also the mother.

Threatening or incipient uterine rupture

There are a lot of reasons leading to the threat of uterine rupture. This may be the wrong conduct of childbirth, discoordination of tribal forces, and much more. In case of absence timely treatment(massive tocolysis, that is, relief of uterine contractions), a threat or a rupture that has begun will very quickly turn into an accomplished, that is, a completed rupture, while both “participants” in childbirth, a woman and an unborn child, die.

Incompetent scar on the uterus

Seam on uterine wall happens not only after abdominal delivery, but also after other gynecological operations (for example, conservative myomectomy). The usefulness of the scar is determined by ultrasound, and the thickness of the scarred surface should reach 3 mm or more, the contours of the scar are even in the absence of connective tissue. If there was a complicated course in the postoperative period (for example, fever, endometritis, or prolonged healing of skin sutures) in the anamnesis, this indicates an inferiority of the scar.

Two or more scars on the uterus

If there are two or more caesarean sections in the anamnesis, the question of self-delivery is not worth it, since such a condition of the uterus significantly increases the risk of rupture along the scar.

Severe forms of preeclampsia in the absence of a positive effect from therapy and unfinished birth canal

Eclampsia (convulsive seizure) may end lethal outcome for a woman and for her child (see). So given state requires immediate relief from the burden. Exactly 2 hours are allotted for the treatment of preeclampsia (preconvulsive stage), if there is no effect, they proceed to an immediate operation. Nephropathy of severe and moderate degree should be treated for no more than two weeks, after which the issue of surgery is decided.

Severe extragenital diseases

The list of indications for surgery includes:

• heart disease in the stage of decompensation
• pathology of the nervous system
• severe thyroid disease
• diabetes
• hypertension and more

A caesarean section for vision is performed in cases of myopia of the 3rd degree (6 or more), complicated myopia, vision surgeries, etc. At poor eyesight it is necessary to exclude the period of attempts, since significant physical activity can lead to retinal detachment and blindness of a woman.

Anomalies in the structure of the uterus and vagina

In the presence of these defects, the contractile activity of the uterus is disrupted, and the fetus is not able to pass through the birth canal on its own during childbirth.

• Tumors of the cervix, ovaries and other pelvic organs
• Such tumors close the birth canal and create an obstacle for the baby to come out into the world.
• extragenital cancer and malignant tumor cervix
• Age primiparous

The indication for caesarean section by age (over 30 years) should be combined with obstetric pathology and extragenital diseases. In age-related primiparas, the elasticity of the muscles of the vagina is reduced and pelvic floor, so the risk of perineal ruptures is high. In addition, such women in labor often develop anomalies of the birth forces that are not stopped by therapy.

Fetal factors requiring operative delivery:

• Malposition

At normal pregnancy the fetus should be located longitudinally, head towards the small pelvis. O wrong position the unborn child is said when he lies obliquely, transversely, or the pelvic end is presented. Caesarean section for breech presentation carried out with a child weighing more than 3600 gr. or less than 1500 gr., as well as with a male fetus (compression of the testicles at birth of the pelvic end can cause infertility in a boy). Breech presentation (legs, pelvic end present) requires surgery, because the baby's head is larger than the pelvic end, and at the birth of the latter, the birth canal is not sufficiently dilated for unhindered advancement and birth of the head.

Example from practice: AT maternity ward A woman with strong contractions arrived at night. The birth was the third, but she never had an ultrasound during the entire pregnancy. During the vaginal examination, I found that the legs are present, the opening of the cervical canal is 5 cm, and this is an absolute indication for delivery through surgery. When I cut open the uterus and removed the fetus, I was dumbfounded - the fetus was anencephalic with a split spine in cervical region(congenital deformity). Of course, he died immediately after cutting the umbilical cord. On the one hand, an operation with such an anomaly of development is contraindicated, but on the other hand, who knew if the woman was not examined?

• Acute fetal hypoxia

This condition means that the child suffers in utero, he does not receive enough oxygen, and each contraction exacerbates hypoxia. There is only one treatment - immediate delivery.

Case Study: This was my first independent caesarean after my internship. I spent the whole night fiddling with a primiparous woman, and in the morning I heard with my “ear” that the child was suffering - the heartbeat was slow and muffled, bradycardia. And we didn’t have a CTG (cardiotocograph) then, there’s nothing to check on. I went for the surgery at my own risk. And on time, as she took out the child, who did not even squeak and did not move his arms and legs. In my youth, I decided that he had died, but, fortunately, the child then recovered and was discharged healthy with his mother.

