Update: October 2018
The pinnacle of modern obstetrics is the completion of childbirth and
the birth of a child through surgery
– Cesarean section.
Historians have established that the origin of this operation has
direct connection with the times of antiquity, but only now
time this kind of labor is often salvation, as for
mothers, so and for child.
Significant amount of cesarean section today
due to the high risk of resolution of the burden of the expectant mother
Of course, abdominal delivery, like the rest
surgical interventions hiding a huge number of possible
complications / consequences, however, cases of their occurrence are extremely
rare, and the scales weighs in the direction of the birth of a live child
and saved mother’s life, not potential complications.
The history of the name of the operation has acquired a huge number of legends and
myths. The most significant is the story of the birth of Gaius Julius Caesar
– autocrat of the Roman Empire. Death of Caesar’s mother during childbirth
caused his father to cut the womb of a woman with a sword and
extracted son. Hence the saying: “Caesar is Caesar’s.”
Conditions for the operation
Caesarean section can be planned, planned and
emergency About planned surgery delivery say when she
produced 6 to 15 days before the date of expected birth
maternal and / or fruit indications and the absence of first
manifestations of labor activity (see calculator
estimated date of birth).
A planned operation – this means that the indications for it are known.
in advance, often in the first weeks and even days of gestation
future baby. The need for emergency urgent section
due to urgent, immediate, approximately within
one to two hours of delivery and is mainly shown in the process
independent childbirth. A planned caesarean section is said when
childbirth has just begun or the preterm amniotic fluid has poured out,
но имеются относительные показания для operations. That is, a woman
allowed to give birth, but according to the plan of management of childbirth end them
So, the necessary factors for the surgical method
- наличие живого fetus, способного существовать внеутробно
(considered a relative condition, since for some
circumstances, an operation is done in the interest of the woman with
saving her life);
- written consent of the woman to the cesarean section;
- empty bladder (preferably set to constant
- there are no signs of infection during childbirth (also very conditional
- availability of an experienced obstetrician surgeon and operating room.
What are the indications for surgery?
All the causes that lead to abdominal delivery,
can be divided into two subgroups.
- BUTбсолютные показания буквально вынуждают врача родоразрешить
a woman through surgery, that is, without an operation can not do.
- Relative indications are said when the situation
analyzed by a council of doctors and a conclusion is approved
or another way to complete the delivery. That is, a woman can give birth
and independently, but the probable risks for it are taken into account, as well as
In addition, there are factors leading to forced
operations during pregnancy or directly in the process
childbirth. Another gradation of indications for operative delivery
they are considered to be divided into maternal and fetal factors.
BUTбдоминальное родоразрешение: абсолютные показания
To factors on the part of the mother, in the case of which
impossible to do without cesarean section surgery include:
BUTнатомически узкий таз (учитывается степень сужения, то есть 3
– 4, in which the true conjugate is 9 cm or less)
The narrow pelvis is divided into 2 groups according to the shape of the narrowing.
- The first group includes: transversely pelvis, flat pelvis
(simple flat pelvis, flatrakhitichesky and pelvis with a decrease
wide part of the cavity), and, of course, a general-equated pelvis. it
fairly common forms of pelvic constriction.
- The second group (rare forms) includes the skewed pelvis,
oblique pelvis, pelvic deformity by bone exostoses, bone
tumors or due to fractures, kyphotic pelvis,
funnel-shaped pelvis and other types of narrow basins.
BUTнатомически узкий таз со степенью 3 или 4 может осложнить
течение childbirth. During схваток почти у 40% рожениц возникает:
- weak uterine contractions (contractions)
- early discharge of waters
- возможно выпадение пуповинной петли или ручек/ножек fetus
- development of chorioamnionitis, endometritis and infection of the future
- а также внутриутробная гипоксия fetus
During потужного периода могут появиться следующие
- secondary weakness
- fetal hypoxia
- birth injury
- разрыв uterus
- tissue necrosis with the formation of urogenital fistulas, intestinal
- trauma to the pelvic joints and nerve plexuses
- and if the birth will reach the third period, it can not be avoided
sequential and / or postpartum hemorrhage.
