Regardless of the direction of the cut, the initial stage classical operation Caesarean section is the release of the lower segment from the peritoneal cover with the formation of a flap of the vesicouterine fold, which is subsequently used for peritonization of the uterine wound. For this purpose, the peritoneum of the vesicouterine fold is grabbed with tweezers at the place of its free mobility (2-3 cm above the place of attachment to the bladder or 1-1.5 cm below the level of its tight attachment to the anterior wall of the uterus), and then with scissors open in the center.
Through the formed hole with scissors, possibly after the preliminary formation of the canal between the peritoneum and the wall of the uterus with their folded branches, the vesicouterine fold is dissected in the transverse direction, almost close to the round ligaments of the uterus.
Opening the peritoneum of the vesicouterine fold with scissors in the transverse direction
The angles of the cut direct the steam upward so that the cut has a semi-lunar shape, convex downwards.
The length of the peritoneal incision should be sufficient, taking into account the subsequent opening of the myometrium and extraction of the fetus. If the length is short, it is unrealistic to provide adequate displacement Bladder, the formation of a flap of the vesicouterine fold sufficient for peritonization; when removing the fetus, the incision will continue into the gap, which may result in additional bleeding or injury to the bladder. At the same time, excessive continuation of the peritoneal incision should be avoided due to the risk of injury to the veins passing along the ribs of the uterus in the broad ligaments.
Upon completion of the opening of the vesicouterine fold, the peritoneum with bladder lowered down to expose the lower segment of the uterus. In most cases, it is not necessary to deflate the bladder more than 5 cm, since the possibility of bleeding from the venous plexus is high. In addition, in women in labor with a smoothed cervix, the risk increases due to a too low subsequent incision (at the level of the cervix or vagina) (Cunningham F.G. et al. 1997).
In full-term pregnancy and in the absence of adhesions, the peritoneum of the vesicouterine fold is well mobile. As a result, this stage of the operation can be easily performed using a blunt method, using fingers or a small blunt forceps on a clamp. Along with this, when creating a detachment of the peritoneum, it is advisable to point the instrument towards the wall of the uterus, and not the bladder, in order to avoid damage to it.
If there are difficulties in detaching the peritoneum (in most cases due to adhesions at the end of a previous cesarean section), first of all you need to make sure that the level and layer in which the surgeon is operating are correctly selected, after which the peritoneum is carefully separated acute method using narrow scissors. The formed flap of the vesicouterine fold with the bladder is placed behind a wide suprapubic mirror, which, on the one hand, protects them from injury, and on the other, leaves the lower segment of the uterus free for manipulation.
For more reliable fixation of the vesical-uterine fold, some authors recommend first placing 2-3 provisional sutures on its vesical edge, which are grabbed with clamps and placed behind the mirror (Blepykh A.S. 1986). These sutures may also be necessary for quickly clarifying topographic relationships in an urgent situation after the birth of the fetus with a sharply thinned lower segment, the occurrence of massive bleeding, or spontaneous extension of the incision into a rupture in the lower segment of the uterine wall.
When determining the level of the transverse incision in the lower segment of the uterus with a cephalic presentation of the fetus, the first thing to strive for is that it, if possible, falls on the projection area of the largest diameter of the head. Along with this, the removal of the head into the wound and its birth occur smoothly. If the incision is made too low, then, in addition to the risk of damage to the vaginal wall and bladder, difficulties arise in extracting the fetus, since most of its head will be significantly higher than the level of the incision, which prevents its eruption into the wound.
With a large incision level, on the contrary, most of the head is significantly lower than the wound opening. In this situation, insert the hand behind the head and guide it towards the incision, exerting measured pressure in the direction of the fundus of the uterus. Both with an extremely low and large level of incision, the need to apply additional efforts can lead to injury to the uterus and fetus, an increase in the time before its removal, hypoxia and blood loss.
In a normal situation, the incision in the uterine wall extends no less than 4 cm above the base of the bladder and no lower than 1 cm from the beginning of the vesicouterine fold. To ensure adequate surgical access to the lower segment, a suprapubic mirror is used.
Exposure of the lower segment using a suprapubic speculum
The anterior wall of the lower segment of the uterus, with caution, so as not to injure the fetus or the umbilical cord loops, is opened in the transverse direction for 2-3 cm.