• Presentation/prolapse of the umbilical cord

In this situation, the operation must be done immediately, since the dropped loop is pinched by the presenting part of the baby in the small pelvis, as a result of which the fetus is deprived of oxygen. Unfortunately, it is very rare to have time to operate on a woman and save a child.

• The death of a woman with a live fetus

In cases of continued agony, the child remains alive for some time and can be saved by abdominal delivery. The operation in such a situation is carried out in the interests of the fetus.

Relative readings

Maternal factors in which the issue of the need for abdominal delivery is decided (relative):

• Clinically narrow pelvis

A similar diagnosis is made during childbirth and means that the head of the fetus does not correspond to the size of the woman's pelvis (the entrance to the small pelvis smaller head). The reasons for the development of such a situation are numerous: a large fetus, discoordination of tribal forces, improper insertion of the head, weakness of contractions, and so on.

• Divergence of the pubic joint

During the gestation of the fetus long before childbirth (observed both 2 weeks and 12), a woman may experience a divergence of the symphysis or pubic joint. This pathology is characterized by pain in the area of ​​the symphysis and when probing the pubis, clicking during palpation of the joint, edema is formed above the womb and swelling of the pubis.

The pregnant woman notes discomfort when walking, getting up from a low chair or bed, climbing stairs. The woman's gait also changes, she becomes like a duck, waddling. During palpation of the pubic joint, a cavity is found, where the pad of the fingers fits freely. If the diagnosis is confirmed by ultrasound (radiography of the pelvis is harmful to the fetus), the woman is prescribed bed rest, limitation of physical work and wearing a corset.

When the divergence of the pubic articulation is 10 mm or more, especially if the estimated fetal weight reaches 3800 g. and more, there is an anatomical narrowing of the pelvis, then the woman is prepared for a planned abdominal delivery in order to prevent rupture of the pubic symphysis during independent childbirth.

• Weakness of tribal forces

When it is not possible to stimulate labor by opening the fetal bladder to reduce intrauterine volume and administering oxytocin, it is necessary to end the birth by caesarean section. Weakness of labor forces leads to fetal hypoxia, postpartum hemorrhage and birth trauma.

• Postterm pregnancy

When the issue of abdominal delivery during a post-term pregnancy is being decided, the ability of the head to be configured in childbirth, the intensity of contractions and aggravating factors (presence of extragenital diseases and gynecological pathology, no effect of labor induction, etc.).

• ECO, artificial insemination or

This indication must be combined with a complicated obstetric and gynecological history (), stillbirth, gynecological diseases, etc.).

• Chronic fetal hypoxia, intrauterine growth retardation

Considering that the fetus did not receive enough oxygen throughout the pregnancy and nutrients, and the treatment turned out to be ineffective, the question of operative delivery before the term for the benefit of the child is raised.

• Hemolytic disease of the fetus

A caesarean section for this indication is performed in the presence of an unprepared (immature) cervix.

• large fruit

They talk about a large fetus when its estimated weight exceeds 4 kg, and about a giant one, if the mass reaches 5 or more kg. Childbirth ends with an operation with existing concomitant pathology (complications in childbirth, gynecological problems and extragenital diseases).

• Multiple pregnancy

Abdominal delivery is performed with the presentation of the pelvic end of the first fetus or in the presence of three or more fetuses.

• Significant varicose veins in the vulva and vagina

There is a certain risk of damage to varicose veins in the pressing period, which is fraught with intense bleeding.

• Pregnant woman's request for surgery

In the West, for example, in England, the expectant mother has the freedom to choose the delivery. That is, it is possible to deliver a pregnant woman by caesarean section at her request. In Russia, this indication is not officially recognized, but there are no documents prohibiting abdominal delivery at the request of the pregnant woman. As a rule, this indication is combined with other relative indications.

Contraindications for abdominal delivery

All contraindications to caesarean section are relative, since the operation is always performed either in the interests of the mother or in the interests of the baby:

• unfavorable condition of the fetus (death in utero, prematurity of 3-4 degrees, fetal malformations incompatible with life);
• probable or apparent clinical picture infection (long anhydrous interval - over 12 hours);
• prolonged labor (over 24 hours);
• more than 5 vaginal examinations;
• fever during childbirth (chorioamnionitis, etc.);
• unsuccessful attempt at natural delivery (obstetrical forceps, vacuum extraction of the fetus).

