LECTURE 14 CESAREAN SECTION IN MODERN OBSTETRICS. MANAGEMENT OF PREGNANT WOMEN WITH A UTERUS SCAR

LECTURE 14 CESAREAN SECTION IN MODERN OBSTETRICS. MANAGEMENT OF PREGNANT WOMEN WITH A UTERUS SCAR

C-section - delivery operation: removal of a viable fetus and placenta by cutting the uterus. This is the most common delivery operation in modern obstetrics.

Caesarean section in abdominal surgery is one of the most ancient operations of abdominal surgery. In its development, it went through many stages, at each of which the technique of its implementation was improved. Caesarean section surpasses all other abdominal operations in frequency, even appendectomy and hernia repair combined. For example, in Russia it is produced with a frequency of 13.1%. According to foreign statistics, the European region is characterized by a caesarean section rate of 12-18%. The incidence of this operation in the United States in 2002 was 26.1%, the highest rate ever recorded in the United States. Over the past 10 years, the number of operations has increased approximately 1.5-2 times.

In ancient times, a caesarean section was performed at the behest of religious laws on a woman who died during childbirth, since burying her with an intrauterine fetus was unacceptable. At that time, caesarean sections were performed by people who did not even have medical education.

At the end of the 16th - beginning of the 17th century. This operation began to be performed on living women. The first reliable information about its performance by the German surgeon I. Trautmann dates back to 1610. The famous French obstetrician Franrois Mauriceau wrote at that time that “performing a caesarean section is tantamount to killing a woman.” This was the pre-antiseptic period in obstetrics. At that time, there were no developed indications and contraindications for the operation, no anesthesia was used, and the uterine wall was not sutured after the fetus was removed. Through an unsutured wound, the contents of the uterus entered the abdominal cavity, causing peritonitis and sepsis, which became the cause of mortality.

Operated women died in 100% of cases from bleeding and septic diseases.

In Russia, the first caesarean section was performed in 1756 by Erasmus, the second in 1796 by Sommer, both with favorable outcome. Until 1880 (according to A.Ya. Krassovsky), only 12 caesarean sections were performed in Russia.

Use of asepsis and antisepsis in obstetrics various methods pain relief, the introduction and improvement of the uterine suture reduced maternal mortality by the end of the 19th century. up to 20%. Therefore, the indications for this operation began to gradually expand, and it subsequently became firmly established in the daily practice of obstetricians and gynecologists.

There are at least three explanations for the origin of the term "caesarean section".

1. According to legend, Julius Caesar was born in this way.

2. The name of the operation is taken from the code of laws of the legendary Roman king Numa Pompilius, who lived in the 8th century. BC. (lex regia, and in the era of emperors - lex caesarea). Among other things, the code required that every pregnant woman who died without permission have her child cut out before her burial (sectio caesarea; German name "Kaiserschnitt")

3. "Caesarean section" is a mistranslation of the term's ectio caesarea." Word "caesarea" derived from ab utero caeso(Pliny). Children born through this operation were called "caesones" which means "cut out". Word sectio comes from the verb seco- cut, and the word caesarea is the same root as the words caesura, excisio, circumcisio and comes from the verb caedere- cut out. Thus, the exact translation "sectio caesarea" should sound like a “cutting section” (tautology).

One of the features of modern obstetrics is the expansion of indications for cesarean section due to the development and improvement of obstetric science, anesthesiology, resuscitation, neonatology, blood transfusion services, pharmacology, asepsis and antiseptics, the use of new broad-spectrum antibiotics, new suture material and other factors.

Reasons for the increase in frequency caesarean section (Fig. 92, 93) are as follows: an increase in the number of primigravidas over 30 years of age; introduction into obstetric practice of modern diagnostic methods for studying the condition of the mother and fetus during pregnancy and childbirth; expansion of indications for caesarean section for breech presentation, severe

Rice. 92. Caesarean section rate

Rice. 93. Cesarean section and birth rates per vias naturales after caesarean section in 1989-2002. in USA

max gestosis, premature pregnancy; refraining from applying cavity forceps and a vacuum extractor; increasing number of pregnant women with various extragenital and gynecological pathologies; an increase in the number of pregnant women with a uterine scar after cesarean section; improvement of intensive care for newborns; insufficient qualifications of obstetricians and gynecologists in terms of rational management of childbirth; socio-economic and demographic factors.

However, expanding the indications for caesarean section performed to reduce perinatal mortality can be justified only to certain limits. An unreasonable increase in the frequency of surgery is not accompanied by a further reduction in perinatal losses, but is fraught with a serious threat to the health and life of a woman (Table 20), especially if contraindications to surgery are underestimated. The risk of maternal complications during abdominal delivery increases 10 times or more, and the risk of maternal mortality increases 4-9 times.

Table 20

Maternal mortality rate after cesarean section and vaginal birth birth canal in Great Britain for 1994-1996. (Hall and Bewley, 1999)

The issue of caesarean section is decided in accordance with the condition of the pregnant woman and the fetus. Currently, the list of indications for surgery has changed significantly, new ones have appeared: pregnancy after in vitro fertilization and embryo transfer, stimulation of ovulation, etc. Many authors distinguish between indications from the mother and from the fetus, but this division is largely arbitrary.

Indications for cesarean section during pregnancy

Complete placenta previa.

Incomplete placenta previa with severe bleeding.

Premature abruption of a normally located placenta with severe bleeding and the presence of intrauterine suffering of the fetus.

Inconsistency of the uterine scar after cesarean section or other uterine surgeries.

Two or more scars on the uterus after cesarean sections.

Anatomically narrow pelvis II-III degree of narrowing (true conjugate 9 cm or less), tumor or deformation of the pelvic bones.

Condition after operations on the hip joints and pelvis.

Malformations of the uterus and vagina.

Tumors of the cervix and other organs of the pelvic cavity blocking the birth canal.

Multiple large uterine fibroids, degeneration of myomatous nodes, low (cervical) location of the node.

Severe forms of gestosis in the absence of effect from therapy and unprepared birth canal.

Severe extragenital diseases (diseases of cardio-vascular system, diseases nervous system, high myopia, especially complicated, etc.).

Scar narrowing of the cervix and vagina after plastic surgery on the cervix and vagina, after suturing genitourinary and enterogenital fistulas.

Scar on the perineum after suturing a third degree tear during a previous birth.

Severe varicose veins in the vagina and vulva.

Transverse position of the fetus.

Conjoined twins.

Breech presentation of the fetus in combination with an extended head, with a fetal weight of more than 3600 g and less than 1500 g, or with anatomical changes in the body.

Breech presentation or transverse position of the 1st fetus during multiple pregnancy.

Three or more fetuses in case of multiple pregnancy.

In vitro fertilization and embryo transfer, artificial insemination in case of complicated obstetric and gynecological history.

Chronic fetal hypoxia, fetal hypotrophy, not amenable to drug therapy.

The age of the primigravida is over 30 years, in combination with obstetric and extragenital pathology.

A history of long-term infertility in combination with other aggravating factors.

Hemolytic disease of the fetus due to unprepared birth canal.

Post-term pregnancy in combination with a burdened gynecological or obstetric history, unprepared birth canal and lack of effect from labor induction.

Extragenital cancer and cervical cancer.

Exacerbation of herpesvirus infection of the genital tract.

Indications for cesarean section during childbirth

Clinically narrow pelvis.

Premature rupture of amniotic fluid and lack of effect from induction of labor.

Anomalies of labor that are not amenable to drug therapy.

Detachment of a normal or low-lying placenta, threatening or incipient uterine rupture.

Presentation and prolapse of umbilical cord loops with unprepared birth canal.

Incorrect insertion and presentation of the fetal head (frontal, anterior view of the facial, posterior view of the high straight position of the sagittal suture).

State of agony and sudden death mothers in labor with a living fetus. Caesarean section is often performed for combined, complex

indications.

They are a combination of several complications of pregnancy and childbirth, each of which individually does not serve as an indication for cesarean section, but together these complications create a real threat to the life of the fetus in the event of vaginal delivery.

Of significant interest is the study of the location of cesarean section for preterm birth. Main indications for abdominal

long-term delivery in the latter - severe forms of gestosis, breech presentation of the fetus, premature placental abruption, placenta previa, severe placental insufficiency. To achieve good results, it is necessary to have a highly qualified neonatal service that allows you to care for low birth weight babies. Caesarean section during pregnancy is usually performed in in a planned manner, less often - in emergency (bleeding during placenta previa, failure of the uterine scar, etc.), and during childbirth, as a rule, emergency indications.

More than half of the operations are performed as planned (54.5%), which indicates a good prenatal diagnosis of the fetal condition, anatomical features of the pelvis, obstetric and extragenital pathology requiring abdominal delivery. The structure of indications for surgery is different for planned and emergency delivery. Yes, when planned caesarean section

the most common indications are the age of a primigravida over 30 years old in combination with obstetric and extragenital pathology; scar on the uterus after cesarean section; breech presentation of the fetus; fetal distress. At caesarean section during childbirth

indications are often fetal distress; anomalies of labor; clinically narrow pelvis; bleeding caused by premature placental abruption.

It should be emphasized: when deciding on abdominal delivery, you must always think about the future generative function of the mother, especially if this is her first such operation. Reserves cesarean section - improvement of the management of vaginal birth using modern tracking systems and medications, development of a method for careful management of vaginal birth in the presence of a scar on the uterus after cesarean section in the lower segment.

The previously existing axiom of E.V. Cragin (1916) “once a caesarean section, always a caesarean section” is no longer valid because it refers to a time when corporal caesarean sections were performed and caesarean sections are now mostly performed in lower segment uterus with a transverse incision, in which the conditions for the formation of a scar on the uterus are more favorable. Please note: the incidence of uterine rupture after corporal cesarean section is quite high and is about 12%.

A special role in the outcome of the operation (for both the mother and the fetus) is played by contraindications to it and the conditions for its implementation.

Currently, many provisions have been revised. This is primarily due to improved surgical techniques, the use of new suture material, the use of broad-spectrum antibiotics, improved anesthesia, improved intensive monitoring in the postoperative period, etc.

