Types of caesarean section according to the author. Is natural childbirth possible after cesarean? Indications for a vertical incision on the uterus

Modern doctors are increasingly deciding during natural childbirth about surgical intervention, in which the child is removed from an incision made in the uterus. A long time ago C-section causes controversy about how dangerous this operation is for mother and baby. There is no clear opinion, but in most cases it is this decision that saves lives and allows one to avoid severe birth injuries. The consequences of CS are not so critical and most of them are eliminated. Complications after it do not occur more often than after other abdominal operations.

Depending on where and what kind of incision is made, as well as the urgency of the operation, there are different types of cesarean section, each of which has its own characteristics.

At the location of the incision

Abdominal view

This option of cesarean section is the most common. It involves a suprapubic or longitudinal (from the navel to the pubis) incision of the peritoneum followed by dissection of the lower segment of the uterus. It is carried out under anesthesia, so it lasts no more than 10-20 minutes so that the drug does not enter the baby’s body. The amniotic sac is ruptured, the baby is removed, and the placenta is removed.

Corporal view

A corporal (trunk) cesarean section involves an infero-median incision across the entire abdominal wall. It should be located exactly in the middle of the uterus so as not to provoke profuse bleeding. The abdominal cavity after the incision is isolated so that particles of the placenta and amniotic fluid do not get into it, which can lead to internal inflammatory diseases.

Extraperitoneal view

Extraperitoneal (extraperitoneal) caesarean section is performed without such dangerous interference into the sensitive area of the abdominal cavity. The incision is made longitudinally, offset to the left from the middle of the abdomen, only the muscles are dissected. This type of cesarean section is contraindicated for placental abruption, uterine rupture, scars from previous operations, and tumors.

Vaginal view

Rarely used, requires high surgical skill and experience. This is an abortion in 3-6 months of pregnancy, with scarring on the cervix, a sharp deterioration in the woman’s health, or placental abruption. Can be produced according to two different techniques.

A small part of the uterus is dissected along the anterior wall. The cervix remains intact, injuries are excluded, and the young mother is recovering quickly.
It is much worse when an incision during a caesarean section of this type is made along the walls of the vagina and uterus. It severely damages internal organs and requires a longer rehabilitation period.

Minor caesarean section

This is also an abortion, but already later pregnancy (from 13 to 22 weeks) with severe functional impairment in the mother or child. An incision is made along the anterior wall and cervix, through which the embryo and placenta are removed. This caesarean section is very traumatic and is prescribed when no other birth is possible.

By urgency

Depending on whether the upcoming complications were previously known, or whether they arose suddenly during delivery, a caesarean section can be of two types - planned and emergency. The first allows both the woman and the doctor to prepare as much as possible for surgery. It is much more difficult when problems arise already at the moment the baby is born.

Planned surgery

It is carried out if, even during the pregnancy stage, during examinations, indications for surgical intervention were identified. Since they entail complications for the health and life of the mother and fetus, a decision is made to prepare the woman for surgery.

Indications

Indications for a caesarean section can be absolute when there is no other choice, since the life and health of the mother and child are in the balance. They can also be relative, when the threat is not so great. In the latter case, the spouses’ opinions are asked whether they agree to the CS or not. Depending on which side the pathologies are found on, the reasons for the operation may relate to the conditions of the woman in labor or the fetus.

Testimony from the mother

Narrow pelvis;
risk of uterine rupture;
abnormal placenta previa;
its detachment;
scars on the uterus;
previous corporal (peritoneal) caesarean section;
T or J-shaped uterine incision;
previously performed uterine operations of any nature;
two or more CS already performed;
HIV infection;
genital herpes;
any kind of cardiovascular disease;
vision problems;
pathologies of a pulmonary, neurological, gastroenterological nature;
injuries, tumors of any origin of the pelvic organs;
late toxicosis in severe form;
plastic surgeries performed on the perineum;
genitourinary or entero-genital fistulas;
gastroschisis - prolapse of intestinal loops (this can be other internal organs) through a cleft in the abdominal cavity;
teratoma - ovarian tumor;
abdominal infections;
uterine cancer;
gestosis;
preeclampsia is a type of gestosis with clear signs cerebrovascular accidents.

Fetal indications

breech or transverse presentation;
malpresentation multiple pregnancy;
monoamniotic twins;
too long dehydration in the fetus;
twin fusion;
delayed development of one fetus in multiple pregnancies;
premature birth.

Here are the cases in which a cesarean section is performed: the medical indications for this operation must be observed very strictly. In their absence, a woman’s mere desire to give birth this way is not enough. For abdominal surgery, which will have a lot of consequences for the health of mother and child, we need good reasons. Fear of pain during childbirth is not one of them. After identifying the indications, a decision is made about a CS and the preparation stage begins.

Attention! If an ultrasound shows that monoamniotic twins are developing in the womb, they can be born exclusively by caesarean section. These twins develop in the same bladder, they share one placenta, and they cannot be born on their own without injury.

Preparation

As soon as the doctor has identified complications and pathologies that prevent natural course childbirth, preparations begin for a caesarean section, regardless of whether it is planned or emergency.

In the first case, everything will go much easier and better, since much more time will be spent on this stage. The woman will have time to prepare herself mentally for the operation and will be better prepared physically. Preparation will include two stages - at home, at last weeks before childbirth, and in the maternity hospital, immediately before the scheduled date of the operation.