If large vessels enter the incision (in most cases with an unformed lower segment, premature pregnancy), the surgical field may be flooded with blood, which prevents reliable completion of the incision. In this situation, if drainage with gauze swabs or through vacuum suction is ineffective, the assistant should press the upper and lower edges of the incision with gauze swabs on clamps or with fingers, which helps reduce or stop bleeding and allows penetration into the uterine cavity without injuring the presenting part of the fetus.
To reduce the risk of fetal injury and reduce blood loss, N.S. Shetapp (1988) recommends creating a careful incision in layers. The purpose of this method is to cut the uterine wall without damaging the membranes, which are opened after its complete completion. When using this layer-by-layer technique, the pressure of the fetal bladder on the lower segment and the edges of the incision helps reduce blood loss. But this method applicable only for intact amniotic fluid.
From the moment the uterine wall is opened by 2-3 cm, two methods of continuing the incision are currently used. The first option (according to Derfler) involves increasing the incision in lateral directions under the control of the surgeon’s index and middle fingers inserted into the wound. The incision at the corners should be slightly raised upward (lunate), which corresponds to the course of the muscle fibers and allows for increased access to the uterus for easy birth of the fetal head without damaging the vascular bundles. For reliable birth of the fetus during a cesarean section in full-term pregnancy, the length of the uterine incision must be 10-12 cm.
According to L.A. Gusakov (1939) had a cesarean section performed with an incision at the level of the vesicouterine fold without separation and displacement of the bladder. After completing the transverse incision of the lower segment of the uterus, the expansion of its wound is achieved by blunt dilation using the index fingers.
This method is quite reliable and fast. Thus, Madapp et al. (2002) demonstrated a decrease in blood loss when using the technique of blunt dilation of the uterine wound during cesarean section. S.I. Kulinich et al. (2000) over the past 5 years have noted an increase in the frequency of use of the renal incision according to L.A. Gusakov from 85% to 91%. IN AND. Kulakov et al. (1998) suggest that in a situation of heavy bleeding in the incision area, to prevent injury to the fetus with a scalpel, first perforate the uterus with your fingers, then use the technique of blunt wound opening.
At the same time, some obstetricians prefer a semilunar incision with scissors (according to Derfler), believing that it is this method allows you to correctly calculate its size and movement, avoid additional ruptures, and the formation of clusters of displaced muscle fibers, which are not well matched when suturing the wound (Krasnopolsky V.I. et al. 1997; Jovanovic R. 1985). Based on morphological studies of biopsy specimens V.A. Ananyev et al. (2004) concluded that when cut with scissors, dystrophic and necrobiotic transformations of the myometrium are less pronounced.
To compare two options for increasing the uterine incision A.I. Rodriguez et al. (1994) conducted a study in 296 women who delivered by cesarean section. A continuation of the incision into the gap was considered to be situations when the planned size of the uterine incision upon completion of fetal extraction was found to be 2 cm larger. The results of the study did not find differences in the frequency of prolongation of the incision into the gap, as well as in other indicators (duration of operation, blood loss, postoperative complications). According to the authors' point of view, the risk of extending the incision into the gap largely depends on the thickness of the lower segment and increases from the state of pregnancy to the first, and then the second stage of labor, amounting to 1.4%, respectively; 15.5%; 35%.
The choice of uterine incision technique should be determined by the specific obstetric situation. The technique of blunt wound opening in the lower uterine segment is preferable in full-term pregnancy and childbirth with a well-formed lower segment, while in premature pregnancy and an undeveloped segment, an incision with scissors is used.
Upon completion of the opening of the uterus and membranes, the fetus is removed, after which the placenta is applied, window clamps are applied to the bleeding corners of the incision and the restoration of the integrity of its wall begins.
During a caesarean section in the lower uterine segment, which is performed during full-term pregnancy or childbirth, the incision is made in a stretched, thinned part of the wall containing a relatively small amount of blood vessels. As a result, in a simple situation, there is no need to resort to ligation before suturing the wound, which completely stops the bleeding. If there is a separate bleeding vessel, an additional clamp (fenestrated, Kocher or Mikulicz) is temporarily applied.
A.N. Strizhakov, O.R. Baev
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This method of cesarean section in the lower segment of the uterus, proposed by L. A. Gusakov (1939), is most widespread in our country. The operation is a modification of the Doerfler method, which was used abroad for a long time until it began to be replaced by retrovesical caesarean section.