Contraindications to abdominal delivery are the unfavorable condition of the fetus (intrauterine death, deep prematurity, fetal deformities, severe or long-term intrauterine fetal hypoxia, in which stillbirth or early fetal death cannot be excluded), the presence of a potential or clinically significant infection (anhydrous interval of more than 12 hours), protracted labor(more than 24 hours), a large number of vaginal examinations (more than five), intrauterine monitoring control, an increase in body temperature during labor above 37.5 ° C (chorioamnionitis, etc.), a failed attempt at vaginal delivery (vacuum extraction of the fetus, obstetric forceps). However, these contraindications are only relevant when the operation is performed in the interests of the fetus; they are not taken into account in the presence of vital indications from the mother (for example, bleeding associated with placental abruption, etc.).

The question of the method of delivery in conditions of latent or clinically pronounced infection with a living, viable fetus remains controversial to this day. IN Lately in the absence of conditions for rapid delivery through the natural birth canal, in the presence of a latent or clinically pronounced infection, a number of authors speak in favor of abdominal delivery. It is recommended to use a number of methods to prevent the development of an infectious process in the postoperative period. These include intraperitoneal cesarean section with broad-spectrum antibiotics and wound drainage;

temporary delimitation of the abdominal cavity before opening the uterus; extraperitoneal caesarean section; removal of the uterus after a caesarean section. Conditions

to perform a caesarean section are as follows. 1. Live and viable fetus. This condition is not always feasible; for example, in case of danger that threatens the life of a woman (bleeding with complete placenta previa, premature abruption of a normally located placenta, uterine rupture, etc.), a caesarean section is performed with a dead and non-viable fetus. 2. I agree

these women for surgery (in the absence of vital indications). 3. Empty bladder (it is advisable to use a permanent catheter). 4) No symptoms of infection during childbirth. One of the necessary conditions, as with any surgical intervention, is the choice of the optimal time, i.e. the moment when abdominal delivery

It will not be a too hasty intervention or, on the contrary (even worse), an operation of desperation. This is primarily important for the fetus, but also affects a favorable outcome for the mother.

For the success of the operation, it is important to have an experienced specialist, an equipped operating room with the necessary personnel and sterile kits, as well as a highly qualified anesthesiologist and neonatologist, especially if a caesarean section is performed in the interests of the fetus. Preoperative preparation. Caesarean section can be planned (50-60%) or emergency. If planned, the day before they give a light lunch (thin soup, broth with white bread, porridge), for dinner - sweet tea, an enema is given in the evening, and a sleeping pill is prescribed at night. In the morning, an enema is also given (2 hours before the start of the intervention), if necessary, elastic bandaging is performed lower limbs

If a caesarean section is an emergency, then when the stomach is full, it is first emptied through a tube and, in the absence of contraindications (bleeding, uterine rupture, etc.), an enema is given. In such cases, the anesthesiologist must be aware of the possibility of regurgitation of acidic stomach contents into the airways and the development of Mendelssohn's syndrome. On the operating table, it is necessary, as in the first case, to listen to the fetal heartbeat and perform catheterization of the bladder.

The results of a cesarean section, like many others, depend on timely execution; methods and scope; patient's condition; surgeon qualifications; anesthesiological support; medication provision; presence of suture material; blood and its components, infusion agents; instruments and technical equipment of the clinic; management of the postoperative period.

Despite the apparent technical simplicity, cesarean section should be classified as a complex surgical procedure (especially repeat cesarean section) with a high incidence of complications during surgery and in the postoperative period.

Pain relief method during a caesarean section, they are selected taking into account the condition of the pregnant woman, the woman in labor, the fetus, whether the operation is planned or urgent, and the availability of a qualified anesthesiologist-resuscitator. In addition, pain relievers must be safe for the mother and fetus.

The most appropriate type of anesthesia for caesarean section is spinal or epidural (used in almost 90% of cases). In emergency situations, when rapid pain relief is necessary, endotracheal anesthesia with nitrous oxide in combination with neuroleptics and analgesics is used. When performing general anesthesia, it must be remembered that no more than 10 minutes should pass from the start of anesthesia to the extraction of the fetus.

Technique of cesarean section operation.

Abdominal caesarean section (sectio caesarea abdominalis):

Intraperitoneal methods - cesarean section with opening of the abdominal cavity (classical cesarean section, corporal cesarean section, cesarean section in the lower uterine segment with a transverse incision modified by Eltsov-Strelkov, Stark; isthmic-corporal cesarean section);

Methods of abdominal caesarean section with temporary delimitation of the abdominal cavity;

Methods of abdominal cesarean section without opening the abdominal cavity - extraperitoneal cesarean section.

Vaginal caesarean section according to Dursen (section caesarea vaginalis). Depending on whether the abdominal cavity is opened or not, intraperitoneal or extraperitoneal caesarean section is distinguished. The method of operation depends on the specific obstetric situation and the surgeon’s mastery of operative techniques.

The most rational method of caesarean section is currently considered throughout the world to be an operation in the lower segment of the uterus with a transverse incision (94-99%).

The advantages of cutting the uterus in the lower segment with a transverse incision are as follows.

1. The operation is performed in the thinnest part of the uterine wall (lower segment), due to which a very small amount of muscle fibers enters the incision. As the lower segment and neck involute and form postoperative suture sharply decreases, and a small thin scar forms at the incision site.

2. The entire operation takes place with little blood loss, even when the placental area enters the incision. In this case, bleeding dilated vessels can be ligated in isolation.

3. With this method, it is possible to perform ideal peritonization of a sutured uterine wound due to the vesicouterine fold (plica vesicouterina).

4. In this case, the incisions of the parietal and visceral peritoneum do not coincide, and therefore the possibility of the formation of adhesions of the uterus with the anterior abdominal wall is small.

5. The risk of uterine rupture during subsequent pregnancies and vaginal births is minimal, since in most cases a full-fledged scar is formed.

Corporal caesarean section despite many disadvantages, it is still used for severe adhesions in the lower segment of the uterus after a previous cesarean section; pronounced varicose veins in the lower segment or the presence of a large myomatous node in the lower segment of the uterus; the presence of a defective scar after a previous corporal cesarean section; complete placenta previa with its transition to the anterior wall of the uterus; premature fetus and undeveloped lower segment of the uterus; conjoined twins; transverse position of the fetus. Corporal cesarean section is currently used in cases where immediately after cesarean section it is necessary to perform supravaginal amputation or hysterectomy (according to indications: multiple uterine fibroids, Couveler's uterus). In addition, this method is used in a dead or dying patient with a living fetus. During a corporal caesarean section, an incision in the anterior abdominal wall is made between the pubis and the navel, the uterus is not removed from the abdominal cavity; Thus, the incision in the uterus and the incision in the anterior abdominal wall coincide with each other, which leads to an adhesive process, and the incision in the body of the uterus leads to an incompetent scar in subsequent pregnancies.

In case of premature pregnancy and non-expanded lower segment of the uterus, it is possible to perform isthmic-corporal caesarean section.

Currently, to perform a cesarean section, the anterior abdominal wall is usually opened with a transverse suprapubic incision according to Pfannenstiel (sometimes according to Joel-Cohen) and less often with a longitudinal incision between the pubis and the navel (Fig. 94). It is important that the incision in the abdominal wall is sufficient to perform the operation and carefully remove the child.

Rice. 94. Incisions of the anterior abdominal wall during caesarean section

An incision on the uterus is made according to the method of L.A. Gusakova. In the area of ​​the lower segment of the uterus, a small transverse incision 2 cm below the level of the incision of the vesicouterine fold is used to open the uterine cavity, then the index fingers of both hands carefully stretch the edges of the wound to 10-12 cm in the transverse direction. In some cases, an incision modified by Derfler is used: after a small dissection of the lower segment of the uterus (2 cm) is made with a scalpel, the incision is extended to the right and left of the midline in an arcuate manner with scissors to the desired size. When making an incision of the uterus in the lower segment, you should be very careful not to injure the vascular bundle and the fetal head with a scalpel.

During a caesarean section in the lower segment of the uterus with a transverse incision, detachment of the bladder by 5-7 cm is not performed, primarily due to the risk of bleeding from the paravesical tissue and the possibility of injury to the bladder.

The well-known traditional aspirations to reduce the duration of intervention became the basis for the development in 1994 of the Stark method (Misgav-Ladach operation). Only a combination of several well-known techniques and the exclusion of some optional stages allow us to speak of this operation as a new modification of cesarean section, which has a number of advantages (rapid fetal extraction; significant reduction in: the duration of abdominal delivery, blood loss, the need for postoperative use of painkillers, the incidence of paresis intestines, frequency and severity of other postoperative complications; earlier discharge; significant savings in suture material).

Thanks to them, as well as its simplicity, the Stark method is quickly gaining popularity.

The next moment of abdominal delivery is removal of the fetus from the uterus. Its importance is determined by the fact that in approximately every third case the operation is performed in the interests of the fetus.

The extraction of the fetus depends on the presentation and position of the fetus in the uterus.

Yes, when cephalic presentation The left hand (II-V fingers) is usually inserted into the uterine cavity so that the palmar surface is adjacent to the fetal head, the head is grabbed and carefully turned with the back of the head anterior, then the assistant lightly presses on the fundus of the uterus, and the surgeon moves the head anteriorly with the hand inserted into the uterus , in this case the head is extended, and it is removed from the uterus. Then the index fingers are inserted into the armpits and the fetus is removed. To remove the fetal head from the uterine cavity, you can use a spoon of obstetric forceps (Fig. 95).

Currently, in order to prevent infectious postoperative complications during cesarean section, the anesthesiologist intravenously administers to the mother (if she does not have antibiotic intolerance) one of the broad-spectrum antibiotics (usually cephalosporins).

Rice. 95. Extraction of the fetal head during caesarean section in the lower uterine segment: I - extraction of the fetal head by hand; II - extraction of the fetal head using a spoon using obstetric forceps.

After removing the child, to reduce blood loss during surgery, 1 ml of a 0.02% solution of methylergometrine is injected into the uterine muscle and an intravenous drip of 1 ml (5 units) of oxytocin is started. If there is a disturbance in the hemostasis system (hypocoagulation), administration of fresh frozen plasma is indicated. In addition, it is necessary to grasp the edges of the wound, especially in the area of ​​the corners, with Mikulicz clamps.

Whether the placenta separated independently or was separated by hand, in any case, subsequent inspection of the walls of the uterus by hand is necessary to exclude the presence of remnants of the fertilized egg, submucosal uterine fibroids, septum in the uterus and other pathologies. Sometimes there is a need for an instrumental (using a curette) examination of the uterus.

