Caesarean section is one of the most popular obstetric operative practices. Over the past 30 years, the share of surgical deliveries in the total number of births has increased worldwide. In Russia, back in the 80s of the last century, no more than 3% of children were born surgically. Today it is about 15%, and in some large perinatal centers the number of operative deliveries exceeds the average values, and this number is close to 20%.
Expectant mothers who have to give birth to their baby on the operating table are concerned with the question of timing: which week of pregnancy should be considered optimal for the birth of a baby? In this resource, we will explain how the timing for surgical delivery is determined and why it might change.
Who needs surgery?
Surgical childbirth, named after the Roman emperor Gaius Julius Caesar, does not imply the passage of the baby through the mother's birth canal. The child is born as a result of laparotomy and hysterotomy - incisions of the abdominal wall and the wall of the uterus.
This method of delivery is sometimes life-saving. It is carried out urgently in order to save the lives of a woman and her baby if something went wrong during physiological childbirth or as a result of injury. An emergency caesarean section takes no more than 7-9% of all surgical deliveries. The rest is allocated to scheduled operations.
A planned cesarean section is always a thorough preparation, as a result of which the risks of complications are significantly reduced.
Indications for elective surgery may appear from the very beginning of pregnancy, and may become apparent only at the end of the gestation period. Therefore, the decision on the timing of the operation is made at different times.
For an emergency caesarean section, the issue of timing is irrelevant. It is carried out when there is an urgent vital need for it. Planned surgery is carried out according to the indications provided for in the list in the clinical guidelines of the Ministry of Health of Russia. This list is regularly revised and amended.
Today it provides for the following situations:
- Pathological location of the placenta - low placentation with incomplete overlap of the internal os or complete placenta previa.
- Postoperative scars on the genital organ from cesarean or other surgical procedures on the uterus. Also, caesarean is recommended as the only delivery option if there are two or more caesarean sections in the history.
- Clinical narrowness of the pelvis, pathology of the bones and joints of the pelvis, trauma and deformity, tumors of the pelvic organs, polyps.
- Pathological discrepancy of the bones of the pubic articulation - symphysitis.
- Pathological position of the fetus. By the 36th week of pregnancy - pelvic, oblique, transverse. Also, some types of presentation are pathological, for example, buttock-leg presentation.
- The estimated weight of the child is more than 3.6 kg with its incorrect location in the uterus.
- Multiple pregnancy, in which the fetus closest to the exit is located in the breech presentation.
- Monozygous twins (twins are inside the same fetal sac).
- IVF pregnancy with twins, triplets, and often singleton.
- Inconsistent cervix, with scars, deformation, scars in the vagina, left after a difficult previous birth, which took place with tears higher than the third degree of severity.
- A significant delay in the development of the baby.
- The lack of effect from conservative stimulation of labor during prolongation - after 41-42 weeks.
- Preeclampsia of severe form and degree, preeclampsia.
- The inability to push because of the prohibition on such an action with myopia, retinal detachment of a woman's eyes, some heart diseases, and also in the presence of a kidney - a transplant.
- Long-term compensated fetal hypoxia.
- A blood clotting disorder in a mother or baby.
- Genital herpes, maternal HIV infection.
- Fetal developmental anomalies (hydrocephalus, gastroschisis, etc.).
On an individual basis, a decision can be made about a planned operation for some other reasons.
Optimal time
If circumstances that are an indication for surgery arise already in the process of carrying a baby, for example, a breech presentation is found with a large fetus or a placenta previa, then doctors wait until 34-36 weeks of pregnancy. It is this period that is considered "control". If by 35 weeks the child does not turn over to the correct position, if the placenta does not rise, then the indication for surgery becomes absolute. An appropriate decision is made, and the date of operational delivery is set.
When circumstances implying surgical delivery as the only possible or the only rational occur from the very beginning after pregnancy, the issue of caesarean section is not considered separately. Operative delivery is implied a priori.
Contrary to the opinion widespread among women that a cesarean section is optimal when contractions have begun, since this is "closer to nature", doctors prefer to operate on relaxed and calm muscles of the uterus, rather than straining during labor pains.
So there will be fewer complications, and the surgical delivery will be more successful. Therefore, it is better to carry out the operation before the start of physiological labor.
The Ministry of Health of Russia in the protocol and clinical guidelines for carrying out a caesarean section names quite specific terms at which the operation is considered most desirable. It is recommended to do a caesarean routine after 39 weeks of pregnancy.