IN modern form The method of caesarean section according to L. A. Gusakov is as follows. Transection is performed as usual - lower middle or Pfannekstiel. After fencing abdominal cavity napkins, expansion and fixation of the wound abdominal wall Using a wide suprapubic mirror and a retractor, the mobile part of the vesicouterine fold, loosely connected to the uterus, is found (preferably with tweezers). In the middle between two tweezers, which lift the fold of the peritoneum, it is cut with scissors (or a scalpel). Then one branch of the scissors is inserted under the peritoneum and the vesicouterine fold is dissected to the side, parallel upper limit bladder, moving 2 cm away from it. The peritoneum is dissected in the same way in the other direction. This point of the operation is essentially exactly the same as for a retrovesical caesarean section. However, in the future, detachment of the bladder is not performed; at the same level of opening the vesicouterine fold, after a small (1-2 cm) shift of the peritoneal layers up and down with a scalpel in the transverse direction, an incision is made in the uterine wall to the amniotic sac, the index fingers of both are inserted into the incision hands and the wound on the uterus is bluntly pushed apart. Further stages of the operation: removing the child, the child's place, suturing the wound on the uterus, etc. - are carried out using the methods described above.
Performing a cesarean section at the level of the vesicouterine fold without separating the bladder cannot be completely satisfactory. This method is good only in the first or early second stage of labor, when the fetal head is located in the lower segment of the uterus according to the level of its incision. In addition, at the end of pregnancy or even earlier, with this method of opening the uterus, stretching the uterine incision with the fingers is more difficult and subsequently it is more difficult to suture the uterine wound due to the different thickness of the edges of the incision - the lower edge, which belongs to the lower segment, is thinner, and top edge, which already belongs to the body of the uterus, becomes much thicker after its contraction. But, most importantly, with such a standard location of the uterine incision, its level cannot be changed depending on the standing height of the presenting part of the fetus.
C-section with a longitudinal incision of the uterine isthmus has no advantages compared to a transverse one. A longitudinal incision can be made after significant, almost complete, detachment of the bladder, when the lower segment along its entire height becomes accessible to intervention. Without this condition, it is impossible to extract the baby through a small opening in the uterus. If the opening in the uterus increases in the upper direction or is performed without detachment of the bladder (which is the same thing in the final result), then it is not the isthmus that is cut, but the body of the uterus, and the caesarean section becomes corporal with all its inherent features.
It's like this surgery, during which the anterior abdominal wall of the woman in labor is first dissected, then the wall of her uterus, after which the fetus is removed through these incisions.
Caesarean section in modern obstetrics
In modern obstetrics, caesarean section is the most frequently performed operation. Its frequency in last years reaches 10-20% of the total number of births.
Indications for caesarean section
A caesarean section is performed only in situations where vaginal birth is fraught with serious danger to the life and health of the fetus or the woman herself.
There are absolute and relative indications for surgery
Absolute readings to a cesarean section are clinical situations in which vaginal delivery poses a danger to the woman’s life.
To the group relative readings diseases and obstetric situations that adversely affect the condition of the mother and fetus are included if childbirth is carried out naturally.
| Absolute readings | |
| Narrowing of the pelvis III - IV degree | Narrowing of the pelvis I - II degrees in combination with other unfavorable factors (breech presentation, large fetus, post-term pregnancy) |
| Tumors of the uterus, ovaries, bladder, blocking the birth canal and preventing the birth of a child (for example, uterine fibroids) | Incorrect head insertion |
| Placenta previa | Threatening or in progress oxygen starvation fetus during labor (hypoxia) |
| Premature placental abruption with severe bleeding | Violations labor activity(weakness, incoordination), untreatable |
| Transverse and oblique position of the fetus in the uterus | Breech presentation of the fetus |
| Scar on the uterus after a previous caesarean section | Post-term pregnancy when the body is not ready for childbirth |
| Severe late toxicosis of pregnancy (eclampsia) | Late toxicosis of mild or moderate severity |
| Cancer of the genital organs, rectum, bladder | Age of first birth over 30 years in the presence of other unfavorable factors |
| Threat of uterine rupture | Large fruit |
| A state of agony or death of the mother with a living and viable fetus | Uterine malformations |
| Discrepancy between the sizes of the mother's pelvis and the fetal head | Maternal diseases requiring quick and careful delivery |
| Sharply expressed varicose veins veins of the vagina and external genitalia | Loss of umbilical cord loops |
As you can see, most indications for cesarean section are due to concerns about maintaining the health of both mother and child. In one case, already at the very beginning of pregnancy, during examination, the woman reveals preconditions that she may not be able to give birth on her own (for example, severe narrowing of the pelvis, or a scar on the uterus from a previous operation). In another, indications for cesarean section delivery appear as the gestational age increases (for example, the fetus has established a transverse position in the uterus or placenta previa has been determined by ultrasound). The doctor warns the pregnant woman about this fact immediately, explaining to her the reason. In both of these cases, the woman is prepared for a caesarean section. in a planned manner, that is, upon admission to maternity ward They begin to prepare her not for childbirth, but for surgery.