When performing a caesarean section on a planned basis before the onset of labor and there is no confidence in the patency of the cervical canal, you should pass it with your finger, and then change the glove.

The technique of suturing the uterus is very important. The fact is that among the causes of mortality after cesarean section, one of the first places is occupied by peritonitis, which develops mainly due to the failure of the sutures on the uterus.

Very important have a technique for suturing the uterus, suture material. Correct comparison of wound edges is one of the conditions for prevention infectious complications, scar strength.

Suture material should be used sterile, durable, non-reactive, convenient for the surgeon, universal for all types of operations, differing only in size depending on the required strength. Vicryl, dexon, monocryl, polyamide, etc. have these properties.

The traditional suture material in obstetric practice, catgut, due to its high capillarity and the ability to cause a pronounced inflammatory and allergic reaction of tissues, can no longer meet modern surgical requirements.

It is considered advisable to apply a continuous enveloping single-row suture (Vicryl? 1 or 0, Dexon? 1 or 0, etc.) on the uterus with puncture of the mucosa and subsequent peritonization by the vesicouterine fold (Fig. 96). Advantages of a single-row seam consist in less disruption of tissue trophism, less suture material in the suture area, more rare development swelling in the postoperative period, reducing the duration of the operation, less consumption of suture material. Continuous two-

it is advisable to use a row suture (Fig. 97) in case of pronounced varicose veins in the area of ​​the lower segment of the uterus and in case of increased bleeding.

During a corporal caesarean section (Fig. 98), a two-row continuous suture (Vicryl, Dexon, etc.) is usually applied.

At the end of peritonization, an inspection of the abdominal cavity is performed, during which it is necessary to pay attention to the condition of the uterine appendages, the posterior wall of the uterus, the appendix and other organs. When layer-by-layer suturing of the anterior abdominal wall is performed, a continuous intradermal “cosmetic” suture with synthetic absorbable suture material is usually applied to the skin.

Immediately after the operation, on the operating table, the vagina should be toileted, which contributes to a smoother course of the postoperative period. It is necessary to pay attention to the color of the urine (admixture of blood!) and its quantity.

In case of potential and clinically significant infection, a living and viable fetus, and in the absence of conditions for vaginal delivery, it is advisable to use an extraperitoneal cesarean section using the Morozov method (Fig. 99). With this method, the abdominal wall (skin, subcutaneous fat, aponeurosis) is opened with a transverse suprapubic incision (according to Pfannenstiel) 12-13 cm long. The rectus abdominis muscles are divided with a blunt one, and the pyramidal ones - sharp way. Then the right rectus muscle is bluntly peeled off from the preperitoneal tissue and retracted to the right with a mirror. The right rib of the uterus and the fold of the peritoneum are exposed. The detection of this fold is helped by the displacement of tissues (preperitoneal cells

Rice. 96. Application of a single-row continuous suture during caesarean section

Rice. 97. Suturing the uterine incision during caesarean section: a - muscle-muscular suture; b - muscle-muscle suture; c - peritonization of the vesicouterine fold (plica vesicouterina).

Rice. 98. Applying a continuous suture to the uterine incision during a corporal caesarean section:

a - mucomuscular suture; b - seromuscular suture; c - gray-serous suture.

buds, peritoneum) to the left and up; As a result, the fold is stretched in the form of a “wing”. In addition, it has a whiter color. Somewhat below the fold of the peritoneum, the loose connective tissue is bluntly separated to the intrapelvic fascia. To find the place of detachment of the vesical ma-

Rice. 99. Extraperitoneal cesarean section (modification by V.N. Morozov) a - exposure of the vesicouterine fold; b - peeling of the vesicouterine fold from the lower segment of the uterus; c - exposure of the lower segment of the uterus and selection of the incision site; 1 - fold of peritoneum; 2 - medial umbilical-uterine ligament; 3 - lateral umbilical ligament; 4 - vesicouterine fold; 5 - bladder; 6 - rectus abdominis muscle (left); 7 - lower segment of the uterus;

For the exact fold, look for a “triangle” formed from above by the fold of the peritoneum, from the inside by the vesico-umbilical lateral ligament or the lateral wall of the apex of the bladder, and from the outside by the rib of the uterus. Then the intrapelvic fascia is opened with scissors or tweezers and two fingers pass under the vesicouterine fold and the apex of the bladder to the left rib of the uterus.

For the best exposure of the lower segment of the uterus, the fingers are spread to the sides, downwards and especially upwards to the place of intimate attachment of the peritoneum to the uterus.

The “bridge” formed by the vesicouterine fold and the apex of the bladder is retracted to the left with a mirror and the lower segment of the uterus is exposed. Opening the lower segment of the uterus and removing the fetus is carried out according to the technique adopted for a regular cesarean section, but before removing the child, the side speculum holding the right rectus abdominis muscle should be removed, and the speculum that holds the vesicouterine fold and the top of the bladder should be left in place , which promotes better access to the lower segment and less trauma to the bladder. A continuous single-row (less often double-row) Vicryl and Dexon suture is applied to the incision on the uterus. The anterior abdominal wall is restored layer by layer.

Preoperative sanitation of the birth canal (plivasept, furatsilin, etc.) and rational antibiotic prophylaxis during surgery and for 24 hours after it contribute to reducing the incidence of postoperative complications.

The best drugs for prophylactic use should be considered broad-spectrum penicillins and cephalosporins, which affect the main causative agents of infectious complications and have low toxicity to the mother and fetus. In order to prevent the development of endometritis, in the etiology of which non-spore-forming anaerobes play a major role, it is advisable to combine these drugs with metronidazole or lincomycin or clindamycin.

During abdominal delivery, antibiotics are administered to women in labor during surgery after clamping the umbilical cord. This causes the creation of a therapeutic concentration of the drug in the operated tissues even during surgery and protects the fetus from adverse effects. A number of studies have shown that the effectiveness of infection prevention when administering antibiotics to women in labor before and after umbilical cord clamping is approximately the same; it is more pronounced than with postoperative administration. The ineffectiveness of preventive use of antibiotics after surgery is explained by the lack of therapeutic levels of drugs in tissues during colonization and subsequent reproduction of microorganisms in them. In addition, ischemia in the suture area and subsequent hypertonicity of the uterus lead to a decrease in the content of antibiotics in the operated tissues.

Most researchers recommend using the intravenous method of administering antibiotics for prophylactic use, in which the drug quickly reaches the damaged tissue. High concentrations of drugs in tissues can be achieved with local application antibiotics using irrigation or irrigation of the uterine cavity, layers of the incision, however, this method is not very popular among specialists.

Almost all antibiotics used to treat endometritis after cesarean section are, to one degree or another, recommended for its prevention. This:

III generation cephalosporins 1 g after clamping the umbilical cord, then after 8 and (if necessary) after 16 hours intravenously;

Fixed combinations of penicillins with inhibitors β -lactamase (augmentin);

Carbapenems (imipenem - cilastatin) 0.5 g after clamping the umbilical cord, then intravenously after 8 hours (at a very high risk of infection).

The choice of these antibiotics for prophylaxis seems optimal, since they are effective against aerobic and anaerobic bacteria, have a bactericidal action, diffuse well into tissues, and do not cause serious side complications.

It should be emphasized: only a technically correctly performed cesarean section, regardless of the technique, ensures a favorable outcome and a smooth course of the postoperative period.

Management of the postoperative period. At the end of the operation, cold and heaviness are immediately prescribed to the lower abdomen for 2 hours. Due to the risk of hypotonic bleeding in the early postoperative period, intravenous administration of 1 ml (5 units) of oxytocin or 1 ml of a 0.02% solution of methylergometrine in 500 ml of isotonic sodium chloride solution is indicated , especially women at high risk of bleeding.

In the first 2 days after surgery, infusion-transfusion therapy is carried out. The amount of liquid administered is 1000-1500 ml.

To prevent pneumonia, breathing exercises are indicated. In uncomplicated cases, antibiotics should not be used. However, if there is a risk of postoperative infectious diseases It is recommended to prescribe broad-spectrum antibiotics.

Pain relief in the postoperative period: not prescribed on days 1-3 after surgery. narcotic analgesics: analgin 50% - 2.0 ml, baralgin 5.0 ml 1-3 times a day; if ineffective - narcotic analgesics: promedol 2% 1 ml, omnopon 2% 1 ml.

In the postoperative period, it is also necessary to carefully monitor bladder and bowel function. In order to stimulate the activity of the latter, on the 3rd day after the operation, 20-40 ml of a 10% sodium chloride solution is administered intravenously, 0.5-1 ml of a 0.05% solution of proserin is administered subcutaneously and after 30 minutes a cleansing enema is given.

To enhance the contractile activity of the uterus and prevent bleeding in the postoperative period, 0.5-1 ml of oxytocin solution is administered subcutaneously 2 times a day. If there is insufficient secretion of lochia, especially during surgery before the onset of labor, 2 ml of no-spa solution is injected subcutaneously 30 minutes before the administration of oxytocin.

The postpartum woman is allowed to get up at the end of the 1st day (in the absence of contraindications), and to walk - on the 2nd day. Early rising of patients in the postoperative period is a method of preventing intestinal paresis, urinary disorders, pneumonia, and thromboembolism.

In the first 2-3 days, the postoperative suture is treated daily at 70° ethyl alcohol and apply an aseptic sticker. In the absence of contraindications from the mother and child, breastfeeding can be allowed.

On the 2nd day after surgery, blood and urine tests, determination of blood clotting time, and in some cases, a coagulogram and biochemical blood test are required.

To clarify the condition of the suture, identify possible inflammatory and other changes in the uterus in the postoperative period, an ultrasound is indicated on the 5th day. Women are usually discharged on the 7-8th day after surgery.

Currently, much attention is paid to issues adaptation of newborns after caesarean section and timely implementation of resuscitation measures. In children removed by elective cesarean section, due to a decrease in adaptive abilities, disorders of the cerebral circulation (encephalopathy), respiratory system in the form of respiratory distress syndrome, primary atelectasis, aspiration syndrome, transient tachypnea, as well as conjugation jaundice may be observed. The reason is the absence during planned abdominal delivery of the mechanical and metabolic factors necessary for the fetus that affect it during childbirth. In response, a powerful release of stress hormones (adrenaline, norepinephrine, dopamine, etc.) occurs in the fetus’s body, helping the child overcome negative influences and more easily endure the process of adaptation to extrauterine life.