At home

Regularly visit a gynecologist, come to the antenatal clinic at his first request, and take all necessary tests.
Enroll in special courses to prepare for a planned cesarean section.
Inform your doctor about any deviations in your health and condition.
Eat properly.
Lead a healthy, proper lifestyle, follow a daily routine.
Be physically active in moderation.
Before sending to the maternity hospital, prepare things, documents, money, clothes, and pack bags in advance.

In the maternity hospital

Do not shave your pubic area yourself, as this can cause infection.
Two days before a cesarean section, you should not eat solid food.
Approximately 12 hours before surgery, you should not eat at all, as anesthesia can cause vomiting.
The day before, all the details are discussed again with the doctor: is everything okay with the baby? this moment time, whether any of the relatives will be with the woman in labor at this crucial moment.
If a caesarean section is performed as an emergency, preparation is reduced to several hours and includes screening for allergies to anesthesia and medications used during the operation. It is also specified when the woman in labor last took food.

Throughout the entire preparatory period for a cesarean section, the woman in labor is monitored and led to the operation by a whole team of doctors: a gynecologist, an anesthesiologist, a surgeon, and a therapist (if indications are identified from the mother’s side). Their joint task is to eliminate as much as possible all complications during the operation. Find out in advance what week you will have a CS in order to agree with the doctors on a date that is convenient for everyone.

Opinion. Some consider the big advantage of a cesarean section to be that you can accurately plan the baby's birth date. Indeed, you can make it coincide with some holiday or birthday of one of the other family members. Natural childbirth does not have such an advantage, since it is never possible to accurately guess its timing.

Deadlines

As part of your preparation, ask your doctor in advance about the timing of a caesarean section so that there are no problems with the appointed date. There are indications for this too.

Normal timing elective surgery are almost the same number of weeks as during natural childbirth: 39-40.
In case of multiple pregnancy, the mother is HIV-infected, the operation is performed at 38 weeks.
In the presence of monoamniotic twins, a planned CS is scheduled at 32 weeks.

In any case, even these recommended periods are purely individual and depend on a combination of a large number of factors. These include the health of the mother and the intrauterine condition of the baby. Once the cherished date has been set, all that remains is to wait for it. To be sure, some women learn the progress of the operation in detail, so as not to worry and know what happens at one time or another during a caesarean section.

Keep in mind! The date of the planned CS is set by the doctor, you can only ask him if it can be moved. Usually 1-2 days are not significant.

Progress of the operation

Since during epidural anesthesia the woman remains conscious, even before the operation begins, she is interested in knowing how a caesarean section is performed in order to be internally calm and not be surprised by anything, as well as how long this whole procedure lasts in order to be patient and calculate her strength. This allows you to relax and not distract doctors with unnecessary questions during the operation.

Preparation

They give an enema.
A catheter is inserted.
They put on an IV (most often with antibiotics).
They give pain relief.

Operation

An incision is made.
The child is removed.
The placenta is removed.
The wound is stitched up. Typically, the operating time is calculated from the moment the incision is made until the last suture is placed.

Recovery

The woman in labor is transferred to the intensive care unit (depending on her condition, she will spend 1-2 days there).
Body support medicines through an IV.
If there are no complications, the young mother is transferred to the ward.
You can get out of bed (very carefully and briefly) on the 3rd or 4th day.
Before discharge, an ultrasound is prescribed after a cesarean section, which allows you to check for internal bleeding and the condition of the seams. Ultrasonography uterine examination is performed regularly after this operation during the first six months to identify complications.

A caesarean section is not complicated at all. Most of all, women are usually concerned about how long the entire operation lasts. On average, from 25 minutes (in the absence of complications or surprises) to 2 hours. For multiple pregnancies, the procedure usually takes at least an hour. These indicators are also very individual and not always predictable.

Wow! Oddly enough, the longest stage of a caesarean section is suturing the wound, as this is truly a jeweled job that requires real skill from the surgeon.

Recovery period

One of the most important stages- rehabilitation after cesarean section, because every woman wants to care for her newborn as quickly as possible. However, this does not always work out. If there are complications, recovery may take an indefinite period. To speed it up and eliminate factors that inhibit it, you should follow medical recommendations.

First days

You will have to spend the first day in intensive care under IV drips. On day 2, they are transferred to a regular ward. Then they are allowed to stand up for a short time, walk, eat more or less normal food and care for the baby. In three days they will be allowed to land. So special care After a caesarean section, the woman in labor does not need to take care of herself.

Nutrition

On the first day after surgery, you are allowed to drink only water. Next, during the week you should adhere to a diet that prevents constipation: they should be avoided by any means after a cesarean section.

Figure restoration

This is perhaps the most difficult thing. There are only two ways to remove a sagging tummy, tighten your breasts, and lose excess weight. The first is diet, but it is contraindicated during lactation. Second - physical exercise, which after surgery are possible only six months later. You can get out of this situation by not overeating, eating right, and also leading active image life. You can walk a lot and do simple exercises at home, designed specifically for young mothers after a cesarean section.

Cycle recovery

The menstrual cycle after a cesarean section takes longer to recover than after a natural birth. If for some reason a woman was unable to breastfeed her baby, the previous rhythm returns after 2-3 months. During lactation, menstruation after a cesarean section may be delayed by 3-4, or even 6-7 months.

Restoration of the uterus

The uterus after a cesarean section also takes a little longer to heal than after a natural birth. In this regard, they can be released for 6-8 weeks. Sex life it will be possible to start exactly from the moment they end (we already wrote about this in).