Certainly, psychological aspect The “rejection” of cesarean sections by expectant mothers is understandable. Few people feel "craving" for surgical interventions into the affairs of his own body. But cesarean section is an everyday reality (judge for yourself: on average, 1 out of 6-8 pregnant women give birth this way). Therefore, the doctor always tries to explain all the pros and cons of the upcoming operation and reassure the woman.
But sometimes, when there seemed to be no signs of danger throughout the entire pregnancy and the woman began to give birth on her own, emergency situations(for example, the threat of uterine rupture or oxygen starvation of the fetus, persistent weakness of labor) and labor ends in urgent indications operation of caesarean section.
What clinical situations are considered a contraindication for a caesarean section?
- Intrauterine fetal death (death of the fetus before birth).
- Deep prematurity of the fetus.
- Fetal deformities.
- Prolonged oxygen starvation of the fetus, in which there is no confidence in the birth of a living child.
- Infectious and inflammatory diseases mother.
What conditions are considered most favorable for the operation?
- The optimal time for the operation is considered to be the beginning of labor, since in this case the uterus contracts well and the risk of bleeding is reduced; in addition, in the postpartum period, discharge from the uterus will receive sufficient outflow through the slightly open cervix.
- It is better if the amniotic fluid is intact or no more than 12 hours should pass after its release.
- A viable fetus (this condition is not always feasible: sometimes, if there is a danger to the life of the mother, the operation is performed on a non-viable fetus).
What is a woman's preparation for elective surgery Caesarean section?
When preparing a pregnant woman, a detailed examination is carried out, including a study of blood counts, electrocardiography, examination of vaginal smears, examination by a therapist and an anesthesiologist.
In addition, a comprehensive assessment of the fetal condition is required ( ultrasonography, cardiotocography).
The night before the operation, the pregnant woman is given a cleansing enema, which is repeated on the morning of the operation. At night, as a rule, sedatives are prescribed.
What are the methods of pain relief for a caesarean section?
Endotracheal anesthesia - This is general anesthesia with artificial ventilation lungs; is currently the main method of pain relief for caesarean section. It is performed by an anesthesiologist and monitors the woman’s condition throughout the operation.
Operation stages
An incision of the skin and subcutaneous fat is made along the lower fold of the abdomen in the transverse direction.
The incision on the uterus is made carefully (so as not to damage the fetus) in the lower uterine segment (the thinnest and most stretched place on the uterus). The incision is initially made small, also in the transverse direction. Then the surgeon index fingers carefully stretches the incision to 10-12 cm.
The next and most crucial moment is the extraction of the fetus. The surgeon carefully inserts his hand into the uterine cavity and brings out the fetal head, and then removes the entire baby. Afterwards the umbilical cord is cut and the baby is transferred pediatrician and a nurse.
The placenta with membranes (afterbirth) is removed from the uterus, the uterine incision is carefully sutured, the surgeon checks the condition of the abdominal cavity and gradually sutures its wall.
What unpleasant moments are possible after surgery?
Possible discomfort during recovery from anesthesia (and even then not for everyone). This may include nausea, dizziness, and headaches. Besides, surgical wound could also be a source pain at first time. The doctor usually prescribes medications that reduce or eliminate pain (taking into account the effect of the medications on the newborn if the mother is breastfeeding).
Troubles also include the need for bed rest at first (1-2 days, walking is allowed on the 3rd day after surgery), the need to urinate through a catheter inserted into the bladder (not for long), a larger than usual number of prescribed medications and tests , constipation and some hygienic restrictions - a wet toilet instead of a full shower (before the stitches are removed).
What is the difference postpartum period for women after caesarean section?
Mainly because it will take longer for a woman to feel like she did before pregnancy, as well as the sensations and problems associated with the post-operative scar.