Cesarean section. Stages of the operation. New suturing technologies

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

Student: *

Krasnoyarsk 2008

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

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

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

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

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

Classification of indications for caesarean section

A. Absolute readings:

I. Pathology excluding vaginal delivery:

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

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

pelvis with pronounced osteomyelitic changes;

bladder stones blocking the pelvis;

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

pronounced cicatricial narrowing of the cervix and vagina;

complete placenta previa.

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

incomplete placenta previa in the presence of bleeding;

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

transverse and stable oblique position of the fetus;

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

urogenital and enterogenital fistulas in the past and present;

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

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

pronounced varicose veins of the vagina and external genital organs;

threatening uterine rupture;

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

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

B. Relative readings:

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

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

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

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

threatening or beginning fetal hypoxia;

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

pelvic presentation of the fetus;

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

late gestosis mild or medium degree severity, requiring delivery in the absence of conditions for its implementation through the natural birth canal;

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

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

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

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

large fruit;

prolapse of the umbilical cord;

malformations of the uterus;

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

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

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

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

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

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

caesarean section is a more aseptic method of delivery;

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

There is no consensus regarding caesarean section. Some believe that this is a great way to avoid the pain that is natural during spontaneous childbirth, while others are terrified of such a surgical intervention. However, it is worth clarifying that this is, first of all, an operation performed under special anesthesia, which means that there are certain medical indications for a caesarean section, according to which the attending physician prescribes this method of obstetric care to the expectant mother.

2. Indications for caesarean section and on the part of the fetus

2.1. Malposition
2.2. Polyhydramnios or a very small amount of water
2.3. hypoxia
2.4. multiple pregnancy
2.5. placenta previa
2.6. Insufficient incision on the uterus

3. Caesarean section at the request of the woman. Is it possible?
4. Video

These include both indications from the mother and from the fetus.

Mother's testimony

The most common reasons for a caesarean section are the age of the mother and the presence of various diseases.

Age

Today, women who decide to give birth after 27 years of age automatically fall into the risk group (they are sometimes also called “primiparous” or even “old-bearing”). Age itself is, of course, not a fundamental factor for caesarean section.

Weak vision

But if we add to it, for example, problems with vision, then - yes, the issue with the operation has been resolved. And if until recently it was believed that a woman whose vision has reached the mark - 5 (nearsightedness) or lower, it is necessary to prepare for surgical intervention, then a number of other indicators related to vision are currently needed: deterioration of the retina (its deformation or detachment), as well as increased eye pressure. With such indicators, even the straining period is prohibited, since in the process of contractions a woman can lose her sight for a certain period of time.

A woman will learn about how she will give birth around 18-20 weeks (if the issue of caesarean section has not been discussed before), when she fills out the “slider”. The doctor must give a conclusion, which will indicate the method of childbirth: natural or through surgery. Throughout pregnancy, the data obtained changes, so it is important to conduct examinations as often as possible.

However, there are a number of other indicators related to the health of the mother and leading to surgical intervention:

narrow pelvis

Because of anatomical features buildings the child will not be able to pass through birth canal; or in the process of childbirth, he may receive injuries that are not compatible with life;

various kinds of "obstacles" - tumors, fibroids, scars from previous operations.

Caesarean section at first birth

By the way, a woman who had previously had a caesarean section reoperation assigned independently of other indicators. In very rare cases, doctors recommend that mommy try to give birth on her own (of course, under the close supervision of doctors), but only if the reason for which a cesarean was performed during a previous pregnancy has been eliminated. More terrible and even deadly is the situation when the uterus can burst - then the operation is inevitable.

Placental abruption

In this case, an emergency caesarean section is always prescribed to help save the mother and child from coma (or death);

prolapse of the umbilical cord into the cervix - fetal hypoxia may occur - the operation is performed on an emergency basis.

if the mother has acute chronic diseases: oncology, neurology, diseases of the kidneys, liver and heart, and especially diabetes;

Large baby weight

Varicose veins

It can also be a reason for a caesarean section, but this disease is considered only in conjunction with other ailments that occur during pregnancy.