But conceiving the next baby is recommended no earlier than after 2 years. According to research, this is how long it takes for muscles to fully recover after surgery. Otherwise, the stitches may come apart and the uterus itself may rupture. It is because of its contraction that after a cesarean section the stomach hurts for 2-3 weeks. Then these discomfort should quiet down.

Healing of sutures

Home, self-care after cesarean section suggests hygiene procedures: treatment with antiseptics, applying bandages, avoiding contact with water in the first week. In the presence of bleeding and suppuration, self-medication is excluded: you must seek help from a doctor as soon as possible.

We should not forget that, in addition to physical recovery body, a woman needs psychological rehabilitation after caesarean section. Numerous conversations that such an operation disrupts the close bond between mother and child give rise to a real inferiority complex in young mothers. It requires titanic internal efforts and the help of family and friends. Moreover, if any complications arise after the CS.

Psychological support

To reassure a young mother, you can tell her which of the modern celebrities gave birth to a baby by caesarean section. Among them are Victoria Beckham (three planned cesareans), Christina Aguilera, Britney Spears, Jennifer Lopez, Claudia Schiffer, Kate Winslet (emergency surgery), Angelina Jolie, Pink, Shakira, Gwyneth Paltrow and many other famous women.

Consequences

You need to understand that this operation is intracavitary, it affects the activity internal organs Moreover, anesthesia has a significant effect on the bodies of the mother and child. Therefore, the consequences of a cesarean section are inevitable. Over time, all these difficulties can be overcome.

If a young mother has a great desire to recover faster, if she leads healthy image life and listens to all the instructions and advice of doctors, all troubles will be left behind. If you take this lightly, living one day at a time, the risks of a cesarean section develop into complications that will require further treatment.

Consequences for the mother

Incorrectly performed epidural or spinal anesthesia leads to serious spinal cord injury and long-term pain;
an allergy not detected in time provokes a severe toxic reaction to the drug administered for pain relief;
difficulties with lactation;
very long recovery period with a number of prohibitions;
at large blood loss anemia develops;
the pain of the sutures forces a woman to take medications that are undesirable during lactation;
a ban on sports in the first six months leads to recruitment excess weight and vagueness of the figure;
the risk of formation of adhesions is very high;
The doctor must immediately warn the woman how long after a caesarean section she can give birth: next conception It is recommended to plan only after a couple of years (pregnancy after cesarean section);
subsequent births in 80% of cases also end in caesarean section.

Consequences for the child

Due to anesthesia, a newborn often experiences a decrease in heart rate, impaired breathing and motor skills, and disorientation in space;
difficulty with the sucking reflex;
disruption of the baby's adaptation to environment;
reduced immunity.

As a rule, complications after a cesarean section appear if something did not go according to plan during the operation: problems arose with anesthesia, the mother’s condition sharply worsened, the child was born with some kind of pathology, etc.

Childbirth is always unpredictable, so there can be no guarantee that everything will go perfectly. However, women should calm down in this regard: at risk undesirable consequences no less than with a cesarean section.

What is the difference between complications? There is a high risk of natural childbirth birth trauma for a child and uterine rupture for a woman. After a cesarean section, most complications are related to the effects of anesthesia and suture dehiscence.

Advantages

To reassure herself, a woman should appreciate in advance all the advantages of a cesarean section, which are noted by doctors and those who have given birth to a baby this way:

This the only way out if there is a threat to the lives of mother and child;
anesthesia;
perineal ruptures are excluded;
the operation ends quickly;
the ability to choose the baby’s birthday;
predictable outcome;
minimal risk of hemorrhoids;
absence of birth injuries.

Most women prefer to give birth by caesarean section precisely because they are afraid pain during childbirth. However, here it is worth considering the other side of the coin: the anesthesia used cannot pass without a trace for either the mother or the baby. Therefore, having assessed the advantages of a CS, do not forget to take into account why a cesarean section is dangerous, i.e. all its possible disadvantages.

Flaws

Many people are frightened by the fact that the disadvantages of a cesarean section are a much longer list than its advantages. However, not all of them necessarily appear after surgery. At proper care and lifestyle, many of them bypass women. Among the most common shortcomings are:

the recovery period lasts many weeks;
mandatory bed rest, which prevents the newborn from fully exercising;
pain in the suture, abdomen, back;
taking painkillers that are undesirable during breastfeeding;
: there may be too little milk, and sometimes it does not appear at all;
ban on intense sports;
the presence of an ugly seam on the stomach spoils the appearance;
after a caesarean section it will be difficult to give birth on your own;
a scar on the uterus complicates subsequent pregnancies and childbirths;
ban on conceiving a child in the next 2 years;
negative effects of anesthesia on the fetus;
poor adaptation of the baby to the environment in the future.

First of all, it is worth assessing all the pros and cons for the child during a cesarean section. He won't get hurt while walking birth canal, as often happens during natural childbirth. But it is worth considering the effect of anesthesia on his small body. So discuss all these points with your doctor in advance.

Amazing fact. Despite the fact that domestic doctors claim that after a caesarean section you will not be able to give birth many times, there are facts that indicate the opposite. For example, the wife of Robert Kennedy (35th President of the United States) experienced 11 successful caesarean sections.

And other features of the CS

Despite the fact that the problems of cesarean section, its pros and cons are widely discussed in the media today, women can rarely calm down their anxiety before the operation. Arises a large number of issues ranging from small nuances to large-scale issues. You will find answers to some of them below.

How many times can you have a caesarean section?