Caesarean section is an intrapartum risk factor for the fetus and newborn. Sometimes the surgical intervention itself is not harmless, since the fetus can be injured when it is removed. Not half-

Anesthesia is also completely safe. About 70% of newborns after abdominal delivery require assistance (in varying amounts), especially during elective surgery, which gives grounds to recommend a wider use of cesarean section (if the obstetric situation allows) after the onset of labor.

However, when talking about the effect of surgery on the fetus and newborn, one should take into account the premorbid background, the initial condition of the fetus and the presence of severe obstetric or extragenital pathology, which served as an indication for abdominal delivery.

Complications, difficulties and errors during a caesarean section are possible at all stages.

With transverse dissection of the skin, subcutaneous tissue and aponeurosis according to Pfannenstiel, one of the most common complications is bleeding from the vessels of the anterior abdominal wall (vessels of the subcutaneous fat, internal muscular arteries - a.a. nutriciae, a.a. epigastrica superficialis).

Often, surgeons, when dissecting the anterior abdominal wall, limit themselves only to applying clamps to the bleeding vessels, without ligating them. At the end of the operation, bleeding after removal of the clamps, as a rule, is not observed, however, in the postoperative period, bleeding may resume with the formation of extensive subcutaneous hematomas. Therefore, careful hemostasis is necessary before opening the abdominal cavity.

In addition, when making a Pfannenstiel incision, the aponeurosis is cut with scissors, and bleeding is often observed in the corners of the incision. Its cause with a semilunar incision of the aponeurosis is the dissection of the branches a. epigastrica superficialis, which, heading up the posterior layer of the aponeurosis and intimately adjacent to it, anastomose quite widely with small internal arteries. An undetected injury can lead to the formation in the postoperative period of extensive, sometimes fatal hematomas, located in the tissue between the transverse fascia and the muscles of the anterior abdominal wall, and sometimes occupying the entire suprapubic space.

When the aponeurosis is detached towards the navel and womb, a violation of the integrity is often observed a.a. nutriciae bleeding from which leads to the formation of a subgaleal hematoma. The frequency of subgaleal hematomas diagnosed by ultrasound and requiring evacuation is 0.76%. Therefore, when the aponeurosis is detached to the side, it is necessary to effectively ligate a.a. nutriciae. Particularly thorough

hemostasis when opening the anterior abdominal wall is needed for disorders of the blood coagulation system and varicose veins.

In all cases of cesarean section, within 1.5-2 hours after surgery to the area surgical field apply an ice pack.

With a longitudinal midline incision, there is usually no bleeding. Certain difficulties are observed during repeated transection, especially when several transections have taken place. So, if transsection was performed in the past due to intestinal obstruction or other surgical pathology, then intimate soldering of the intestine or omentum to the anterior abdominal wall and their injury during the operation is possible.

Every obstetrician-gynecologist must remember the likelihood of injury to neighboring organs (bladder, ureter, intestines), and if injury occurs, diagnose it in time and take appropriate measures. The bladder is usually damaged when opening the peritoneum, especially during repeated abdominal dissections, during dissection of the vesicouterine fold of the peritoneum, separation of the bladder from the uterus during adhesions, during extraperitoneal access when attempting hemostasis due to bleeding caused by prolongation of the incision into the vascular bundles or the cervix uterus.

The ureter is usually damaged when the incision is extended into the vascular bundles, with uncontrolled application of hemostatic clamps and suturing. For better orientation, especially during repeated transections, it is recommended to insert a permanent catheter into the bladder. In all doubtful cases, before suturing the abdominal cavity, the surgeon must fill the bladder with a solution of methylene blue in isotonic sodium chloride solution or inject a solution of methylene blue intravenously.

The bladder wound is sutured in two rows with vicryl or catgut. Damage to the bladder over the past 10 years occurred in 0.14%, injury to the intestine - in 0.06% of cases.

Often, injury to the urinary system occurs not during surgery, but during hysterectomy after cesarean section.

The most common complication of a caesarean section is bleeding, which occurs when the uterus is cut. To avoid it or reduce the frequency of blood loss, it is necessary to choose optimal place cut. During a corporal cesarean section with a longitudinal dissection of the uterine body, bleeding is always significant, especially if the placenta is located on the anterior wall. Therefore, when

In the case of the need to dissect the uterus with a longitudinal incision, preference is given to an isthmic-corporal incision. After opening the uterus with a longitudinal incision, its increase to the required size up and down should be carried out with scissors under the control of two fingers, which are inserted into the uterine cavity, thereby reducing the risk of damage to the fetus and reducing blood loss.

Rational from an anatomical point of view is a transverse incision of the uterus in the area of ​​the lower segment, in the “avascular” zone, where the anatomical structures of the uterus, including its vascular network, are least injured. However, even with this incision, bleeding is possible due to injury to the coronary artery of the isthmus, as well as damage to the vessels of the varicose venous plexus. If it is impossible to select an avascular area, it is recommended to press the wall of the uterus to the presenting part of the fetus with fingers or a tamper above and below the intended incision, thereby achieving compression of the vessels and reducing bleeding. If bleeding does not allow you to control the depth of the uterine incision, then you should then bluntly perforate the uterus with your fingers at the incision site, which avoids damage to the presenting part of the fetus.

Extending the incision in the lower segment of the uterus laterally, either bluntly or sharply, can damage the vascular bundle and cause life-threatening bleeding. Sometimes the transverse incision of the lower segment of the uterus is extended not only in the lateral direction, but also downwards, towards the cervix, under the bladder. Most often, this occurs during emergency surgery, with full dilatation of the cervix, with a low level of the incision on the uterus, with a low position of the presenting part of the fetus, with a large fetus, during rotation of the fetus in its transverse position, or in violation of the technique for removing the presenting part, as well as during rough manipulations.

After removing the fetus from the uterus when the placenta has not separated, Mikulicz clamps are applied to the corners of the incision and the bleeding upper and lower edges of the wound on the uterus, and 1 ml of methylergometrine is injected into the uterine muscle. If it is impossible to find bleeding vessels, it is recommended to remove the uterus from the abdominal cavity and perform hemostasis under visual control.

One of the unpleasant complications of uterine dissection is injury to the presenting part of the fetus, which is mentioned only in passing in the literature. It is predisposed to: the presence of a thin lower segment; bleeding

during the incision, the uterus; lack of amniotic fluid; violation of the technique of opening the uterus. There is a great danger of such injury when the fetal face is turned anteriorly.

During a caesarean section, difficulties and complications may arise during the removal of the fetal head. They are observed when the head is high above the entrance to the pelvis or very low, especially often when the uterus is dissected with a transverse incision in the lower segment. If the head is located high above the incision, and it cannot be brought down and removed, then it is necessary to find the fetal leg, carefully rotate it and remove it. It is very difficult to extract the fetus when the head is located low (with a large segment in the entrance plane or in a wide part of the pelvic cavity). If it is not possible to freely remove the head in the usual way, then you should help the surgeon by presenting the head from the vagina. This significantly reduces trauma to the fetus, the likelihood of extending the incision to the sides and injury to vascular bundles.

If it is impossible to remove the fetal head during caesarean section in the lower segment of the uterus with a transverse incision, it is permissible to dissect the uterus upward in the form of an inverted letter “T”. Difficulties in removing the fetal head are also caused by insufficient dissection of the anterior abdominal wall and insufficient relaxation (when the head is already removed from the uterus), and non-compliance with the removal technique. In such a case, it is necessary to extend the existing one or make an additional incision in the anterior abdominal wall.

At the stage of removal of the placenta during surgery, various complications can be observed, many of them cannot be predicted in advance.

Most obstetricians are proponents of manual separation of the placenta and release of the placenta during surgery. Manual separation of the placenta can reveal: its tight attachment and accretion; uterine septum; bicornuate or saddle uterus; thinning of the uterine wall or its rupture and other features.

True placenta accreta, Couveler's uterus with a violation of its contractile function are indications for removal of the uterus.

In case of bleeding from the septum in the uterus (which occurs especially often if the placenta was attached to it), excision of the septum and suturing of the bleeding surface are indicated.

The main complication after removal of the placenta is bleeding, which can be caused by hypo or atony of the uterus, a violation of the blood coagulation system.

Measures to stop bleeding from the uterus after removal of the placenta:

Massage of the uterus;

Removing blood clots;

Introduction of uterotonic agents into the thickness of the myometrium and intravenously;

Fresh frozen plasma transfusion;

Ligation of uterine vessels;

If treatment is ineffective, the uterus is removed.

One of the complications when suturing a wound on the uterus is suturing the bladder when it is not sufficiently detached from the lower segment.

Serious error during surgery - sewing top edge incision of the lower segment of the uterus to its posterior wall. This error is possible due to the fact that the lower edge contracts and goes under the bladder, especially if the incision is made very low. Back wall The uterus contracts and protrudes in the form of a cushion; it is mistaken for the lower edge of the wound. To avoid this, immediately after the fetus is removed, even before the placenta is removed, Mikulicz clamps are applied to the corners of the wound and the edges of the incision (upper and lower).

The question of indications for expanding the scope of surgery to hysterectomy during cesarean section and in the postoperative period is complicated. The main indications for removal of the uterus are bleeding that does not respond to conservative therapy, multiple uterine fibroids (degeneration of myomatous nodes), Couveler's uterus with impaired contractility. The incidence of hysterectomy after cesarean section varies widely, from 2.16 to 9.2%.

The issue of the scope of surgical intervention for uterine fibroids, which often accompanies pregnancy, remains controversial. The obtained scientific data and accumulated clinical experience made it possible to develop indications for conservative myomectomy during cesarean section. These include pedunculated subserous myomatous nodes, the location of nodes in the area of ​​the proposed incision of the lower segment of the uterus, and the presence of large intramural nodes.

The question of sterilization during caesarean section is decided by the pregnant woman herself. The basis for such an operation is only a documented application from the woman, drawn up and submitted in writing.

An important role in reducing maternal morbidity and mortality during abdominal delivery is played by correctly and timely measures to prevent various complications in the early postoperative period, among which bleeding is the most common.