Late preeclampsia

Severe edema, protein in the urine, high blood pressure, the appearance of black or white flies before the eyes, headache and sometimes convulsions.

Termination of labor activity

When the child does not move well or does not move at all, and some sexual diseases, for example, genital herpes - in this case, the operation is prescribed to reduce the risk of infection of the newborn (and treatment is already carried out after childbirth).

Indications for caesarean section and on the part of the fetus

Malposition

As a rule, the most likely reason for a caesarean is the breech presentation of the fetus, since during the natural birth, it can suffocate or be injured

Polyhydramnios or a very small amount of water

Not so much clear reason, however, it is taken into account in conjunction with other conditions for the operation;

hypoxia

Oxygen starvation is very dangerous for the development of the child, therefore, if it cannot be treated, then a decision is made on an emergency operation;

various kinds of delays in the development of the child - are detected in the process of ultrasound.

multiple pregnancy

caesarean section is done if the pregnant woman bears 3 or more children.

As a rule, these factors are clarified in advance - during routine examinations and ultrasound. By the way, the identified anomalies can serve as an indication not only for a planned caesarean section, but also for an emergency one.

placenta previa

For example, placenta previa, accompanied by bleeding, can be a serious reason for an unscheduled operation.

Insufficient incision on the uterus

Another one possible reason causing injury in both premature and post-term fetuses (even damage to the spinal cord and brain is possible).

Caesarean section is also performed for mixed indications. In other words, if several conditions specified above are taken, each of which individually is not considered the basis for a caesarean section, and in their totality they will pose a real threat to the life of the mother and child, then the operation is inevitable.

Cesarean section at the request of the woman. Is it possible?

Caesarean section, although it is not the most difficult abdominal operation, but like any surgical intervention be made only if there is evidence, but not at the request of the woman.

And yet, today, more and more often, expectant mothers have a question: is it possible to do a caesarean section at will. There is no single answer to this question. Doctors try to protect the mother's body from the stress and potential risks associated with abdominal surgery.

anesthesia (unpleasant, but tolerable), when you have to get up and wash for the first time after the operation, walk along the corridor and pick up the baby. In addition, there is a possibility of divergence or suppuration of the seam, and no one is immune from the consequences of anesthesia.

Therefore, before the operation, the time of the planned operation is discussed with the woman in labor and all possible complications fixed in writing. In this document, the patients also express their consent to the operation. In the event that the life of a pregnant woman is in danger, for example, she is in unconscious, the caesarean section will be performed with the consent of relatives, or for medical reasons.

In his book "Caesarean section: a safe way out or a threat to the future?" the famous obstetrician Michel Auden analyzes absolute and relative. Relative most often depend on the doctors taking delivery 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 undertake to analyze all possible situations, the information will take up volumes. There are several ways to classify causes for birth" upper way". We will try to separate the absolute and relative indications for surgery.

Absolute indications for caesarean 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 prolapse of the umbilical cord. Sometimes with the outflow of amniotic fluid - spontaneous or after artificial opening of the fetal bladder - the umbilical cord loop can fall through the cervix into the vagina and be outside. At the same time, it can be squeezed, and then the blood stops flowing to the child. This is an undeniable indication for a caesarean section, except in cases where the birth is already at the stage when the baby is about to be born. During term birth in cephalic presentation, prolapse of umbilical cord loops is extremely rare if the fetal bladder is not opened artificially. More often it occurs in preterm labor or during labor in a foot presentation. For a few minutes before an emergency caesarean section, a woman should be in a position on all fours - this will reduce the compression of the umbilical cord.

In the case of complete placenta previa, it is located in the cervix and prevents the baby from leaving. Most vivid 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 a low placement of the placenta is detected in the second trimester of pregnancy, it is very likely that in the remaining weeks it will rise and take a safer position. Talking about placenta previa in the middle of pregnancy is illegal.

Placental abruption can occur both before and during childbirth. This means that the placenta, or a significant part of it, separates from the uterine wall before the baby is born. In typical and obvious cases, there is a 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 occurred, unless the cause is obvious, such as trauma (from a traffic accident or domestic violence) or the development of preeclampsia. In the classic form, when bleeding occurs, overt or hidden (if blood outflow is impossible), by the usual measures emergency care are blood transfusion and immediate operative delivery while the baby is alive. In milder cases, when the placenta exfoliates at the edge, in a small area, painless bleeding usually occurs. Nowadays, such forms of placental abruption are diagnosed using ultrasound. In general, if the doctor suggests a caesarean section due to placental abruption, this indication is better not to discuss. Premature abruption of the placenta is one of the main causes intrauterine death fetus.

