Caesarean section is a real salvation when independent childbirth is either impossible or dangerous for a woman and her baby. This operation allows the baby to appear not through natural physiological pathways, but through two incisions. Laparotomy - opening the abdominal wall, and hysterotomy - cutting the uterine wall. These two artificial holes become the exit for the baby and the placenta.
In this article, we will talk about how the surgical delivery is carried out in stages, what the doctors do before the operation, during the operative delivery and after them. This information will help women to be more aware in the process of preparing for an elective surgery.
Hospitalization terms and preparation
In modern obstetric practice, caesarean section as a method of delivery occurs in about 15% of all deliveries, and in some regions the number of operative deliveries reaches 20%. For comparison, in 1984 the share of surgical deliveries was no more than 3.3%. Experts tend to associate such an increase in the popularity of the operation with a general decrease in the birth rate, with an increase in the number of women who think about their first child only after 35 years, as well as with the prevalence of IVF.
Planned operations account for approximately 85-90% of all celiac diseases. Emergency operations are carried out quite rarely, only for health reasons.
If a woman is to have a caesarean section, then the decision on the timing of the operation can be made both in the early stages and at the end of the gestation period. This is due to the reasons why independent childbirth is impossible. If the readings are absolute, that is, irreparable (narrow pelvis, more than two scars on the uterus, etc.), then the question of alternatives is not raised from the very beginning. It is clear that there can be no other way of delivery.
In other cases, when the grounds for the operation are found later (large fetus, abnormal presentation of the fetus, etc.), the decision to carry out an operative delivery is made only after 35 weeks of pregnancy. By this time, the size of the fetus and its estimated weight, some details of its location inside the uterus, become clear.
Many have heard that babies who are born at 36-37 weeks are already quite viable. This is true, but the risk of slow maturation of lung tissue in a particular child exists, and this can cause the development of respiratory failure after childbirth. Therefore, the Ministry of Health, in order to avoid unnecessary risks, recommends a planned operation after 39 weeks of pregnancy. By this time, the lung tissue is fully mature in almost all children.
In addition, delivery is considered more favorable, as close as possible to the expected date of birth - for the woman's body, stress will be reduced, and lactation will begin, albeit with a slight delay in comparison with physiological childbirth, but still almost on time.
If there is no indication for an earlier operation, then the referral to the maternity hospital in the antenatal clinic is issued at 38 weeks. In a few days, a woman should go to the hospital and start preparing for the upcoming surgical delivery. Preparation is an important stage, which largely determines how successfully and without complications the operation and the postoperative period will pass.
On the day of hospitalization, the woman is taken the necessary tests. These include a general blood test, an analysis to determine and confirm a blood group and Rh factor, a biochemical blood test, and in some cases a coagulogram to determine the rate of blood clotting and other factors of hemostasis. A general urine test is done, a laboratory examination of a vaginal smear is performed.
While laboratory assistants are doing these tests, the attending physician collects a complete and detailed obstetric history of his patient - the number of births, abortions, miscarriages, a history of a frozen pregnancy, and other operations on the reproductive organs.
The condition of the baby is also examined. An ultrasound scan is done to determine its location in the uterus, dimensions, the main of which is the diameter of the head, calculate the estimated weight of the baby, determine the location of the placenta relative to the anterior wall of the uterus, on which the incision is planned. CTG is performed to determine the heart rate of the baby, his physical activity and general condition.
About a day later, a woman meets with an anesthesiologist. The doctor identifies the presence of indications and contraindications for certain types of anesthesia, together with the woman plans her anesthesia, not forgetting to tell how she will act, how long and what are its side effects. After the patient signs an informed consent for epidural, spinal or general anesthesia, she is prescribed premedication.
Eating is prohibited from the evening of the previous day. On the morning of the operation, it is forbidden to eat and drink. A woman is given an enema to cleanse the intestines, her pubis is shaved, and dressed in a sterile shirt.