These patients require more rest and help with household chores and with the baby, especially in the first week after discharge, so it is helpful to think about this in advance and ask family members for help. Upon discharge, there should be no particular pain in the area of the postoperative suture.
The incision area may be tender for a few weeks after surgery, but this will gradually subside. After discharge, you can take a shower and you should not be afraid to wash the seam (followed by treating it with brilliant green).
During the healing process of the suture, a tingling sensation, skin tightening or itching may occur. These are normal sensations that are part of the healing process and will gradually disappear.
For several months after surgery, a feeling of numbness in the skin in the scar area may persist. If you experience severe pain, redness of the scar, or brownish, yellow or bloody discharge from the suture, you should consult a doctor.
Complications after cesarean section and their treatment
Peritonitis after cesarean section occurs in 4.6 - 7% of cases. Mortality from peritonitis and sepsis after cesarean section is 26 - 45%. The development of peritonitis causes infection of the abdominal cavity (from complications of cesarean section - chorioamnionitis, endometritis, suture suppuration, acute inflammatory processes in the appendages, infections penetrated by hematogenous or lymphogenous route - with paratonsillar abscess, with soft tan abscess, pyelonephritis).
Risk factors for the development of sepsis and peritonitis are similar in clinical practice and management tactics:
- spicy infectious diseases during pregnancy
- chronic infectious diseases and existing foci of chronic infection.
- All vaginosis (nonspecific) and specific colpitis.
- Age: under 16 and over 35 years old.
- A long period without water (more than 12 hours), that is, an untimely cesarean section.
- Frequent vaginal examinations (more than 4).
- Peritonitis after chorioamnionitis or endometritis during childbirth
Therapy program and treatment
Diagnosis is always late, as is treatment. Developed tactics of surgical treatment (with removal of the uterus, since this is the primary source of peritonitis). The operation is most often performed on days 9-15; operations are rarely performed on days 4-6. Severity should be assessed by the progression of symptoms.
Treatment
- Surgical intervention. The sooner it starts surgery Once the diagnosis of peritonitis is made, the fewer organ disorders will be observed after surgery. Removal of an organ as a source of infection (uterus with peritonitis after cesarean section) is etiologically directed. The uterus and tubes are removed, the ovary is usually left if it is not in them inflammatory phenomena. Hysterectomy is more often performed than amputation. The lower segment is close to the cervix, therefore supravaginal hysterectomy is performed with removal fallopian tubes with revision of the abdominal organs.
- Antibiotic therapy: cephalosporins and antibiotics acting on gram-negative microorganisms - gentamicin in maximum doses, preferably intravenously. Metronidazole drugs - metragil intravenously (acts on gram-negative flora, fungal flora). The spectrum of sensitivity of microorganisms to antibiotics must be done.
- Treatment and relief of intoxication syndrome. Infusion therapy with drugs that have detoxification properties: reopolyglucin, lactasol, colloidal solutions. The administration of solutions improves the patient's condition. Drugs that increase the oncotic pressure of the blood are also prescribed - plasma, aminokrovin, protein preparations, amino acid solutions. The amount of liquid is 4-5 liters. Therapy is carried out under the control of diuresis.
- Restoration of intestinal motility: all infusion therapy crystalloid solutions and antibiotics improve motility. They also use drugs that stimulate intestinal motility (cleansing, hypertensive enemas), antiemetics, prozerin subcutaneously, intravenously; oxybarotherapy). The first 3 days should be a constant activation of intestinal motility.
- Antianemic therapy - fractional blood transfusion (preferably warm donor blood), antianemic drugs.
- Stimulation of immunity - the use of immunomodulators - timolin, complex, vitamins, ultraviolet radiation of the blood, laser irradiation blood.
- It is important to care for and combat physical inactivity, parenteral nutrition, then complete enteral nutrition - high-calorie, fortified - dried apricots, cottage cheese, raisins, dairy products. The fight against physical inactivity involves breathing exercises, early turning in bed, massage
Caesarean section is one of the most pressing topics among expectant mothers. There are pregnant women who are terrified of this operation, while others, on the contrary, believe that a caesarean section is easier and safer than an independent birth. There are also women who believe that a caesarean section can be done at will.
What myths exist about caesarean section? And where is the truth hidden?
Myth No. 1. A caesarean section can be performed at the woman’s request.
This is a very common misconception and completely unfounded. The doctor performs a caesarean section only when independent childbirth impossible or dangerous for the woman or fetus. A caesarean section is not performed upon request.