If bleeding occurs in the early postoperative period, the chance to stop the bleeding should be taken with conservative means, which include timely emptying of the bladder; external massage uterus; administration of uterotonic drugs intravenously; digital or instrumental emptying of the uterus (with a full operating room and under intravenous anesthesia); administration of uterotonic agents into the cervix and intravenously; infusion-transfusion therapy (fresh frozen plasma, etc.) The effectiveness of this therapy is 82.4%. If ineffective, relaparotomy and hysterectomy are indicated.

The most unfavorable and dangerous consequences abdominal delivery - purulent-septic complications, which often become the cause of maternal mortality after surgery.

The incidence of postoperative inflammatory complications ranges from 3.3 to 54.3%. In the structure of postoperative morbidity, one of the first places is occupied by endometritis, which, in the absence of adequate prevention and treatment, often turns into a source of generalized infection.

Appearance in last years a new generation of broad-spectrum antibiotics allows for the prevention and effective treatment of severe postoperative infectious complications.

Currently, death from infection should be considered as a result of a cesarean section in the presence of contraindications, when choosing an inadequate surgical method and suture material, with poor surgical technique and insufficiently qualified management of the postoperative period. The generally accepted and best method of preventing the development of infection after cesarean section is intraoperative intravenous administration of broad-spectrum antibiotics (after clamping the umbilical cord) followed by their administration after 6 and 12 hours or 12 and 24 hours. In the presence of a potential or clinically significant infection, patients continue to receive antibiotics at in accordance with generally accepted methods.

Often maternal mortality during cesarean section is caused by bleeding and untimely, inadequate volume

surgical intervention, inadequate replacement of blood loss; often - a severe form of gestosis, not amenable to conservative therapy (although the immediate causes of death in these cases are cerebral hemorrhages, cerebral edema, multiple organ failure).

Thus, the reserves for reducing maternal mortality during cesarean section are: prevention of the development of purulent-septic complications; adequate anesthetic care; timely, adequate surgical intervention and replacement of blood loss during bleeding; timely resolution of the issue of abdominal delivery in the absence of effect from conservative therapy for severe forms of gestosis.

Reserves for reducing perinatal losses of children during pregnancy and childbirth include improving and finding diagnostic capabilities for assessing the condition of the fetus, increasing the proportion of planned cesarean sections and reducing the number of emergency operations, as well as the timely provision of qualified neonatological care.

Primary resuscitation of newborns after cesarean section is important. Often the obstetrician underestimates the importance of placental transfusion and, having raised the extracted baby high, crosses the umbilical cord. Sometimes incorrectly assessed fetal anesthesia depression becomes an indication for the unjustified massive use of resuscitation measures, including aggressive ones.

A previous caesarean section has a certain impact on the subsequent reproductive function of women: they may experience infertility, recurrent miscarriage, disorders menstrual cycle. Therefore, timely and correct technical performance of the operation, proper management of the postoperative period, and follow-up in the future are required.

Pregnancy in the presence of a scar on the uterus often occurs with scar incompetence, threatened miscarriage, and placental insufficiency. Pregnant women with a uterine scar should be under careful medical supervision and placed in a hospital in advance (2 weeks before birth). The choice of method of delivery for these pregnant women should be special attention, it is still a subject of debate. Spontaneous births in such patients should be managed by the most highly qualified specialists, in a hospital with constantly functioning anesthesiology, neonatology and other services.

Despite a fairly large number of scientific developments and practical recommendations for the management of pregnancy and childbirth in women with a uterine scar, the problem is very far from a final solution. This primarily applies to dispensary observation of this contingent of pregnant women, identifying symptoms of uterine scar failure at various stages of pregnancy, optimal timing hospitalization for normal and complicated pregnancy and, finally, to methods of delivery of women with a scar on the uterus (repeat cesarean section or vaginal delivery).

When managing pregnant women with a uterine scar in the antenatal clinic, special attention should be paid to the following. At the patient’s first appearance for an appointment, it is necessary to assess the condition of the postoperative scar based on the anamnesis, a detailed extract from maternity hospital(where methods for examining the scar in the early postoperative period should be indicated), obtain information about examining the scar outside pregnancy (hysteroscopic and ultrasound methods). Evidence of scar failure serves as a basis for termination of pregnancy up to 12 weeks. In this case, the woman must be informed about complications (up to uterine rupture) during pregnancy continuation and vital indications for termination of pregnancy.

Almost all obstetricians make a big mistake, already from the early stages of pregnancy they direct all women with a scar on the uterus to have a second surgical delivery. As studies have shown, vaginal birth in such women is not only possible, but also advisable. Repeated cesarean section with a full scar should be an alternative to spontaneous labor, and not vice versa.

In addition to conducting routine obstetric examinations during subsequent visits of pregnant women to antenatal clinic, the obstetrician should pay special attention to the complaints of patients with a uterine scar: first of all, to pain, its location, nature, intensity, duration, connection with physical activity; on the nature of discharge from the genital tract (in the presence of a scar, low placentation often occurs along the anterior wall of the uterus). At each visit, the scar on the uterus must be palpated through the anterior abdominal wall. It is easier to determine the condition of the scar in the area of ​​the uterine body, but much more difficult when it is localized in the lower segment of the uterus. In case of pop-

river suprapubic incision of the anterior abdominal wall, palpation of the scar is made difficult by cicatricial changes in the skin, subcutaneous tissue, aponeurosis, and high location of the bladder. Nevertheless, pain on deep palpation in the suprapubic region (in the area of ​​the supposed scar on the uterus), especially local, may indicate the inferiority of the scar, and the patient should be immediately hospitalized in a hospital, regardless of the stage of pregnancy, for a more detailed examination and to resolve the issue of the possibility of prolongation of pregnancy.

Rupture of the uterus along a scar located in the lower segment, according to most researchers, occurs much less frequently during pregnancy than after a corporal cesarean section. However, during dispensary observation of pregnant women with a scar after cesarean section, constant monitoring of the condition of the uterine scar is necessary, carried out from 32 weeks of pregnancy using ultrasound (before this period the information content of the method is minimal), as well as the condition of the fetus, the function of the fetoplacental system, the location of the placenta in relation to internal uterine os and scar.

During a normal pregnancy, ultrasound in women with a uterine scar should be performed at least three times (at registration, at 24-28 weeks and at 34-37 weeks). It is very difficult to assess the consistency of a uterine scar sonographically before 34-36 weeks of pregnancy. However, additional information obtained from echography can significantly help the doctor in choosing further tactics. You should pay attention to the tone of the uterus, the condition of the internal os of the cervix, the place of placentation, the correspondence of the size of the fetus to the given gestational age, the height of the bladder, etc. If there is a threat of miscarriage in the first half of pregnancy, urgent hospitalization in a hospital is necessary, where, after a thorough examination of the woman, adequate “conserving” therapy is prescribed.

The frequency of threatened abortion in the presence of a scar on the uterus, according to various authors, ranges from 16.8 to 34%. A careful differential diagnosis of this pathology with scar failure is necessary. The diagnosis should be clarified only in a hospital setting, with dynamic observation, based on clinical symptoms, ultrasound data, and the effect of therapy aimed at prolonging pregnancy. The main clinical symptom of uterine scar failure is local pain in the lower segment.

If the effect of “saving” therapy is positive, patients can be discharged from the hospital under the supervision of a doctor at the antenatal clinic. If there is a failure of the uterine scar, pregnant women should be in the hospital until delivery. Ultrasound monitoring of the condition of the scar should be carried out every 5-7 days.

Placentation is of significant importance in predicting pregnancy outcome in women with a uterine scar. When the placenta is located along the anterior wall, especially in the area of ​​the uterine scar, the risk of failure of the latter is very high. Such women need to be given the closest attention; they are indicated for planned hospitalization at 24-28 weeks of pregnancy, even with a favorable course. Invasion of chorionic villi is accompanied by the release of proteolytic enzymes that destroy connective and muscle tissue, and leads to the development of incompetent uterine scar.

In such pregnant women, the risk of uterine rupture (as a rule, in the absence of symptoms indicating the presence of risk) is very high; abruption of the low-lying placenta, intrauterine growth restriction syndrome, and termination of pregnancy often occur. Women require urgent hospitalization if the placenta is located on the anterior wall with increased uterine tone, if nagging pain

lower abdomen, attacks of nausea or weakness, with frequent or painful urination. When carrying out therapy that preserves pregnancy, it is necessary to remember that a number of drugs containing prostaglandin synthetase inhibitors (baralgin, aspirin, indomethacin, trigan, maxigan, etc.) increase the pain threshold of sensitivity with the threat of uterine rupture along the scar. A frequent complication in pregnant women with the placenta located in the area of ​​the uterine scar is the development of placental insufficiency and, as a consequence, hypoxia and malnutrition of the fetus. When examining the fetus, it is necessary to monitor the correspondence of its size to the given stage of pregnancy and perform Doppler measurements of blood flow in the vessels of the umbilical cord and the aorta.

clear anamnestic data and the results of additional research methods, with an uncomplicated course of this pregnancy. The history should include details of:

a) previous caesarean section; this information is drawn from an extract from the hospital where the operation was performed, or from the birth history, if the previous delivery took place in the same institution;

b) studies of the uterine scar conducted outside of pregnancy and during this pregnancy;

c) parity (whether there was spontaneous labor before the first cesarean section);

d) the number of pregnancies between cesarean section and real pregnancy, their outcome (abortions, miscarriages, complications);

e) the presence of living children, stillbirths and deaths of children after previous births;

f) during the current pregnancy.

After a comprehensive examination of the pregnant woman and diagnosis of the condition of the fetus, the question of the method of delivery is decided.

Methods for studying the condition of the scar on the uterus during pregnancy are practically limited to only one thing - ultrasound scanning. Ultrasound becomes most informative and practical from 35 weeks of pregnancy.

Many works of domestic and foreign authors are devoted to the development of ultrasound criteria for the consistency of a scar on the uterus after a cesarean section.

Echoscopic signs of failure of a uterine scar located in the lower uterine segment include not so much the overall thickness of the scar as its uniformity. Many authors believe that a scar with a thickness of more than 0.4 cm can be classified as complete, and less than 0.4 cm - defective. A scar with local thinning, regardless of its overall thickness, is considered defective. Studies have shown that “thick” scars are also ineffective. Despite their anatomical completeness (their total thickness was, as a rule, 0.7-0.9 cm), elements predominated in them connective tissue(morphological inferiority), and childbirth in such women due to cervical dystocia (functional inferiority) ended in repeated surgery.