It is recommended to bandage the legs with an elastic bandage or wear compression stockings to exclude an unpleasant, but quite likely complication of the operation - the development of thromboembolism.
After the preparatory measures, the woman is taken to the operating room. Everything is ready for the scheduled operation there. A surgical team and an anesthesiologist are already waiting for her, who, in fact, begins the first stage of the operation - pain relief.
Anesthesia
Pain relief is necessary because the operation is abdominal and lasts from 25 to 45 minutes, and sometimes longer. The first stage is adequate pain relief. It depends on him how comfortable the patient will feel and how easy it will be for the surgeon to work.
If it was determined that epidural anesthesia would be used, then the operation itself would start a little later, since it takes about 15-20 minutes from the moment of anesthesia to achieve the appropriate effect. The woman is placed on her side with her legs tucked in (fetal position), or she sits on the operating table with her head and shoulders tilted low forward and her back round.
The lumbar spine is treated with an antiseptic, the anesthesiologist performs a lumbar puncture - a puncture is made between the vertebrae with a thin special needle, a catheter is inserted and a test dose of anesthetic is injected into the epidural space of the spine. After three minutes, if nothing extraordinary happens, the main dose of anesthesia is administered. After 15 minutes, the woman begins to feel numbness and tingling in the lower body, stops feeling the legs, lower abdomen.
The anesthesiologist constantly monitors the pressure, heart rate and condition of the patient, communicates with her. He performs a sensory and motor sensitivity test, after which he instructs the surgical team about the patient's readiness for surgery. A screen is installed in front of the woman in labor (it is completely unnecessary for a woman to contemplate what is happening), and the doctors proceed directly to the operation. The woman is awake, but does not feel pain, because drugs inside the epidural space block the transmission of nerve impulses from nerve endings to the brain.
General anesthesia takes less time. The woman is placed on an operating table, her hands are fixed, a catheter is inserted into a vein and anesthetics are injected through it. When the patient falls asleep, and this happens in a matter of seconds, the anesthesiologist inserts an endotracheal tube into the trachea and connects the patient to a ventilator. During the operation, the doctor may add or reduce the dose of medications. Doctors can start an operation, during which the woman in labor is sound asleep and does not feel anything.
The course of an operative delivery in stages
It should be noted that there are many methods of performing the operation. The surgeon chooses the specific one depending on the situation, circumstances, anamnesis, indications and personal preferences. There are techniques in which each layer is then cut and sutured, there are methods in which tissue dissection is minimized, and muscle tissue is simply manually pulled aside. The incision can be either vertical or horizontal.
A low horizontal incision in the lower uterine segment is considered the best option, since such sutures heal better, allow you to endure a subsequent pregnancy without problems and even give birth to a second child naturally, if the woman wants it and there are no medical contraindications.
Whatever the method of delivery chosen by the doctor, the operation will include the main stages, which we will discuss in more detail.
Laparotomy
The abdomen is treated with an antiseptic, isolated from other parts of the body with a sterile tissue and proceeds to dissect the anterior abdominal wall. With a vertical incision, a lower midline laparotomy is performed - an incision is made four centimeters below the navel and is brought to a point located four centimeters above the pubic joint. In a horizontal section, which is called a Pfannenstiel laparotomy, an arcuate incision is made along the skin fold above the pubis, 12 to 15 centimeters long, if necessary, longer.
A Joel-Cohen laparotomy can also be performed, in which the incision runs horizontally below the navel, but well above the peri-pubic fold. If necessary, such a cut can be lengthened with special scissors.
The muscles are gently pushed aside, and the bladder is temporarily removed to the side so as not to accidentally injure it. Only the wall of the uterus separates the doctor from the child.
Dissection of the uterus
The reproductive organ can also be dissected in different ways. If the surgeon is a big fan of the traditional technique, he can make an incision along the body of the uterus horizontally, vertically along the midline according to the Sanger method, or a pubic incision according to Fritsch, which runs through the entire uterus - from one edge to the other.