Frontal presentation is the position of the fetal head when it is in the middle position between full flexion (common "occipital presentation") and full extension ("face presentation"). The diagnosis of frontal presentation can sometimes be presumably 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 with a vaginal examination: the obstetrician's fingers find the superciliary arches with eye sockets, ears and even the baby's nose. In frontal presentation, the fetal head passes through the pelvis with the largest diameter (from the back of the head to the chin). With continued frontal presentation, the indications for caesarean section are absolute.

The transverse position of the fetus, which is also called brachial presentation, means that the child 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 by the end of pregnancy or at the very beginning of labor. If this does not happen, childbirth through natural routes will not be possible. This is another absolute indication for caesarean section.

Relative indications for caesarean section

Cases when there are absolute indications for caesarean section are extremely rare. More frequent relative readings are highly dependent on factors as diverse as personality, age, and professional experience midwives and doctors; the country where the child is born, the protocols and accepted norms existing in this clinic; character, lifestyle, family environment and circle of friends of the expectant mother; the latest research published in reputable medical journals and media coverage, 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 after a previous caesarean section) is an example of a relative and debatable indication: the rate of operative delivery for this reason has risen and fallen at various points in the history of childbearing. Today, general attention is drawn to the risk of stillbirth for an unexplained reason, although its absolute risk is very small. The presence of a caesarean section in history is such a common situation and so actual problem that we will consider it separately.

"Lack of progress during labor" is often cited as a reason for a first caesarean section. In most cases, the lack of progress in childbirth is due to the widespread misunderstanding of the physiology of childbirth in our time. It will take decades to re-understand that humans are mammals and their key need for childbirth is peace and privacy. It will take decades to understand that the midwife is, first of all, a figure like a mother, that is, a person next to whom you feel safe, who does not scrutinize or criticize us. Under the current circumstances, it would be dangerous to make it a priority to reduce the frequency of caesarean sections. The immediate consequences of this will be an increase in the number of dangerous interventions in vaginal delivery and an increase in the number of newborns in need of pediatric care. In the meantime, we must recognize that in the age of industrialized childbirth, most caesarean sections are quite justified, and the lack of progress in childbirth is the most common indication for surgery.

The discrepancy between the size of the pelvis and the fetal head simply means that the baby's head is too large to pass through the bones of the small pelvis. This is a vague concept, because the correspondence between the size of the baby's head and the mother's pelvis depends to a large extent on the exact position of the head and how it "configures" during childbirth. In the case when a decision is made to perform a caesarean section in childbirth, it can be difficult to distinguish between a mismatch in the size of the pelvis and the head of the fetus from "lack of progress in childbirth": in the same circumstances, a woman can be arbitrarily named either the first or the second as a reason.

Suffering (distress) of the fetus is also a vague concept, since different specialists use different criteria to diagnose this condition. Suffering of the fetus often occurs in the absence of progress in childbirth. As a result, it can be difficult to separate these two indications for caesarean section. Currently, labor induction is one of the main risk factors for the complex of complications that will later be recorded in the history of childbirth as weakness of labor activity, mismatch in the size of the fetal head and mother's pelvis, or fetal distress.

• The best place and environment is one where there is no one but an experienced midwife - motherly, caring and silent, who tries not to attract attention and is not afraid to give birth in a breech presentation.
• The first stage of labor is diagnostic. If it passes easily and without problems, childbirth through natural routes is possible. But if the first stage of childbirth is long and difficult, you should, without delay, perform a caesarean section until the moment when there is no turning back.
• Since the first stage of labor is diagnostic, it is very important not to try to artificially alleviate it, either with drugs or by immersion in water.
• Once the "point of no return" is reached, peace and privacy become the keywords. The most important thing here is to make childbirth as easy and fast as possible. Even listening to your heartbeat can become a harmful, distracting activity. The main goal should be to create conditions for a powerful fetal expulsion reflex.
• In cases of pure breech presentation, you can act more boldly than with other types of breech presentation.

This tactic of conducting labor in the breech presentation can significantly reduce the overall frequency of caesarean section, since breech presentation during full-term pregnancy occurs in 3% of cases.