It is not recommended to do this operation more than three times. After the third operation, doctors warn the young mother that the condition of the uterus and the scars on it is becoming more and more critical each time, which is fraught with ruptures, bleeding and death of the fetus. However, everyone’s body is so individual that reusable CS, especially in the West, is not prohibited today. The question of how long a caesarean section can be performed specifically in your case can only be answered by a doctor after a series of medical studies.

How to protect yourself after a caesarean section?

Of all the methods of protection against unwanted pregnancy you need to choose the most optimal and safe one. An almost 100% guarantee after a caesarean section is provided by a spiral, but it can only be installed six months after the operation. In the meantime, you will have to be content with a condom or vaginal suppositories. Contraceptive drugs are not recommended during lactation.

Will treatment be required?

Drug treatment after cesarean section is prescribed only if complications are detected. These are inflammatory processes, infection in the abdominal cavity, the formation of adhesions, rotting of sutures, divergence of the uterine scar, endometritis, etc. Each disease requires special diagnostics and a mandatory course of therapy.

What to do if your condition worsens after a CS?

The first month after surgery is the most dangerous. Bleeding, pain, stitches and other troubles can cause serious complications. Therefore, at the slightest deviation in her condition, a young mother should seek advice and help from a supervising doctor. In particular, red flags may include:

temperature after cesarean section indicates an inflammatory process that has begun in the body, which will require treatment;
pain after cesarean section at the suture site indicates their healing or the onset of inflammation; in the stomach - about education adhesive processes or contraction of the uterus; in the back - about the consequences of epidural anesthesia;
hematoma after cesarean section at the site of the suture is a common hemorrhage into soft tissues, which you should not be afraid of, in most cases it goes away very quickly;
blood after a cesarean section can be released either from the uterus ( postpartum lochia), or from a healing suture; if the first phenomenon is quite natural and lasts from 4 to 8 weeks, then in the second case you need to be more careful: if the suture bleeds for a long time and profusely, something is preventing it from healing, so you need to inform the doctor about this.

These are the main features of a cesarean section that you should not be afraid of. At the slightest deviation, you just need to take appropriate measures in time, according to medical recommendations.

The most important thing is to understand that doctors resort to this operation only in the most extreme and in rare cases. It is she who saves the lives of the mother and child in case of complications and pathologies. If you tune in to a positive mood, this method of delivery will not affect the mother-child relationship in any way. It doesn’t matter how the baby was born: the main thing is that he is healthy and is next to his loving mother.

C-section- surgery, intended for removing the fetus and placenta through an incision in the abdominal wall (laparotomy) and uterus (hysterotomy), when vaginal delivery is impossible for some reason or is accompanied by various complications for the mother and fetus.

The frequency of this operation is obstetric practice currently stands at 13 - 15%. Over the past 10 years, the frequency of surgery has increased approximately 3 times (3.3% in 1985) and continues to increase. The risk of maternal mortality during cesarean section is 10-12 times higher, and the risk of other complications is 10-26 times higher than during vaginal delivery; perinatal mortality with surgical delivery is reduced.

Reasons for the increase in the number of operations: decrease in parity of births (decrease in birth rate); an increase in the number of age-related (elderly) primigravidas; improvement of prenatal diagnostics of the fetus; history of caesarean section; the desire to expand the indications for caesarean section in the interests of the fetus; improvement of CS technique.

Absolute indications for caesarean section:

1. Anatomically narrow pelvis III and VI degrees of narrowing.

2. Clinical discrepancy between the maternal pelvis and the fetal head.

3. Complete placenta previa.

4. Incomplete placenta previa with severe bleeding due to unprepared birth canal.

5. Premature detachment a normally located placenta with severe bleeding due to an unprepared birth canal.

6. Threatened or incipient uterine rupture.

7. Tumors of the pelvic organs that prevent the birth of a child.

8. Defective scar on the uterus after surgery.

9. Condition after operations to restore genitourinary and enterogenital fistulas.

10. Unhealed third degree cervical ruptures, rough scar changes cervix and vagina.

11. Severe gestosis in pregnant women with unprepared birth canal.

12. Sharply expressed varicose veins veins in the vagina and vulva area.

13. Extragenital cancer and cervical cancer.

14. Extragenital diseases: high myopia, retinal detachment, brain diseases, cardiovascular diseases with signs of decompensation, diabetes mellitus, diseases nervous system and etc.

P.S. To perform a CS operation, 1 absolute indication is sufficient.

Relative indications for cesarean section:

1. Anomalies labor activity, not amenable to conservative therapy.

2. Incorrect positions fetus

3. Breech presentation of the fetus.

4. Incorrect insertion and presentation of the head.

5. Presentation and prolapse of umbilical cord loops.

6. Malformations of the uterus and vagina.

7. Older primigravidas (over 30 years old).

8. Chronic placental insufficiency.

9. Post-term pregnancy.

10. Multiple pregnancy.

11. Long-term history of infertility.

P.S. To perform a CS operation, 2 or more relative indications are necessary; the operation in this case is performed according to combined (combined) indications, they are a combination of several complications of pregnancy and childbirth, each of which individually does not serve as an indication for CS, but together they create a real threat to fetal life in case of vaginal delivery.

Indications for cesarean section during childbirth:

1. Clinically narrow pelvis.

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

3. Anomalies of labor that are not amenable to drug therapy.

4. Acute fetal hypoxia.

5. Abruption of a normal or low-lying placenta.

6. Threatening or incipient uterine rupture.

7. Presentation or prolapse of umbilical cord loops due to unprepared birth canal.

8. Incorrect insertion and presentation of the fetal head.

9. State of agony or sudden death mothers in labor with a living fetus.

Contraindications for cesarean section:

1. Intrauterine fetal death (except for cases when the operation is performed for vital reasons on the part of the woman).