It is very important that a woman agrees to one or another method of delivery, primarily to spontaneous birth, if possible.

us. Obtaining the consent of a pregnant woman for a repeat cesarean section is not very difficult.

Many researchers, based on personal experience, have come to the conclusion that with a strong uterine scar and satisfactory condition of the pregnant woman and fetus, vaginal delivery is not only possible and advisable, but also more preferable than a repeat cesarean section. The most important and difficult task is the selection of pregnant women with a uterine scar for spontaneous birth.

Regarding the optimal timing of subsequent pregnancies, it should be said that there is no consensus in the literature on this issue. Most obstetricians believe that a woman should become pregnant and give birth 2-3 years after a caesarean section.

Studying the morphological features of uterine scars at various times after surgery, doctors discovered: after 3-6 months, muscleization of the scars rarely occurs. During these periods, as a rule, young granulation tissue, atrophy and deformation of muscle bundles, and pronounced collagenization of argyrophilic muscle sheaths are detected. 6-12 months after cesarean section, complete regeneration of the myometrium is also not observed. It is dominated by the phenomena of diffuse myofibrosis. 2-3 years after the operation, micropreparations from the scar area reveal signs of diffuse myofibrosis, coarsening and collagenization of argyrophilic muscle sheaths. Similar changes are observed later after cesarean section. Consequently, after surgical delivery there is an organic and functional inferiority of the uterine wall.

In each specific case, an individual approach to choosing a method of delivery is required based on the results of the entire examination complex described above.

No more than one scar on the uterus in the lower uterine segment.

Normal pelvic size.

No other scars on the uterus.

No local thinning of the scar.

Absence of local pain in the lower uterine segment.

Placentation outside the scar area.

Uncomplicated course of the first cesarean section and the postoperative period.

Fruit less than 4000 g.

Absence of extragenital and other pathology that was an indication for the first cesarean section.

Management of childbirth in a large obstetric institution by a highly qualified obstetrician.

Possibility of quick (10-15 min) deployment of the operating room for emergency caesarean section.

A well-established uterine scar in the absence of any complications of pregnancy or extragenital pathology (independent indications for cesarean section) gives grounds to decide on delivery tactics in favor of vaginal delivery under careful clinical and monitoring control and with the operating room ready for immediate surgical delivery in in case of any complications during childbirth.

Repeated caesarean section is a technically more complex operation. When performing it, in some cases, difficulties arise at the time of opening the abdominal cavity, when dissecting the uterus, when removing the fetal head, or when suturing a uterine wound. They may be caused by the presence of a skin scar on the anterior abdominal wall fused to the underlying tissues, or intraperitoneal adhesions that complicate access to the uterus. Adhesions occur between the uterus and the anterior abdominal wall, between the parietal peritoneum and the omentum, between the omentum, intestinal loops and bladder. After a cesarean section, the bladder is often displaced upward as a result of peritonization or due to adhesions. As a result of changes in normal anatomical relationships during repeat cesarean section, injuries to the bladder and intestines are common.

During the removal of the head, especially of a large fetus, due to the intractability and minimal extensibility of the scarred tissue of the lower segment, uterine rupture in one or both directions may occur with damage to the vascular bundles, accompanied by massive bleeding, which entails an expansion of the scope of surgical intervention up to amputation or hysterectomy.

One of the serious complications is ligation or dissection of the ureter when performing hemostasis in the parametrial tissue.

Due to impaired contractile activity of the uterus, hypotonic bleeding often occurs during repeated cesarean section. Moreover, conservative methods of stopping it are often ineffective, which forces one to resort to ligation of the uterine vessels or removal of the uterus.

The high level of postoperative complications of repeat cesarean section also requires the obstetrician to be more careful about this operation. The incidence of endometritis (as a result of impaired uterine involution), as well as peritonitis and intestinal obstruction, is significantly higher than after the first cesarean section.

When studying the long-term results of repeated cesarean section, it was found that women years after the operation have various complaints. 25% of them experience periodic pain in the abdomen, in the suture area, and in the lower back. In 4.2% of women, postoperative hernias or the formation of rough fusions of the skin suture with the underlying tissues were detected.

Almost half of the women whose menstrual function did not change after the first cesarean section experienced various disorders in the form of polymenorrhea or oligomenorrhea after the second operation.

Deviations in the position of the uterus after repeated surgery are found in almost half of women. More often it turns out to be pulled up, less often - shifted to the side or posteriorly.

Repeated abdominal delivery should be even more justified than the first. In modern conditions, only the presence of a scar on the uterus after a cesarean section cannot cause a repeat operation!!!

Indications for re-operation are usually the following: severe extragenital diseases (because of them, the first caesarean section was usually performed), extreme obstetric situations (placental abruption and previa, uterine rupture that has begun and occurred). Absolute indications include a scar on the uterus after a corporal cesarean section, two or more scars on the uterus after surgical delivery, the location of the placenta in the area of ​​the scar, failure of the scar on the uterus according to clinical and echoscopic data. The risk of uterine rupture during spontaneous labor in these situations increases many times.

Thus, repeat cesarean section in pregnant women with a uterine scar cannot be the method of choice for delivery of these patients. Vaginal delivery is preferable. But they must be carried out in a large obstetric institution.

Institute, a highly qualified obstetrician with constant monitoring of the condition of the mother and fetus, with a 15-minute readiness to deploy the operating room, a permanent catheter in the vein and the presence of a sufficient amount of fresh frozen plasma (at least 1000 ml). Well-trained medical personnel should take part in the delivery of women in labor with a uterine scar, and close contact between him and the woman in labor is necessary.

Childbirth per vias naturales in pregnant women with a uterine scar, they are contraindicated in case of a complicated course of the first cesarean section, breech presentation of the fetus, lower-middle uterine scar, large fetus, twins. The risk of uterine rupture doubles for fetal weights >4000 g.

Delivery of women with an operated uterus should be carried out at 38-39 weeks of pregnancy, resorting to induction of labor with the help of prostaglandins or oxytocin. A number of authors recommend programmed spontaneous labor in women with a uterine scar using amniotomy for induction of labor during full-term pregnancy and a mature cervix. The chances of successful delivery through the natural birth canal of women with an operated uterus increase with the spontaneous onset of labor, as well as with induction of labor against the background of the biological readiness of the pregnant woman’s body for childbirth. A comparative analysis of the frequency of uterine rupture depending on the method of induction of labor or spontaneous onset of labor is given in Table. 21.

Table 21

Incidence and relative risk of uterine rupture during delivery of pregnant women with a uterine scar (Lydon-Rochelle et al., 2001)

Expectant management with careful monitoring of the nature of labor, the condition of the uterine scar and the fetus is advisable. For this purpose, external and internal tocography, constant cardiac monitoring of the fetus or pH monitoring are used. The absence of complaints from the woman in labor about local pain in the lower segment of the uterus between contractions or during palpation, regular labor activity recorded clinically and during tocography, and the normal condition of the fetus during monitoring indicate the consistency of the scar.

In the absence of regular labor after amniotomy or when it weakens during spontaneous labor, women with a uterine scar have to resolve one of the important and not yet fully resolved questions about the possibility of using uterine contracting agents.

During childbirth, 11.7-20% of women in labor with an operated uterus showed weakness in labor. With the administration of oxytocin, the risk of uterine rupture increases (Fig. 100), so the attitude towards the use of oxytocin should be reconsidered. The success of vaginal birth in women with a uterine scar is associated with refusal to use oxytocin.

The use of prostaglandins for induction of labor also increases the risk of uterine rupture from 0.5% during spontaneous labor to 2.9% during induction of labor with prostaglandins.

Rice. 100. Risk of uterine rupture per 1000 women giving birth with a uterine scar

During vaginal birth in women after cesarean section, great attention should be paid to adequate pain relief as an important measure aimed at relieving labor stress and allowing the obstetrician to objectively assess the mother's reaction to contractions. Epidural anesthesia is the most widely used method for pain relief during childbirth in women with an operated uterus.

Despite the changing attitude towards spontaneous delivery of pregnant women with a uterine scar and the continuing increase in the number of such births, this tactic remains risky and is still a weak alternative to a repeat cesarean section for many obstetricians.

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.

A transverse incision is made with a scalpel in the lower uterine segment and the index fingers of both hands are 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 the entire fetus by the armpits, trying to keep the child in the same plane with the uterus so as not to disrupt blood perfusion in the umbilical cord and general blood flow, then the umbilical cord is clamped 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)

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.

Highamniotomy (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 to 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

Secure the head in the entrance with rollers from the sides

We are transferred to the prenatal ward only on a gurney

In prenatal – bed rest, on the side, corresponding to the position

Earlyamniotomy (when the uterine os opens by 3-4 cm)

Indications:

1. 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

   Malinovsky M.S. Operative obstetrics.

   - M., 1974

   Chernukha E.A. Generic block. – M., 1996.

   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 its modern form, the cesarean section technique according to L. A. Gusakov is as follows. Transection is performed as usual - lower middle or Pfannekstiel. After fencing off the abdominal cavity with napkins, expanding and fixing the wound of the abdominal wall with 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 to the upper border of the bladder, 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, belonging to the lower segment, is thinner, and the upper edge, belonging to already towards the body of the uterus, after its contraction it becomes much thicker. 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.
   Caesarean 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.

   Video: Operation Caesarean section

   
   Attention, TODAY only!

   wounds of the abdominal wall, a wide suprapubic mirror and a retractor are used to find (preferably with tweezers) the movable part of the vesicouterine fold, loosely connected to the uterus. 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 to the upper border of the bladder, 2 cm away from it. The peritoneum is dissected in the same way in the other direction. This point of the operation is essentially the same as for a retrovesical caesarean section.

   Abdominal delivery rate

   Speaking about the frequent use of cesarean section, one should not consider only the data of individual institutions, nor, when comparing them, criticize certain scientists and cite the authority of others as evidence. The number of cases of this surgical intervention is influenced by numerous factors: the level of hospital care for pregnancy and childbirth in a given area or in the republic, specific gravity obstetric inferiority among hospitalized women preparing to become mothers and women giving birth in a certain maternity ward, generally accepted treatment instructions, doctors' qualifications, workload maternity facility, his profile, etc. In addition, it is advisable to understand the fact that the development of a system for organizing and providing accessible medical care to the population, for example, providing medical care during childbirth, reflects the stage of economic growth of the republic. In foreign countries, some other factors are added to these factors: the ownership of the maternity ward by the city authorities or maybe an individual business entity, mercantile positions and, possibly, the race of women in labor. From this follows diversity in indicators not only for some countries, but also within a particular country.