How long does a cesarean section still take? Yes, any, if need be. But the 39th week is considered the most favorable, because by this time, in the vast majority of children, the lung tissue matures sufficiently for spontaneous breathing to be possible, the child is ready, he does not need resuscitation help, the risks of distress syndrome, the development of acute respiratory failure are minimal.
Children are considered viable from 36 weeks of pregnancyand, children born earlier also survive, but the risks of respiratory failure increase in proportion to the prematurity.
If there is no reason for early delivery, then it is better to give the child the opportunity to gain weight, and his lungs to mature.
When pregnant with twins or triplets, the likelihood of the onset of physiological childbirth a couple of weeks before the expected date of birth is higher, and therefore, in multiple pregnancies, a planned cesarean section is tried to be prescribed at 37-38 weeks, and sometimes up to 37 weeks. Children may need resuscitation help in the first hours of life, and therefore not only surgeons, but also a team consisting of a neonatologist and a pediatric resuscitator, always prepare for such operations in advance.
When the doctor decides on the date of the operation, he takes into account not only the wishes of the pregnant woman, her state of health and the totality of indications, if there are several of them, but also the interests of the child. If, according to the results of examinations, any signs of trouble are revealed in the baby, then the date of the operation can be assigned at an earlier time.
Does this mean that a woman is not given the right to participate in the discussion of the date of birth of her own child? Not at all. The doctor can designate a time frame - a few days in which he considers it appropriate to carry out the operation. A woman can choose one of these days at her own discretion. On weekends and holidays, they try not to carry out scheduled operations.
Reasons for changing dates
If we talk in more detail about the reasons that can lead to a change in the timing of operative delivery, then it should be borne in mind that there are two types of influencing factors: indications from the mother's side and indications from the fetus.
- Maternal indications the operation can be postponed to an earlier date due to the fact that the woman's body begins to actively prepare for childbirth. In a woman, the cervix begins to flatten and shorten, the amount of cervical mucus increases, the mucous plug leaves the cervical canal, a slow and gradual leakage of amniotic fluid begins. Also, the timing will be reduced when signs of a threatening rupture of the uterus appear along the old scar. Deterioration of the woman's condition due to gestosis, increased pressure, severe edema are grounds for earlier delivery, if conservative therapy is ineffective and it is not possible to stabilize the condition of the pregnant woman.
- Earlier delivery by fetal factor carried out if the child shows signs of oxygen starvation, if there is an umbilical cord entanglement around the neck with accompanying signs of trouble, with a pronounced Rh-conflict. If a child has congenital pathologies identified during screening prenatal diagnostic studies, then the deterioration of his condition is also the basis for postponing the operative delivery.
A referral to hospitalization in a maternity hospital or a perinatal center is issued in an antenatal clinic, where a woman is observed, at 38-39 weeks during the first pregnancy, at 37-38 weeks if a repeated cesarean section is necessary for a singleton pregnancy. With multiple fetuses, as mentioned above, they are hospitalized earlier, on average, by 2 weeks.
The 35-36 week of pregnancy for women becomes decisive, it is on it that ultrasound is performed, control tests are done that will help to find out all the nuances of the condition of the fetus and mother.
KS up to 37 weeks
As already mentioned, a cesarean section can be performed earlier for medical reasons, but the risks to which the baby will be exposed increase with prematurity.
A child who is born by caesarean section at week 30, will have little chance of survival, and therefore the operation at this time is carried out only in case of mortal danger to the life of the mother.
At 32-33 and 33-34 weeks pregnancy, the baby's chances of survival increase, but the risks of death after birth are still high.
The main danger is that the child has not yet accumulated a sufficient amount of subcutaneous fatty tissue during this period, and therefore the baby simply cannot keep body heat in a stable state. Also, not enough surfactant has been developed in the lungs - a special substance that ensures the lungs' ability to breathe in and out and at the same time not stick together.
From 36 weeks, the chances of survival increase significantly. From this moment on, the child is formally considered viable.
But the individual characteristics of the development of each baby may differ, and therefore doctors weigh the pros and cons, comparing the risks to the mother and the fetus. The benefits of the proposed surgical intervention should many times exceed the possible harm from its absence at a specific current stage of pregnancy.
For more information on the timing of the operation, see the next video.