2. Congenital defects fetal development incompatible with life.

3. Extreme prematurity.

4. Fetal hypoxia, if there is no confidence in the birth of a living (single heartbeat) and viable child and no urgent indications from the mother's side.

5. All immunodeficiency conditions.

6. Duration of labor is more than 12 hours.

7. The duration of the water-free period is more than 6 hours.

8. Frequent manual and instrumental vaginal manipulations.

9. Unfavorable epidemiological situation in the obstetric hospital.

10. Acute and exacerbation chronic diseases in pregnant women.

Contraindications become invalid if there is a threat to the woman’s life (bleeding due to placental abruption, placenta previa, etc.), i.e. are relative.

At high risk development of infection in postoperative period perform a cesarean section with temporary isolation of the abdominal cavity, extraperitoneal cesarean section, which can be performed when the anhydrous period lasts more than 12 hours.

Conditions for performing a caesarean section;

1. The presence of a living and viable fetus (not always feasible with absolute indications).

2. The pregnant woman has no signs of infection (absence of potential and clinically significant infection).

3. The mother’s consent to the operation, which is reflected in the history (if there are no vital indications).

4. General surgical conditions: surgeon performing the operation; qualified anesthesiologist and neonatologist; availability of equipment.

Types of caesarean section:

1. By urgency: planned, with the onset of labor (planned), emergency.

P.S. A planned CS should be 60-70% in relation to an emergency one, since

it is this that contributes to the reduction perinatal mortality, hypoxia decreases

fetus by 3-4 times, complications in women by 3 times, injuries by 2 times.

2. According to the execution technique:

a) abdominal (through the anterior abdominal wall). An abdominal caesarean section for the purpose of terminating a pregnancy is called a minor caesarean section; it is performed between 16 and 22 weeks of pregnancy, in cases where its continuation is dangerous for the woman’s life (preeclampsia, which cannot be treated, cardiovascular pathology in the stage of decompensation, severe blood diseases, etc.) - usually performed as a corporal cesarean section.

b) vaginal (through the anterior vaginal fornix).

3. In relation to the peritoneum:

a) intraperitoneal (transperitoneal) - with opening of the abdominal cavity: corporal (classical); in the lower segment of the uterus with a transverse incision; Isthmic-corporal cesarean section with a longitudinal incision of the uterus - performed in case of premature pregnancy, when the lower segment of the uterus is not deployed.

b) extraperitoneal - extraperitoneal (according to the method of E.N. Morozov).

c) CS in the lower segment with temporary isolation of the abdominal cavity.

Currently, the most common method is intraperitoneal cesarean section in the lower uterine segment.

Complications of caesarean section:

1. Intraoperative: bleeding; injury to neighboring organs; difficulty in removing the head; difficulties in removing the child; complications of anesthesia.

2. Postoperative: internal and external bleeding; deep vein thrombosis; thromboembolism; pulmonary atelectasis; complications of anesthesia; hematomas of various locations; purulent-septic complications: endometritis, salpingitis, wound infection, obstetric peritonitis, sepsis; intestinal obstruction; genitourinary and enterogenital fistulas.

Stages of a caesarean section: 1. Laparotomy; 2. Incision of the uterus; 3. Extraction of the fetus; 4. Suturing the uterus; 5. Suturing the anterior abdominal wall.

1. Laparotomy. Methods:

a) inferomedian - the incision is made along the white line of the abdomen 4 cm below umbilical ring and ends 4 cm above the pubic symphysis.

b) transverse suprapubic laparotomy according to Pfannenstiel - an arcuate incision is made along the suprapubic fold, 15-16 cm long.

c) transverse laparotomy according to Joel-Cohen - a superficial straight-line skin incision 2.5 cm below the line connecting the anterosuperior spines iliac bones; then, with a scalpel, a deepening of the incision is made along the midline in the subcutaneous fatty tissue; at the same time, the aponeurosis is incised, which is carefully cut to the sides with the ends of straight scissors; then the surgeon and assistant simultaneously separate the subcutaneous fatty tissue and rectus abdominis muscles by gentle bilateral traction along the skin incision line; the peritoneum is opened in the transverse direction with the index finger so as not to injure the bladder; then the vesicouterine fold is dissected.

2. An incision in the uterus.

1) Classic incision (on the body of the uterus):

a) longitudinal section of the anterior wall of the uterus along its midline (according to Sanger);

b) pubic (from one tube angle to another) - according to Fritsch.

2) Incision in the lower segment:

a) transverse in the lower segment up to 10 cm long (according to Rusakov L.A.);

b) semilunar incision without additional muscle dissection (according to Doerfler);

c) longitudinal (vertical) incision in the lower segment with continuation to the body of the uterus (according to Selheim).

3. Fetal extraction performed after incision of the uterus and opening of the membranes with a hand inserted into the uterine cavity (palm); The fruit is extracted depending on the type and position. In case of breech presentation, the fetus is removed by the inguinal fold or by the pedicle; in cases of transverse position of the fetus, it is removed by the pedicle; the head is removed from the uterine cavity using a technique identical to the Morisot-Levre technique. After the fetus is removed, the umbilical cord is crossed between two clamps, and the afterbirth is removed by hand.

If you are not sure of passability cervical canal, you need to go through it with Hegar dilators or your finger (then change the glove).