Byлное предлежание плаценты
As is known, the placenta is the body that
communicates between mother and child organisms. With
normal pregnancy pregnancy placenta is located either in
the area of the bottom of the uterus, either on the front or back wall. If a
the placenta is in the lower segment of the fruit tree, and
completely covering the inner throat, it becomes clear that the output
the child from the womb of the mother naturally becomes impossible.
Moreover, full placenta previa is
potential threat not only for the future baby, but also for his
mothers during the whole period of pregnancy, because at any moment
open bleeding, the intensity and duration of which
impossible to predict.
Withмер из практики: У меня наблюдалась женщина
38 years from the very beginning of pregnancy. Pregnancy was not the first
but very welcome. Despite the absence of any burdensome
circumstances in her history, she had a placenta formed in the lower
one third of the uterus and blocked the internal pharynx (full presentation).
Woman almost all pregnancy was on the hospital, under
under the supervision of doctors, she did not have any bleeding. She is
successfully reached 37 weeks and was hospitalized in the ward
pathology to prepare for a planned caesarean. Well, as usual
for some reason (and perhaps fortunately), the bleeding began in her
Inpatient and weekend. Of course, we immediately went on
immediate cesarean, time could not be wasted. That’s planned
the operation turned into an emergency – the child was born healthy and with
Incomplete placenta previa with severe bleeding
An incomplete placenta previa is said when the last
overlaps only partially inner throat. There are regional
previa and lateral.
- With краевом расположении плаценты она лишь слегка затрагивает
- Whereas when the side covers it by half or 2/3
Incomplete placenta previa also threatens to develop suddenly
bleeding whose massiveness is hard to predict. Feature
such localization of the placenta is interesting because the bleeding
appear more often during contractions, because it is at this time
inner throat раскрывается, а плацента постепенно отслаивается.
The indication for urgent operation with incomplete presentation is
massive blood loss that is life threatening and
maternal and child health.
Premature detachment of a normally located placenta
The placenta can become detached as during the baby’s waiting period,
and during labor (usually). The danger of this condition is also
is the occurrence of bleeding, which happens to be external
(that is, visible) – bloody vaginal discharge is noted,
internal or latent (blood accumulates between the placenta and
the uterine wall, forming a retroplacental hematoma, and mixed
(there is both visible and latent bleeding). Depending on the
square placental abruption distinguish 3 degrees of severity. With
moderate and, of course, severe degrees as necessary
rather give birth to a woman in labor, otherwise you can lose not only
baby, but also mother.
Threatened or started uterine rupture
Withчин, приводящих к угрозе разрыва uterus великое множество. it
there may be misconducting labor, discoordination of labor forces,
large fetal sizes and much more. In the absence of
timely treatment (massive tocolysis, that is, stopping
uterine contractions), the threat or the beginning of the gap very quickly
will be transferred to the accomplished, that is, the gap that has taken place, while
Both “participants” of childbirth and the unborn child perish.
Insolvent uterus scar
The seam on the uterine wall is not only after the abdominal
delivery, but also after other gynecological operations
(for example, conservative myomectomy). Full value of the scar
determined by ultrasound, with the thickness of the scar-modified surface
should reach 3 mm and more, the contours of the scar even in the absence of
connective tissue. If a наблюдалось осложненное течение в
postoperative period (for example, fever, endometritis or
long healing of skin seams) in history, this indicates
inferiority of the scar.
Two or more uterine scars
If a в анамнезе имеются два и больше кесаревых сечений, вопрос о
self-delivery is not worth it, since such a state
the uterus significantly increases the risk of rupture of the scar.