   Why can’t the given figures describe the situation about the real frequency of cases of artificial birth surgery today? A method exclusively based on statistical data for studying the huge number of birth processes in a large developed region can in a certain way level out such differences and determine an approximate figure reflecting the cases of artificial delivery as a delivery method for a given historically important period of time.

   Still, don’t consider the frequency at all abdominal surgery It is also not necessary to give birth in any separate maternity hospital. In favor of the organizers of childbirth, it should remain not indifferent when in a large, well-equipped hospital with qualified medical staff, the frequency of artificial birth operations becomes the same as in a small maternity ward.

   Both abroad and in our country, the press draws attention with some concern to the increase in the frequency of cesarean sections over the past decades, due to a significant improvement in the personal results of such a procedure for women in labor. In case we compare the corresponding figures, this assurance will remain only partially true. From the time when abdominal delivery was firmly included in medical activities, the frequency of this operation in European republics and the United States turned out to be traditionally high, in the republics of the Soviet Union - insignificant.

   
   back next In recent years, the interest of researchers in the problem of cesarean section is explained by a change in obstetric strategy and the expansion of indications for surgical delivery, as well as an increase in the number of pregnant women with a uterine scar. In Russia, there is an annual increase in the rate of caesarean section by approximately 1%. So, in 1997, according to the Ministry of Health of the Russian Federation, this figure was 10.1%, in 2006 - 18.4%.

   One of the important factors in the increase in cesarean section rates over the past two decades is that the operation is performed in the best interests of the fetus. Some correlation can be noted between the increase in cesarean section rates and the decrease in perinatal mortality from 15.8% in 1985 to 12.08% in 2002 and 11.27% in 2006. Currently, no one doubts the role of cesarean section in reducing perinatal mortality and, somewhat less, infant morbidity. However, it is clear that increasing the frequency of caesarean sections cannot solve the problem.

   The issue of cesarean section in premature pregnancy deserves special attention. When the pregnancy is up to 34 weeks, cesarean section is not the operation of choice, and it is performed mainly for emergency reasons on the part of the mother. During these stages of pregnancy, insufficient expansion of the lower segment of the uterus occurs. For a fetus with a gestation period of 26-32 weeks and a fetal weight of up to 1500 g, when careful delivery is extremely important, the nature of the incision on the uterus is important. Today, new indications for surgery have appeared, the frequency of which is quite high (10.6%) - this is induced pregnancy after in vitro fertilization.

   An increase in the frequency of abdominal delivery creates new problem- management of pregnancy and childbirth in women with a uterine scar. The issue of independent vaginal birth after cesarean section has been discussed in our country since the 60s. According to modern data, from 30 to 60% of pregnant women who have undergone a cesarean section can give birth on their own with a favorable outcome for the mother and fetus.
   Despite its widespread use, caesarean section is classified as a complex operation with a high incidence of postoperative complications - 3.3% -54.4%, which are also associated with the intervention technique.

   Currently, various modifications of the cesarean section operation are known, which differ in the method of access to the uterus, the features of the incision and suturing of the wound. The choice of a particular technique is determined by objective prerequisites, which include gestational age, features of presentation and size of the fetus, the presence of a scar and concomitant pathology uterus (uterine fibroids, infectious processes etc.), as well as the surgeon’s preferences, depending on the traditional medical school and his own experience.

   Currently, to perform a cesarean section, transverse transsection according to Pfannen-Stiel, Joel-Cohen, Cohen, or an inferomedian incision is mainly used. Transverse incisions began to be introduced into obstetric and gynecological practice in turn of XIX-XX centuries after J. Pfannenstiel (1887) proved a decrease in the frequency of formation postoperative hernias when using a suprapubic incision. Most researchers consider it advisable to perform a Pfannenstiel laparotomy. When performing this technique, an incision is made along the line of the suprapubic skin fold.

   Today there are many supporters of laparotomy according to Joel-Cohen, first described in 1972. In this modification, laparotomy is performed by a superficial linear transverse incision of the skin 2-2.5 cm below the line connecting the anterosuperior spines iliac bones. Using a scalpel, a deepening of the incision is made along the midline in the subcutaneous fatty tissue, the aponeurosis is incised, which is then cut to the sides with the ends of straight scissors under the subcutaneous fatty tissue. The surgeon and assistant simultaneously separate the hypodermic fatty tissue and rectus abdominis muscles by bilateral traction along the skin incision line. The peritoneum is opened with the index finger in the transverse direction.

   The J. Joel-Cohen incision differs from the Pfannenstiel incision at a higher level, it is straight and not arched, the aponeurosis is not detached, and the peritoneum is opened in the transverse direction. Due to the higher level of the incision and the use of a blunt tissue spreading technique in the angles of the incision, the branches of the pudendal and superficial epigastric vessels and the vessels penetrating the rectus abdominis muscles from the aponeurosis, which are usually damaged during Pfannenstiel laparotomy, are kept intact. As studies by V. Stark (1994) have shown, this access is performed quickly, is practically not accompanied by bleeding and creates adequate conditions for performing a cesarean section. However, the Joel-Cohen incision is inferior in cosmetic terms to the Pfannenstiel incision.

   Currently, obstetricians during laparotomy proceed not only from the size and location of the surgical approach, but also from the time factor. Laparotomy according to Cohen, in contrast to Pfannenstiel, involves a partially blunt entry into the abdominal cavity (opening of the aponeurosis by an acute method), which leads to a significant reduction in the duration of the operation and a decrease in the time before extraction of the fetus.

   Opening the vesico-uterine fold with its subsequent peeling down and displacement of the bladder before making an incision on the uterus is the prevention of its injury and provides conditions for peritonization of the uterine wound after suturing. This provision was introduced into obstetric practice at the end of the 18th century, when the frequency of infectious complications was significant, and it was assumed that the peritoneum creates a barrier sufficient to prevent the spread of infection. It has now been proven that the exclusion of this stage of cesarean section does not lead to an increase in the incidence of infection and adhesions in the postoperative period, but is combined with a reduction in the duration of surgery, reduces the risk of bladder injury, and reduces the need for analgesics.

   In 1912, Kronig proposed making a vertical incision during CS, and Kerr in 1926 - a transverse incision in the lower segment of the uterus. Recently, the most recognized transverse incision is in the lower segment of the uterus. It is believed that it is performed along the circularly located muscle fibers of the lower segment and therefore is more anatomical, and the usefulness of the formed scar gives the lowest frequency of divergence in repeated pregnancies. It is usually performed after opening the vesicouterine fold and bluntly displacing the bladder. The existing disagreements, as a rule, concern the technique of extending the incision on the uterus in lateral directions: this is either a sharp dissection with scissors (according to Derfler) or blunt muscle dilation (according to Gusakov).

   When using the Derfler method to approach the lower segment of the uterus after laparotomy, a transverse incision of the peritoneum is made along the vesicouterine fold and the peritoneum with the bladder is bluntly displaced downward so that the lower segment of the uterus is exposed. Then a transverse incision of the uterus 2-3 cm long is made. Under the control of fingers inserted into the wound and under visual control, the incision is enlarged with scissors in an arcuate manner in the lateral directions.

   According to supporters of the Derfler technique, the advantages of acute dissection are the ability to correctly calculate the size and course of the incision, less traumatic for the uterine tissue (than dissection muscle tissue uterus bluntly according to Gusakov), which avoids damage to the uterine vessels and ensures better access to the fetal head, reducing the risk of injury. However, performing a Derfler incision is difficult in case of severe bleeding during uterine dissection, for example, with varicose veins or localization of the placenta in the area of ​​​​formation of the aperture.

   The technique of L. A. Gusakov, whose supporters are A. S. Slepykh (1986), V. I. Kulakov (1999), E. A. Chernukha (2003), L. M. Komisarova (2004), involves dissection of the uterus at the level vesicouterine fold with minimal displacement of the bladder. After a transverse incision of the lower segment of the uterus, widening of the wound can be achieved by blunt spreading in a horizontal direction using the index fingers. Proponents of this technique note that it is relatively easy, quick and safe to perform.

   A. L. Rodrigues et al. (1994), in a comparative assessment of blunt and sharp dissection of the lower segment, did not find any difference in the ease of removing the child, the amount of blood loss and the incidence of postoperative endometritis.

   Hysterotomy with a vertical incision of the body of the uterus, performed acutely, leads to injury to the muscle layer (transverse dissection), accompanied by significant bleeding, difficulty in peritonization of the wound and the formation of an incompetent scar during subsequent pregnancy.

   To reduce the risk of injury to a low birth weight newborn great importance attached to a vertical incision of the uterus in the area of ​​the lower segment of the uterus. During an isthmic-corporeal caesarean section (formerly the term “caesarean section in the lower segment of the uterus with a longitudinal incision”), before the hysterotomy, the vesicouterine fold is opened, followed by separation of the bladder and the uterus is dissected along the midline in the lower segment, moving to the body of the uterus. At the suturing stage, a continuous double-row suture is applied to the uterine wound, followed by peritonization of the vesicouterine fold. According to N. Mordel (1993), a comparative assessment of cesarean section in the lower segment of the uterus, performed with a transverse or longitudinal incision, did not reveal a significant difference in the incidence of complications and perinatal mortality. It has not been established in relation to uterine ruptures along the scar.

   A. N. Strizhakov et al. (2004) highlight a vertical incision of the uterus in the lower segment, considering it safer with respect to damage to the lateral vascular bundles. To perform it, they recommend freeing the lower segment from the vesicouterine fold in the same way as during a caesarean section with a transverse incision. Then the incision begins in the lower part of the segment, where a scalpel is used to open the uterus in a longitudinal direction in a small area and enlarge it with scissors upward until it reaches an adequate size for extracting the fetus. According to the authors, in most cases there is no need to continue the incision into the body of the uterus (isthmic-corporal incision).