4. Suturing the uterus. Methods:

1) Double-row seam:

a) both rows with separate sutures (according to V.I. Eltsov-Strelkov) - the first row with mandatory capture of the endometrium (mucomuscular), the second row muscular-muscular with immersion of the sutures of the first row.

b) first row - continuous twisting or furrier suture with capture of the endometrium and 1/3 of the myometrium without overlap; the second row - U- or Z-shaped separate sutures with capture of 2/3 of the myometrium, ensuring reliable hemostasis.

c) both rows - continuous seams. The first row is continuous wrapping with the capture of the mucosa and 1/3 of the myometrium without overlap; the second is also continuous musculoskeletal with 2/3 of the myometrium involved and overlapped according to Reverden.

2) Single row seam:

a) single-row muscular-muscular suture with separate sutures (L.S. Logutova, 1996) - the incision on the uterus is sutured through the entire thickness of the myometrium with separate sutures without capturing the mucous membrane at intervals of 1-1.5 cm.

b) single-row continuous suture with simultaneous peritonization.

c) continuous wrapping single-row suture with synthetic threads with piercing of the mucosa and subsequent peritonization by the vesico-uterine fold.

d) continuous seam with locking overlap according to Reverden.

After suturing the uterus, the wound is peritonized using the vesicouterine fold of the peritoneum with a continuous absorbable suture.

5. Suturing the anterior abdominal wall It is performed in layers: either separate silk, dexon, or vicryl sutures are applied to the aponeurosis or sutured with a continuous suture. There is no consensus regarding suturing of subcutaneous fat tissue. The skin is sutured with separate sutures, metal staples, or a continuous (cosmetic) suture.

Intraperitoneal cesarean section with lower segment transverse incision is the operation of choice in modern obstetrics. During the operation, 4 moments can be distinguished: 1) transection; 2) opening of the lower segment of the uterus; 3) extraction of the fetus and placenta; 4) suturing the uterine wall and layer-by-layer suturing of the abdominal wall.

1) Transection– can be performed in two ways: a midline incision between the navel and pubis and a transverse suprapubic Pfannenstiel incision. The suprapubic incision has a number of advantages: with it there is less reaction from the peritoneum in the postoperative period, it is more in harmony with the incision of the lower segment of the uterus, it is cosmetic, it is rarely the cause of postoperative hernias. When performing a transverse suprapubic incision:

A) the skin and subcutaneous tissue are cut along the line of the natural suprapubic fold over a sufficient length (up to 16-18 cm).

B) The aponeurosis is incised in the middle with a scalpel, and then peeled off with scissors in the transverse direction and dissected with them in the form of an arc. After this, the edges of the aponeurosis are captured with Kocher clamps, and the aponeurosis is peeled off from the rectus and oblique abdominal muscles down to both pubic bones and up to the umbilical ring. 3 ligatures or clamps are applied to both edges of the dissected aponeurosis, picking up the edges of the napkins that cover the surgical field.

C) to achieve better access, in some cases a suprapubic incision is made in Czerny’s modification, in which the aponeurotic pedicles of the rectus muscles are dissected in both directions by 2-3 cm.

D) the parietal peritoneum is dissected longitudinally from the umbilical ring to the upper edge of the bladder.

2) Opening of the lower segment of the uterus:

a) after delimiting the abdominal cavity with napkins, the vesicouterine fold of the peritoneum is opened at the place of its greatest mobility with scissors, which are then made under the peritoneum in each direction, and the fold is dissected in the transverse direction.

B) the bladder is easily separated from the lower segment of the uterus with a tuffer and is displaced downward.

C) the level of incision in the lower segment of the uterus is determined, which depends on the location of the fetal head. At the level of the largest diameter of the head, a small incision is made with a scalpel in the lower segment until opening amniotic sac. Inserted into the incision index fingers both hands, and the opening in the uterus moves apart until the fingers feel that they have reached extreme points heads.

3) Extraction of the fetus and placenta:

A) the surgeon’s hand is inserted into the uterine cavity so that its palmar surface is adjacent to the fetal head. This hand turns the head with the back of the head or face anteriorly and extends or flexes it, due to which the head is released from the uterus. If there is a breech presentation, the baby is removed by the anterior inguinal fold or leg. When the fetus is in a transverse position, the hand inserted into the uterus finds the fetal leg, the fetus is turned onto the leg and then removed.

B) The umbilical cord is cut between the clamps and the newborn is handed over to the midwife.

C) 1 ml of methylergometrine is injected into the uterine muscle

D) by gently pulling the umbilical cord, the placenta is separated and the placenta is released. If there is difficulty, the placenta can be separated by hand.

D) after the release of the placenta, the uterine walls are checked with a large, blunt curette, which ensures the removal of fragments of membranes, blood clots and improves uterine contraction.

4) Suturing the uterine wall and layer-by-layer suturing of the abdominal wall:

a) two rows of muscular-muscular sutures are applied to the uterine wound. The extreme sutures are placed 1 cm lateral to the angle of the incision on the uninjured uterine wall to ensure reliable hemostasis. When applying the first row of sutures, the Eltsov-Strelkov technique is successfully used, in which the nodes are immersed in the uterine cavity. In this case, the mucous membrane and part of the muscle layer are captured. The injection and puncture of the needle are made from the side of the mucous membrane, as a result of which the nodes after tying are located on the side of the uterine cavity. The second layer of muscular-muscular sutures corresponds to the entire thickness of the muscular layer of the uterus. Knotted catgut sutures are applied so that they are located between the sutures of the previous row. Currently widespread received a method of suturing the muscle layer with a single-row continuous suture made of biologically inactive material (Vicryl, Dexon, Polysorb).

b) peritonization is carried out due to the vesicouterine fold, which is sutured with a catgut suture 1.5-2 cm above the incision. In this case, the opening line of the lower segment of the uterus is covered bladder and does not coincide with the line of peritonization.