After all, complications may arise during and after surgery. For example, there is a high risk of bleeding, infection, suture dehiscence, etc. After caesarean belly it hurts and pulls in the area of the suture, the body takes longer to recover than after an independent birth.
The operation also does not have the best effect on the fetus. Nature provides for spontaneous childbirth, and a caesarean section for a baby is additional stress. During the operation, the fetus does not pass through the birth canal and does not experience the pressure difference, which is so necessary for the full start of breathing, “turning on” work digestive system etc.
Myth No. 2. Long before a cesarean section you need to go to the maternity hospital.
If the doctors decide that a caesarean section is indicated for the expectant mother, then, of course, it is necessary to prepare for the operation. But long before the cherished date, there is no need to go to the maternity hospital, as before. All tests and examinations that are needed can be done at antenatal clinic. You must arrive at the maternity hospital the day before the operation.
A pregnant woman should do a general and biochemical tests blood, general urine test, coagulogram, ultrasound, cardiotocography (CTG) and electrocardiogram (ECG). To ensure that tests are not “overdue,” you need to start taking them between 36 and 38 weeks of pregnancy.
Myth No. 3. If a pregnant woman is myopic, she will have a cesarean section.
This is nothing more than a myth, since myopia itself is not an indication for a caesarean section. Surgery is needed for completely different “vision problems”: increased intraocular pressure and retinal pathologies. Pregnant women should not push in such cases, as tension can lead to decreased vision or even loss of vision.
But if the problems with the retina are minor, and there were no deteriorations during pregnancy, then the ophthalmologist may even allow you to give birth on your own. True, you still can’t push fully. So that the woman does not tense up while the fetus moves through birth canal, she is given epidural anesthesia. After this injection in the lumbar region, the entire area is anesthetized. Bottom part body, and the woman in labor does not feel any effort.
Myth No. 4. If the fetus “lies” with the pelvic end down, a caesarean section is always performed
The truth is that with a breech presentation, the fetus can be delivered independently. The doctor thinks about a caesarean section if there are complications of pregnancy (fetal pathology or diseases in the expectant mother) in addition to the incorrect positioning of the baby. For example, surgery is needed if the fetus has a large weight (more than 3.6 kg), a woman has a narrow pelvis, etc.
Myth No. 5: Caesarean sections are always performed under general anesthesia.
Not only expectant mothers are afraid of anesthesia, but also many patients who are about to undergo surgery. Pregnant women are afraid that they may not “wake up” after anesthesia, that the medications will have a bad effect on the baby, and also that they will not see their child immediately after birth. Fears, of course, are greatly exaggerated, but they cannot be called completely groundless.
If previously all caesarean sections were performed under general anesthesia, now 90% of operations are performed under spinal anesthesia. An anesthetic medicine is injected into the spinal canal in the lumbar region, and the woman ceases to feel pain below the injection site.
The first advantage of spinal anesthesia is that the woman is conscious and can see her baby immediately after birth. The second important advantage is that the painkiller does not enter the bloodstream and does not harm the fetus. General anesthesia is done only for strict indications or if the spine is severely curved, and spinal anesthesia cannot be carried out.
Myth No. 6. After a cesarean section, a rough scar remains on the skin.
Nowadays, a skin incision is most often “sutured up” with a cosmetic suture. In this case, the thread passes inside the skin, and the edges of the wound are simply connected from the outside. For such a suture, threads are used that dissolve themselves and do not need to be removed. After healing, only a thin white stripe is visible on the skin, which is located at the border of hair growth in the “intimate” area. So after a caesarean section there are no prohibitions on wearing an open swimsuit.
Myth 7. After the operation, the mother and newborn baby are in intensive care until discharge
In fact, the woman is in intensive care only for the first 12-24 hours after the operation, and then she and the baby are transferred to a regular ward in the postpartum department. IN intensive care The anesthesiologist, using special instruments, monitors the pulse, pressure, breathing rate, and prescribes painkillers to the young mother. And an obstetrician-gynecologist regularly examines postoperative suture, makes sure that the uterus contracts well and there is a normal amount postpartum discharge. Such careful monitoring is necessary to ensure that the risk of complications after surgery is minimal.
Myth No. 8. If you have had a cesarean section once, then the operation is required for the next birth.