Now more and more caesarean sections are done in the case of twins. One of the reasons is that in 40% of cases, one of the twins is in a breech presentation, and in 8% of cases, both. Even more often, caesarean section is indicated in cases where one of the children is much larger than the other: this situation is potentially dangerous for a child with a smaller weight, especially if the children are of the same sex. The idea of ​​a planned caesarean section in the case of twins may discourage those who are most concerned about the danger of having a premature baby. Also occasionally there are situations when the second child has to be helped to be born by caesarean section after the first was born naturally. The birth of a second child from twins often seems to be more risky than the first. One reason 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, at least until the second child and the 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 independent triplets are described... including at home after a previous caesarean section!

There is also a trend towards an increase in 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. Between 1994 and 1998, approximately 20% of HIV-infected women had caesarean sections in the United States. In 1998, a study was published that showed that the risk of infection in a child is significantly reduced if vaginal delivery is avoided. After that, between 1998 and 2000, the caesarean section rate in this situation rose 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 the baby during childbirth through natural routes. Often herpetic infection is recurrent. This means that the woman already had exacerbations before pregnancy. In this case, there is almost no risk of infection, since the mother has managed to form antibodies that cross the placenta (IgG), which can protect the baby. The risk is more significant in those rare cases when the primary infection of the mother occurred during pregnancy, when she has time to form only antibodies. class IgM that do not pass through the placenta. In this case, caesarean section can reduce the risk of transmission of the virus.

What about frail babies, especially premature ones, and those who are called "underweight", "out of gestational age"? So much conflicting data has been published that any doctor can always find an article in support of his point of view.

And what about the "special children" who were born as a result of long-term infertility treatment using latest methods artificial insemination? What about other "special" babies born shortly after an unexplained 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 will probably be easier and faster to consider the remaining reasons for deciding to have a vaginal birth than to try to analyze a thousand and one possible indications for a caesarean section.

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

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

Discussion

The third CS was done at the Planning Center by referral and free of charge. The direction was issued in the district consultation, because. the third KS - presentation, ingrowth (was questionable). I came to them for a consultation and immediately after the consultation received a referral for hospitalization. She lay with them for more than 2 months (according to compulsory medical insurance) in anticipation of PCS, but an EX happened.

I did a caesarean in MONIIAG for free, I am very pleased with the quality of the operation. Now I am carrying the second one, the doctors say the seam is very good, they even predict EP this time. The seam did not bother me during the whole pregnancy, soon the birth. But I won't guess. My sister-in-law, almost simultaneously with me, did a COP in Kulakov (her baby is 4 months younger), I was surprised that despite the considerable cost, they saved money on absorbable threads for the outer seam ??, these brackets are not fatal, of course, but unpleasant. I didn’t even think that in our time there are maternity hospitals where stitches are removed. She was in storage in Kulakov, but the birth began spontaneously at night, there was a planned c-section, according to her, the doctors gathered for a long time, about 4 hours after the start of the contractions, she was waiting for the operation. She had a planned due to a stroke that happened during pregnancy, so sitting on contractions in this situation was undesirable.
Also, another friend recommends Sevastopolskaya, she gave birth to 2 children there, she has difficult situation, something with blood incoagulability, says that they helped her very well there. Naturally, it's not free.
I personally didn’t have any indications for copulation, it’s just that the child didn’t want to go out, stimulation didn’t help, she lay with contractions for a long time, weak kind Yes, we decided to have an emergency caesarean. Such a story. I gave birth at the doctor Ketino Nodarovna (I don’t remember her last name, she is Georgian). Here is such a story.

contract and caesarean "at will". I am looking for a doctor with whom I can agree on a planned cesarean without paid services? I have a friend who just gave birth. from indications for caesarean section - 36 years old, first birth ...

Discussion

Doctors tried to persuade me to have a natural birth. But the gynecologist who led advised the same COP. 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 easier for them, as far as I can tell.
I'm pretty pretty that cop. Since after that I had problems and when taking additional tests after childbirth, it turned out that I had some kind of bacterium there, which is completely safe for women and children over 3 months old, but it can be a big problem for newborns .. Like, an analysis is done on it, for example, as planned in America, but we don’t, something like that.
In general, everything is fine with our child, and I am very glad that KC. But I really gave birth late, almost at 40.