C) napkins are removed from the abdominal cavity, and the abdominal wall is sutured tightly in layers

D) a continuous catgut suture is applied to the peritoneum, starting from the upper corner of the wound.

D) the rectus abdominis muscles are brought together with a continuous catgut suture, then interrupted sutures are applied to the aponeurosis and interrupted catgut sutures are applied to the subcutaneous tissue

E) the skin wound is sutured with silk, lavsan or nylon with interrupted sutures.

Despite the fact that the birth of a child is a process provided for and programmed by nature itself, as in any program, failures can occur. Sometimes it is known that one will have to deviate from the “natural course” long before the PDR, but often this becomes clear literally in the maternity ward.

But in both cases, obstetricians-gynecologists resort to surgical intervention - caesarean section - to save the life of the mother and child. Such operations have been known since ancient times. Behind long years doctors have learned to perform them in the most different ways, however, at the moment only some of the most gentle methods are practiced.

Planned and emergency caesarean section
If the upcoming operation is known in advance, then to the expectant mother this is reported during pregnancy and prepared for planned surgical intervention. A woman needs to be examined by a therapist, ophthalmologist, endocrinologist, and in some cases also by a surgeon, neurologist, or orthopedist. Each of these specialists makes a conclusion about the preferred method of delivery, based on which the gynecologist antenatal clinic makes its recommendation. However, the final decision is made by the doctors of the maternity hospital. Each of them has its own characteristics of performing a cesarean section, using pain relief methods, and monitoring the woman in labor in the postoperative period.

Hospitalization usually takes place 8-10 days before the scheduled date of cesarean section, which most often coincides with the preliminary date of natural birth. Doctors are preparing a pregnant woman for an upcoming operation. Most often, during planned intervention, epidural anesthesia is used, that is, the woman remains conscious and sees her baby immediately after he is removed from the uterus.
Doctors sometimes have to make the decision to perform an emergency caesarean section literally in a matter of minutes. That is why in some especially difficult cases used general anesthesia, in which the woman is unconscious and is connected to a machine during the operation artificial respiration. However, if possible, doctors resort to spinal anesthesia. An injection given in the lower back begins to act literally after 5 minutes, and therefore the operation can begin almost immediately. With this type of anesthesia, as with epidural, only the Bottom part body, therefore, during the operation, the woman in labor is conscious and also has the opportunity to see her baby immediately after his birth.

Classic incision site
The “royal incision” is most often performed in the lower uterine segment above the pubic line. The doctor dissects all layers of the anterior abdominal wall layer by layer directly to the uterus, after which the child is removed from the incision of the uterus itself. The operator then cuts the umbilical cord. Some do this immediately after they take out the baby, others wait for the pulsation to stop, and others squeeze out the blood remaining in the umbilical cord to the fetus. However, the latter action threatens to thicken the baby's blood and lead to quite serious problems, therefore this method is used extremely rarely.
As for the separation of the placenta, in most cases, surgeons prefer to do it manually, without waiting for the baby’s place to separate on its own. Firstly, this way precious time is not lost waiting and the volume of blood loss does not increase, and secondly, the placenta may not separate completely, and then another surgical intervention will be required.
IN old times When the Aesculapians first learned to sew up the uterus, they did it with a three-row suture. Now, with modern level development of antiseptics and the use of high-quality suture material, a single-row suture is applied. The ability of the uterus to bear a fetus depends on how well it is performed. next pregnancy.
Next comes the turn of suturing the vesicouterine fold. In classical surgery, doctors follow the basic rule: what has been cut must be sewn up. However, having received last years modifications of cesarean section according to Strack to save time and reduce operational blood loss do not suture all dissected cavities. For independent fusion, the vesicouterine fold, peritoneum, muscles, and subcutaneous fat are left. However, this option also has disadvantages: as a result of the lack of sutures, an extensive adhesive process may occur.
Finally, after examining all the organs of the abdominal cavity, the doctor sutures the anterior abdominal wall layer by layer. The last suture is external, and in the absence of contraindications it is often performed cosmetically, intradermally.

Other seam placement options
There are situations in which the use of a classic incision is undesirable for some reason. For example, if the baby is premature and has malformations diagnosed by ultrasound, or conjoined twins have developed in the uterine cavity, if extensive placental abruption has occurred or the fetus is in a transverse position, the use of a corporal cesarean section is recommended. In addition, additional indications for this species surgical intervention are multiple myomatous nodes, a scar from a previous corporal cesarean section, and pronounced varicose veins in the lower segment of the uterus. In this operation, an incision is made on the anterior abdominal wall can be either longitudinal or transverse, but in practice it is the longitudinal that is most often done, since on the uterus it should only be like this: going from bottom to top, from the vesicouterine fold to the bottom of the uterus and at least 12 cm long. This incision provides the most convenient access to all necessary organs of the abdominal cavity and organs located in the pelvis, which is very important in a difficult situation. Of course, the scar on the uterus with this type of cesarean section turns out to be much larger than with a classic transverse incision.
Another option is extraperitoneal caesarean section. It is used if a woman is at very high risk of post-operative infection (peritonitis). In this case, to prevent the infection from entering the abdominal cavity, an incision on the uterus is made without opening the peritoneum. However, this is a rather complex technique, few specialists know it, and it is used extremely rarely, especially since in a maternity hospital it is always possible to provide sterile conditions.