An incision in the lower segment of the female reproductive organ is considered the most gentle and recommended. It can be transverse according to Rusakov, crescent or vertical according to Selheim.
The doctor opens the fetal bladder with his hand or a surgical instrument. If childbirth is premature, it is considered the best option not to open the membranes, in which the child will be more comfortable to be born, adaptation will be easier.
Removing the fetus
The most crucial moment is coming. When a child is born physiologically or during surgical procedures, doctors are equally worried, because the likelihood of injury to the fetus with CS, although insignificant, still exists. To mitigate these risks, the surgeon inserts four fingers of his right hand into the uterus. If the baby is head down, the doctor's palm goes to the back of the head. Carefully cut the head into the incision on the uterus and remove the shoulders one by one. If the child is in breech presentation, it is removed by the leg or groin fold. If the crumb lies across, they take it out by the leg.
The umbilical cord is cut. The baby is given to the pediatrician, neonatologist or nurse of the pediatric department for weighing, placing a clothespin on the umbilical cord and other procedures. If a woman is awake, then she is shown the child, named gender, weight, height, they can attach it to the breast immediately after birth. In a surgical delivery under general anesthesia, the meeting between the mother and the baby is postponed to a later time, when the woman regains consciousness and recovers from the anesthesia.
Removing the placenta
The placenta is detached by hand. If it has grown, excision of part of the endometrium and myometrium may be required. With total ingrowth, the uterus is removed completely. Also, the surgeon conducts an audit of the uterine cavity, checks that nothing remains in it, checks the patency of the cervical canal of the cervix, if it is impassable, it is manually expanded. This is necessary so that lochia (postpartum discharge) in the postpartum period can freely leave the uterine cavity without causing stagnation and inflammation.
Closure of the uterus
A single-row or double-row suture is applied to the cut edges of the uterus. Two-row is considered preferable. It is more durable, although it takes a little longer to apply it. Each surgeon has a different suture technique.
The main thing is that the edges of the wound are joined as accurately as possible. Then the scar on the uterus will form an even, homogeneous, wealthy, which will not interfere with the next pregnancy.
Suturing the abdominal wall
Aponeurosis is usually sutured with separate silk or vicryl threads, or a continuous suture is carried out. Staples or separate sutures are applied to the skin. Sometimes the skin is sutured with a continuous cosmetic suture, which is very neat.
Early postoperative period
The woman is transferred to the intensive care unit, where she is monitored for 5-6 hours. Everything is important - how the anesthesia comes out, how sensitivity returns, how the uterus contracts. Pain after the return of sensitivity for 2-3 days is blocked with anesthetic drugs. Pressure and temperature are measured, and contraction drugs are injected.
In the absence of complications, after 6 hours the woman is transferred to the general ward, where she can soon begin to sit down and get up. A child is brought to her.
With a partner
Caesarean section is a great way to have a joint childbirth without the risk of unpleasantly shocking a man with what he sees. In the operating room, the husband may not be a passive observer, but an active participant. His task will be to help the anesthesiologist - to talk to his wife, hold her hand, support. If the operation is performed under general anesthesia, there is no sense in joint childbirth, because the woman in labor is fast asleep. But at the request of the spouses, such partner childbirth is quite possible.
In order for a man to be admitted to the operating room, he first needs to undergo a medical examination, provide the hospital with certificates of the absence of infectious diseases, sexually transmitted diseases, fresh data from a fluorographic examination with a description, the conclusion of a therapist, dermatologist.
It should be noted that not all maternity hospitals go to the presence of a stranger in the operating room. Then the joint childbirth looks like this: the doctors operate on the patient, and the husband is in the next room and watches what is happening through a small glass window. The baby is brought to him after birth and given to hold. Thus, it is the husband who becomes the first to take the baby in his arms and hold it to his chest.
The issue of the possibility of a partner caesarean section should be discussed in advance with the medical staff of the selected maternity hospital.
You will learn more about the features of a cesarean section by watching the transfer of Dr. Komarovsky.