   They recommend its use in cases of suspected difficulty in removing the baby through a transverse incision and in cases of premature fetuses to reduce the risk of injury. Other authors proposed making an incision in the lower segment 1.0-1.5 cm above the vesico-uterine fold, 2-3 cm long, to a depth of 0.5 cm, followed by blunt perforation of the uterus to the amniotic sac and enlarging the opening in the uterine wall at the same time diluting the serosa, muscle fibers and mucosa in the longitudinal direction (up and down) to 10-12 cm. Forming a hole (aperture) in the uterine wall along the upper border of the lower segment allows you to control the size of the wound, reduces the risk of injury to the bladder, vascular bundles of the uterus, reduces the amount of blood loss, prevents possible damage to the fetus with a scalpel, improves the conditions for fetal extraction. This creates optimal conditions for regeneration (reduction of the wound and good coaptation due to postpartum involution uterus), which is a certain guarantee of the completeness of the restoration of the lower segment.

   In the interests of the fetus, a “parabolic” incision of the lower segment was also proposed, which is performed 1-2 cm above the level of the vesicouterine fold with an acute extension of a small transverse incision from its corners on both sides along the uterine vessels. It is recommended to make this incision without opening the amniotic sac, which, according to other authors, reduces the risk of injury when removing a premature fetus.

   Along with the advantages of surgery in the lower segment of the uterus with a transverse incision compared to corporal and isthmic-corporal, complications associated with suturing a wound on the uterus are also observed. One of the complications during the operation is the suturing of the bladder in case of insufficient detachment from the lower segment of the uterus. When sutures are applied to the corners of the incision on the uterus, especially with varicose veins, damage to the vein wall is possible with the formation of an intraligamentary hematoma. Also, one of the serious complications is suturing the upper edge of the wound of the lower segment of the uterus to its posterior wall.

   If there is a high risk of developing postoperative infectious complications, cesarean section techniques are used; allowing to reduce the possibility of the spread of infection: cesarean section with temporary delimitation of the abdominal cavity and extraperitoneal cesarean section.

   In recent years, advocates have emerged for removing the uterus from the abdominal cavity (exteriorization) after removing the fetus and placenta. They believe that removing the uterus from the abdominal cavity facilitates suturing the wound, promotes contraction of the uterus and reduces the amount of blood loss. Some obstetricians believe that this should not be done, except in cases of severe bleeding from the corners of the incision on the uterus during its extension, when performing a conservative myomectomy. Other authors believe that when the uterus is removed into the wound, the level of the incision is higher than the heart, which creates a hydrostatic gradient that promotes air embolism of the uterine veins.

   There is no common point of view regarding the methods of suturing a wound on the uterus. Some authors believe that a wound on the uterus should be sutured with a double-row suture, others with a single-row suture. Views differ on the question of whether to pierce the mucous membrane when applying sutures or not. There is no consensus as to which suture should be placed on the uterus - continuous or separate sutures.

   The most common method until the 80s of the last century was the application of separate muscle-muscular sutures in two layers. Some authors considered it more hemostatic to use muscular-mucosal sutures when suturing the first row. In his work, V.I. Eltsov-Strelkov (1980) showed that one of the main reasons for the violation of the tightness of a double-row muscular-muscular suture is the location of the nodes of the first row between the contacting surfaces of the cut, and the absence of sutures on the uterine mucosa does not provide the necessary strength of the suture in in general. L.S.

   Persianinov (1976) also used tying knots of the first row towards the uterine cavity, but the suture passed through all layers, the second row was sutured with separate U-shaped catgut sutures. In order to reduce the incidence of suture infection and the risk of developing scar endometriosis, M.D. Seyradov (1998) applied the first floor of muscular-mucosal sutures using a thread charged at both ends on two needle holders. A number of authors, having studied the course of the postoperative period when suturing the uterus with separate sutures in two and one row, came to the conclusion that the overall frequency of inflammatory complications when suturing with a single-row suture was 1.5-2 times lower.

   However, a continuous suture has been used for more than 20 years and is considered just as effective when suturing a uterine wound. Currently, a continuous “wound” or “furrier” (according to Schmieden) mucomuscular suture is used. The last option differs in that the needle is inserted from the side of the uterine cavity. In this case, double-row suturing of the wound is used. IN AND. Kulakov et al. (2004) suggest placing a second row of sutures between the first row of sutures. The second row can be applied with separate sutures or a continuous suture. Proponents of applying a continuous suture to a uterine wound argue their position by the ease of execution and reduction of operation time while maintaining tightness and good hemostasis, reducing the total amount of suture material, which reduces the activity of the inflammatory reaction and promotes the quality of reparative regeneration processes.

   Currently, suturing the uterus during caesarean section in one layer is more widely used. The basis for the use of this technique is the fact that frequent suturing creates an area of ​​tissue hypoxia with a disorder in the function of myometrial cells, which disrupts the course of reparative processes. In addition, with a double-layer wound suturing technique, the first row of sutures is immersed inward, which leads to a narrowing of the uterine cavity at this level and impedes the natural outflow of lochia, predisposing to the development inflammatory process. In this regard, a number of authors recommend suturing the wound after cesarean section with single-row muscle-muscular sutures or mucomuscular sutures using synthetic absorbable threads. It is proposed to restore the lower segment using a single-row continuous entwining serous-muscular intramucosal suture.

   Quite often, in the process of suturing a wound of the lower segment of the uterus, a continuous suture with a locking overlap is used, which prevents the thread from relaxing. At the same time, it is believed that the overlapped suture increases ischemia and tissue damage. There are different data comparing the long-term results of suturing the uterus in one and two layers.

   D. Kiss et al. (1994), based on a histological examination of the scar 2-7 years after cesarean section, came to the conclusion that with single-layer suturing of the uterus, vascularization and the ratio of muscle and connective tissue in the scar area are significantly better. V.M. Winkler et al. (1992) on a large clinical material showed that a lower incidence of postoperative morbidity was with a single-layer suture. The scar in this group was better vascularized, and its good functional characteristics were evidenced by a low rupture rate (1 observation per 536 cesarean sections).

   In the 8th group of women (256 cases) with double-layer suturing of the uterus, there were 2 cases of uterine rupture along the scar; a hysterosalpinographic study between pregnancies showed a higher frequency of filling defects in this area. However, according to S. Durnwald (2003), with single-layer suturing of the uterus, the risk of the formation of “windows” in the scar at the time of birth may increase.

   Thus, the main provisions of the currently proposed 9 methods of suturing the uterus are a reduction in rows and continuity of application of the uterine suture. Currently, suture material is used that is durable, non-reactive, absorbable, convenient for the surgeon, universal for all types of operations, differing only in size depending on the required strength. Modern suture material contributes to the quality of reparative regeneration of the suture on the uterus. However, changes in the tissues of the uterine wall around the threads are nonspecific and consist of tissue edema, vascular congestion and initial polymorphocellular infiltration. In the experiment M.E. Shlyapnikova (2004) when implanting a thread in close proximity to the endometrium, the infiltrate occupied a large area, and the tissues adjacent to the suture canal showed signs of pronounced edema and congestion of the microvasculature.

   The basis for performing uterine peritonization was laid by the work of Sanger during classical caesarean section more than 100 years ago. Closure of the wound with the visceral peritoneum during CS with a vertical incision in the lower uterine segment was introduced in 1912 by Kronig, and from 1926 Kerr transferred this position to an operation with a transverse incision.

   Today, peritonization of the uterine incision during cesarean section using the vesicouterine fold of the peritoneum is still a traditional stage of this operation. Numerous supporters of peritonealization and suturing of the peritoneum when restoring the anterior abdominal wall believe that suturing the peritoneum is necessary in order to restore the anatomy and compare tissues for better healing, restore the peritoneal barrier in order to reduce the risk of wound divergence and the formation of adhesions. However, techniques for suturing the uterus in one row are already used continuous suture with simultaneous peritonization. At the same time, in modern literature there are works that scientifically refute the need for peritonization of the uterus during caesarean section in the lower segment.

   Back in the 80s. Studies have been conducted that have proven that the number of adhesions formed at the surgical site directly correlates with the quantity and quality of the suture material. Applying a suture to the peritoneum causes additional damage to its cover, disruption of vascularization with ischemia, which contributes to the development of the adhesive process.

   The principled approach of not suturing the peritoneum during caesarean section was further developed in the works of M. Stark (1995) and D. Hull (1991). The authors present the results of operations in which both the visceral and parietal peritoneum were not sutured. At the same time, the advantages of this approach were noted: reduction of operation time, the need for postoperative use of painkillers, the incidence of intestinal paresis, and earlier discharge. M. Stark provides observations of repeated cesarean sections in women who did not undergo suturing of the serous membranes during the first operation. In these observations, the peritoneum evenly covered the lower segment of the uterus; no signs of adhesions were found.

   In the study by A.N. Strizhakova et al. (1995) during laparoscopy 6-8 hours after surgery, pronounced initial signs restoration of the serous cover of the uterus and parietal peritoneum, confirming that suturing the parietal and visceral peritoneum after cesarean section is not necessary for the normal course of the postoperative period and wound healing.

   Currently, there are many supporters of a cesarean section in the lower segment of the uterus as modified by M. Stark (1994), who recommends: dissecting the anterior abdominal wall according to the Joel Cohen method, after opening the peritoneum, dissecting the vesicouterine fold without displacing the bladder, making an incision the lower segment of the uterus in the transverse direction, after removing the fetus and removing the placenta, remove the uterus from the abdominal cavity. The uterine wound is repaired with a single-row continuous vicryl suture using the Reverden method. Peritonization of the suture on the uterus is not performed. The peritoneum and muscles of the anterior abdominal wall are not sutured; a continuous vicryl suture according to Reverden is placed on the aponeurosis. Authors using this method indicate a decrease in the time of the operation, the amount of blood loss and the severity of postoperative pain.

   Thus, in recent years, the technique of caesarean section has changed. The choice of the location of the incision on the uterus is planned taking into account data on the functional morphology of the uterus, structural changes in the isthmus, and the condition of the lower segment during pregnancy and childbirth. Cesarean section techniques are used in the lower segment without bladder detachment, and methods of uterine dissection in the lower segment above the vesicouterine fold. The capabilities of these methods help improve the conditions for fetal extraction, and, consequently, reduce its traumatism, reduce the risk of damage to the bladder and disruption of its function in the postoperative period.

   Rapid involution of the uterus in the postoperative period with an adequate choice of incision site and modern suture material optimizes the processes of reparative regeneration of the suture and reduces the frequency of postpartum inflammatory diseases. The surgeon's qualifications, surgical technique, and modern suture material still play a role main role in improving surgical outcomes.