Possible consequences of cesarean section
The main thing that doctors focus on when choosing a method of performing an operation is which technique in each specific case will be more gentle, and therefore more suitable for the mother and baby. Classic caesarean section in the lower segment of the uterus is the most physiological and at the same time the least traumatic. In addition, the incision is made along the bikini line, and it is sutured cosmetic stitch, which provides the necessary aesthetic effect. However, we should not forget that the health of the mother and her child comes first for doctors, and beauty is not even second. Therefore, when choosing the location of the incision, they focus specifically on expediency, and not on the subsequent attractiveness of the seam.

Various obstetric schools consider their method of performing a caesarean section to be correct. But the main thing is experience, precise movements worked out to the smallest detail. Only the professionalism of the doctor is the key to a successful operation. And a woman should trust specialists who will choose the most suitable method of delivery for her and her baby.

The cesarean section operation is one of the most ancient operations. It is a surgical delivery: the baby is removed from the uterine cavity through an incision in the wall. This intervention became widespread only in the mid-twentieth century, after the introduction of antibacterial agents into practice.

8 direct indications for caesarean section - in what cases is caesarean section prescribed?

A caesarean section can be performed either routinely or for emergency reasons. for the patient, only the doctor decides.

In total, there are 8 main absolute indications for intervention:

Placenta previa
In this case, the exit from the uterus is closed by a low-lying placenta. This arrangement is diagnosed " children's place» in advance during ultrasound in late pregnancy.
Premature placental abruption
This complication threatens the life of the fetus due to the resulting hypoxia, and the life of the mother due to possible heavy bleeding.
Threatened uterine rupture
Most often, the cause of this complication is failed scar on the uterus after previous operations. Also, a rupture can occur as a result of thinning of the organ wall after numerous births or abortions.
Absolutely narrow pelvis ( III-IV degrees narrowing anatomically or clinically)
In this case, there is a clear discrepancy between the size of the pelvis and the presenting part of the fetus: the child cannot pass through the natural birth canal even if additional obstetric techniques are performed.
Mechanical obstructions in the birth canal
Most often, uterine fibroids in the isthmus area interfere with birth. This indication in most cases is identified during a standard examination of a pregnant woman, and allows for a caesarean section to be planned in advance.
Severe gestosis in the second half of pregnancy
Childbirth can threaten a woman’s life, as vascular complications are likely.
Severe varicose veins of the vagina and perineum
Childbirth through natural ways can lead to thrombosis, embolism, bleeding.
Some comorbidities
Complicated high myopia, heart failure, epilepsy, vascular and blood diseases.

Absolute indications for cesarean section make it the only possible choice for delivery.

There are also relative readings to operative delivery . Doctors carefully evaluate everything possible risks for mother and child before deciding on surgery.

In the modern world, the choice in favor of a cesarean section is being made more and more often, as progress in medicine makes the operation quite safe.

Relative indications for cesarean section

Relatively narrow pelvis (anatomical narrowing of degrees I-II).
Incorrect position of the fetus (transverse, pelvic).
Large fruit size.
Developmental defects of the uterus.
Age over 30 years for a primigravida.
Post-term pregnancy.
Long-term history of infertility.

If a woman has a combination of several complications, then the decision in favor of surgery is natural.

How a caesarean section is performed - operation plan, stages, video

Strict adherence to the generally accepted surgical technique allows you to reduce the intervention time to a minimum and reduce blood loss.

Caesarean section operation plan:

You can find a video of a caesarean section on the Internet.

All steps of a caesarean section take about half an hour . From the start of the operation to the birth of the newborn, there is a only 5-7 minutes .

Caesarean section, in the vast majority of cases, is performed under regional anesthesia (epidural, spinal). The woman is conscious. Sometimes anesthesia may be performed during an emergency caesarean section.

Recovery after cesarean section - postoperative period

First day after the operation the woman is in the ward intensive care under constant medical supervision.

From the second day she is transferred to postpartum ward. From now on, early activation is recommended. The woman gets out of bed, walks around the department, and takes care of the baby as best she can.

Nutrition in the postoperative period limited. The first day you can only drink water, then on the 2-3rd day add more chicken bouillon, fruit drink, skim cheese. The body's need for nutrients satisfied by intravenous administration glucose solution, special parenteral mixtures. Only on days 4-5 the patient’s menu expands significantly.

Restoring bowel function happens gradually. Independent stool occurs 3-5 days after surgery.

Every day during the week treatment postoperative suture , changing the bandage. Catgut threads are removed 7-10 days after surgery.

Caesarean section is not a contraindication to breastfeeding . Due to the fact that the hormonal background after surgery is somewhat different compared to natural childbirth, milk appears a little later (on days 3-5).

In the postoperative period some complications may develop . Doctors monitor their appearance in the maternity hospital until the patient is discharged. Further observation is carried out by a gynecologist at the place of residence.

Possible complications of the postoperative period:

Pain syndrome.
Adhesive process in the abdominal cavity.
Infectious complications in the uterus and abdominal wall.
Anemia.
Postoperative pneumonia.
Postoperative thromboembolism, etc.

In order for the recovery period to be favorable, a woman must adhere to the recommendations of doctors and regularly visit a gynecologist.

Within 2 months The patient should not be sexually active, lift weights, or engage in physical exercise.

The next pregnancy is not advisable before in 2-3 years after caesarean section.