Severe forms of preeclampsia in the absence of a positive effect from
therapy and unprepared birth canal
Eclampsia (convulsive seizure) can result in death
the outcome for the woman and for her child (see preeclampsia during pregnancy).
Therefore, this condition requires immediate resolution from
burdens For the treatment of preeclampsia (pre-convulsive stage) is given
Exactly 2 hours, if there is no effect, proceed to immediate
operations. Severe and moderately severe nephropathy should
be treated for no more than two weeks, after which
решается вопрос об operations.
Severe extragenital diseases
The list of indications for surgery includes:
- stage heart disease decompensation
- pathology of the nervous system
- severe thyroid disease
- hypertension and much more
Caesarean section through vision is performed in cases of grade 3 myopia
(6 or more), complicated myopia, eye surgery and so on.
With плохом зрении необходимо исключить период потуг, так как
significant physical exertion can lead to retinal detachment
and the blindness of the woman.
Anomalies of the structure of the uterus and vagina
With наличии указанных пороков нарушается сократительная
the activity of the uterus, and the fetus is not capable of giving birth on its own
go through the birth canal.
- Tumors of the cervix, ovaries and other pelvic organs
- These tumors obstruct the birth canal and create an obstruction.
to bring the child to the light.
- Extragenital cancer and malignant cervical tumor
- Age primiparous
Indication for cesarean section by age (more than 30 years) should
combined with obstetric pathology and extragenital
diseases. Muscle elasticity is reduced in age-borne primiparas
vagina and pelvic floor, so there is a high risk of ruptures of the perineum.
In addition, these mothers often develop anomalies of generic
forces that are not inhibited by therapy.
Fetal factors requiring prompt delivery:
With нормальной беременности плод должен располагаться продольно,
head towards the small pelvis. About the wrong position of the future
the child is told when he lies obliquely, transversely or is present
pelvic end. Caesarean section with pelvic presentation
with a child’s weight over 3600 grams. or less than 1500 gr., as well as
male fetus (testicular compression at birth of the pelvic end
can cause infertility in a boy). Pelvic presentation
(legs, the pelvic end is presented) requires an operation, because
the head of the child is greater than the pelvic end, and at the birth of the latter
the birth canal is not dilated enough for unhindered
promotion and birth of the head.
Withмер из практики: В родильное отделение ночью
entered the woman with strong contractions. Births were third, but she
once for the entire pregnancy ultrasound did not pass. During the vaginal
Inspection I found that bent legs, the opening of the cervical canal
5 cm, and this is an absolute indication for delivery by
operations. When I cut the uterus and extracted the fruit, it was
stunned – the fetus was an anencephal with a split spine in
cervical (congenital deformity). Of course, he died immediately,
after crossing the umbilical cord. On the one hand, the operation with such
developmental anomalies are contraindicated, but on the other hand, who
did you know if a woman was not examined?
- Acute fetal hypoxia
This condition means that the child suffers in utero,
it does not receive enough oxygen, and each
contraction aggravates hypoxia. One treatment – immediate
Withмер из практики: it было моим первым
independent caesarean section after internship. I’m up all night
I was busy with the primiparous woman, and in the morning I heard with my “ear” that
the child suffers – slow and dull edema, bradycardia. BUT
We did not have a CTG (cardiotocograph) then, there is nothing to check.
I went to the operation at your own risk. And in time, since I learned
a child who did not even squeak and did not move his arms and legs. By
when I was young I decided that he died, but fortunately the child later
oklemalsya and was discharged healthy with my mother.
- Umbilical cord looping / prolapse
In this situation, the operation must be done immediately, so
how the loop that has fallen out is clamped by the presenting part of the baby in the small
pelvis, due to which the fetus is deprived of oxygen. Unfortunately, very
it is rare to have time to operate a woman and save the child.
- The death of a woman with a living fetus
In cases of continuing agony, the child has some time.