This statement is not entirely true. When a doctor decides to give birth to a woman with a uterine scar herself or to perform a caesarean section, he takes into account the indications for the first operation and the condition of the scar itself. For example, if during your first pregnancy a caesarean section was performed due to a very narrow pelvis, then this time you cannot do without surgery, because the reason has not gone away. If the reason for the first operation was that the fetus lay across the uterus or was large, but now it is positioned head down and has normal sizes, then independent childbirth is possible. True, pregnancy should proceed without complications, and the scar on the uterus should be evenly dense and stretch well.
Irina Isaeva
An incision on the anterior abdominal wall from the pubis to the navel or according to Pfannenstiel with a transverse opening of the skin, subcutaneous fatty tissue and aponeurosis.
Blunt dilation of the rectus abdominis muscles and longitudinal dissection of the parietal peritoneum.
The uterovesical fold is dissected in the transverse direction and separated towards the bladder, exposing the lower uterine segment.
Produced cross section with a scalpel in the lower uterine segment and the index fingers of both hands, it is bluntly spread to the sides in the transverse direction.
The operator, with his hand inserted between the fetal head and the lower uterine segment, bends and carefully guides the fetal head into the wound, removes the fetal shoulders by the head, then armpits the entire fetus, trying to keep the child in the same plane with the uterus, so as not to disturb the perfusion of blood in the umbilical cord and the general blood flow, then the umbilical cord is pinched and crossed and the placenta is separated and removed from the uterus by hand.
The incision on the uterus is sutured with a single-row continuous vicryl suture in the Reverden modification.
Peritonization is carried out using a continuous suture using the uterovesical fold and the serous covering of the uterus.
After revision of the abdominal cavity, the parietal peritoneum, aponeurosis and skin of the anterior abdominal wall are sutured with a continuous suture using separate silk sutures.
Contraindications to cesarean section
foci of infection local, regional, remote;
somatic conditions of a woman, when surgical intervention can be life-threatening;
the presence of a dead fetus (in the absence of vital signs from the mother).
Amniotomy.
Varieties – simple, early, high Indications
(during childbirth):
Weakness of labor (for the purpose of strengthening)
Flat amniotic sac (symptom of incoordination)
Incomplete variant of placenta previa
Before obstetric surgery (classical rotation, obstetric forceps, fetal extraction by the pelvic end, fetal destruction operations)
For twins (before the birth of the second fetus)
During childbirth in women with long-term gestosis, with high blood pressure values)
With PONRP and low-lying
Delayed rupture of amniotic fluid
Polyhydramnios Indications (for pregnant women) for the purpose of inducing labor –
mature cervix!
Contraindications:
Breech presentation (pure foot)
Central variant of placenta previa
Transverse position of the fetus
Presentation of the umbilical cord loop and small parts of the fetus
Relative – meningeal attachment of umbilical cord vessels
Preparing a woman:
Special room for vaginal examinations
Treatment of the external genitalia with disinfectant. solution, iodonate
In 30-40 minutes - an antispasmodic (since the AMF changes for a short time and the BMD may be impaired + prevention of embolism with amniotic fluid). Doctor
– washes hands as if for surgery – with chlorhexidine. Tools
– branch of bullet forceps.
Technique:
We perform a vaginal examination (we check whether there is a condition for the development of labor)
We insert the instrument strictly along the finger and open it in the center.High amniotomy
(with polyhydramnios).
Listening to the fetal heartbeat
The assistant, using the 4th Leopold maneuver, holds the head above the entrance to the pelvis (for fear that the fetus will move into a transverse position) Amniotic sac - on the side behind the uterine os,
eccentric. Release the water as much as possible slower
(we are afraid of detachment)
After the head is pressed, we spread the membranes beyond the edge of the internal pharynx, otherwise they will stretch on the head
Listen to the fetal heartbeat
We are transferred to the prenatal ward only on a gurney
In prenatal – bed rest, on the side, corresponding to the position
EarlyHigh (when the uterine os opens by 3-4 cm)
Indications:
Diseases of the cardiovascular system, kidneys
Weakness of labor
Ailamazyan E.K. Obstetrics. - St. Petersburg, 1987
Bodyazhina V.I., Zhmakin K.N. Obstetrics. - M., 1998
Knyazeva T.P., Bloshchinskaya I.A. Anatomically narrow pelvis in modern obstetrics (educational and methodological recommendations for 6th year students of the Faculty of Medicine). - Khabarovsk, 2000
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