It remains to live and you can have time to save it by abdominal
delivery An operation in a similar situation is carried out in the interests of
Maternal factors for deciding whether to
abdominal delivery (relative):
- Clinically narrow pelvis
Byдобный диагноз ставится в родах и означает, что головка fetus
not correlated with the size of the pelvis of a woman (the entrance to the small pelvis is less
heads). Withчины, обуславливающие развитие такой ситуации,
numerous: large fruit, discoordination of generic forces,
incorrect insertion of the head, weakness of contractions and so on.
- Divergence of the symphysis joint
During gestation, long before childbirth (observed as
2 weeks, and for 12) a woman may have a discrepancy
symphysis or pubic symphysis This pathology is characterized
pains in the symphysis area and when probing the pubis, clicking in
palpation of the articulation, swelling and swelling
Pregnant notes discomfort when walking, rising from low
chair or bed, climbing stairs. Change and gait
women, she becomes like a duck, waddling. During
palpation of the symphysis pubisus reveals a cavity where it is free
fits fingertip. If the diagnosis is confirmed on
Ultrasound (pelvic radiography is harmful to the fetus), a woman is prescribed
bed rest, restriction of physical work and wearing
When the divergence of the pubic symphysis is 10 mm or more,
especially if the estimated weight of the fetus reaches 3800 gr. and more,
there is an anatomical narrowing of the pelvis, then the woman is prepared for the planned
abdominal delivery in order to prevent the rupture of the pubic
joints at independent childbirth.
- Weakness of generic forces
When it is not possible to stimulate labor by opening
bladder to reduce intrauterine volume and the introduction
oxytocin, it is necessary to complete the delivery by cesarean section. Weakness
labor forces leads to fetal hypoxia, postpartum hemorrhage and
When is the issue of abdominal delivery at
post-term pregnancy, takes into account the ability of the head
configured in labor, contractions intensity and aggravating
factors (presence of extragenital diseases and gynecological
pathology, no effect of labor induction, etc.).
- IVF, artificial insemination or prolonged
it показание должно сочетаться с осложненным
obstetric and gynecological history (abortions (consequences),
stillbirth, gynecological diseases, etc.).
- Chronic fetal hypoxia, intrauterine growth retardation
Given that the fetus did not receive enough oxygen during the entire pregnancy and
nutrients, and the treatment was ineffective,
the question of operational delivery is raised before the deadline for
- Гемолитическая болезнь fetus
Caesarean section at the indicated indication is carried out in the presence of
неподготовленной (незрелой) шейки uterus.
- Large fruit
A large fruit is spoken of when its intended weight exceeds
4 kg, and about giant, if the weight reaches 5 kg or more. Childbirth
complete the operation with existing comorbidities
(labor complications, gynecological problems and extragenital
- Multiple pregnancy
BUTбдоминальное родоразрешение производят при предлежании тазового
конца первого fetus или при наличии трех и более плодов.
- Significant varicose veins in the area of the vulva and
There is a certain risk of damage to varicose veins in
prolonged period, which is fraught with intense bleeding.
- Pregnant’s request for surgery
На Западе, например, в BUTнглии будущая мать имеет свободу выбора
delivery That is, it is possible to give birth to a pregnant
cesarean section at her request. In Russia, this is officially
the testimony is not recognized, but there are no documents prohibiting
abdominal delivery at the request of the pregnant. Usually,
This indication is combined with other relative
Contraindications to abdominal delivery
All contraindications to cesarean section are relative,
since the operation is always done either in the interest of the mother or
in the interests of the baby:
- неблагоприятное состояние fetus (смерть внутриутробно,
недоношенность 3 – 4 степени, пороки развития fetus, несовместимые
- probable or clinically manifested infection
(long anhydrous period – over 12 hours);
- prolonged labor (over 24 hours);
- more than 5 vaginal examinations;
- fever in labor (chorioamnionitis, etc.);
- failed attempt at delivery in a natural way
(акушерские щипцы, вакуум-экстракция fetus).