Abdominal delivery - caesarean section according to Gusakov. Caesarean section Caesarean section according to Gusakov

LECTURE 14 CAESAREAN SECTION IN MODERN OBSTETRICS. MANAGEMENT OF PREGNANT WOMEN WITH UTERINE SCAR

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

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

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

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

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

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

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

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

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

2. The name of the operation is taken from the code of laws of the legendary Roman king Numa Pompilius, who lived in the 8th century. BC. (lex regia, and in the era of emperors - lex caesarea). Among other things, the vault required that every pregnant woman who died unresolved had a child cut out before her burial. (sectio caesarea; German name "Kaiserschnitt").

3. "Caesarean section" - a mistranslation of the term "s ectio caesarea." Word "caesarea" derived from ab utero caseo(Pliny). Children who were born through this operation were called "caesones", which means "carved". Word section comes from the verb seco- dissect, and the word caesarea is cognate with the words caesura, excisio, circumcisio and comes from the verb Caedere- cut out. So the exact translation "section caesarea" should sound like a "cutting section" (tautology).

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

Reasons for the increase in frequency caesarean section (Fig. 92, 93) the following: an increase in the number of primiparous older than 30 years; introduction into obstetric practice of modern diagnostic methods for studying the condition of the mother and fetus during pregnancy and childbirth; expansion of indications for caesarean section with breech presentation, severe

Rice. 92. Cesarean section rate

Rice. 93. Frequency of caesarean section and childbirth per vias naturales after caesarean section in 1989-2002. in the USA

max preeclampsia, premature pregnancy; refraining from applying abdominal forceps and a vacuum extractor; weighting of the contingent of pregnant women with various extragenital and gynecological pathologies; an increase in the number of pregnant women with a scar on the uterus after cesarean section; improvement of resuscitation-intensive care for newborns; insufficient qualification of obstetricians-gynecologists in terms of rational management of childbirth; socio-economic and demographic factors.

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

Table 20

Maternal mortality rates after caesarean section and vaginal delivery in the UK 1994-1996. (Hall and Bewley, 1999)

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

Indications for caesarean section during pregnancy

Complete placenta previa.

Incomplete placenta previa with severe bleeding.

Premature detachment of a normally located placenta with severe bleeding and the presence of intrauterine fetal distress.

Failure of the scar on the uterus after a caesarean section or other operations on the uterus.

Two or more scars on the uterus after caesarean sections.

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

Condition after surgery hip joints and pelvis.

Malformations of the uterus and vagina.

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

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

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

Severe extragenital diseases (diseases of the cardiovascular system, diseases of the nervous system, high myopia, especially complicated, etc.).

Cicatricial narrowing of the cervix and vagina after plastic surgery on the cervix and vagina, after suturing urogenital and enterogenital fistulas.

A scar on the perineum after suturing a rupture of the III degree in previous births.

Expressed varicose veins veins in the vagina and vulva.

Transverse position of the fetus.

Conjoined twin.

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

Breech presentation or transverse position of the 1st fetus in multiple pregnancies.

Three or more fetuses with multiple pregnancy.

In vitro fertilization and embryo transfer, artificial insemination with a complicated obstetric and gynecological history.

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

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

Long history of infertility in combination with other aggravating factors.

Hemolytic disease of the fetus with the unpreparedness of the birth canal.

Post-term pregnancy in combination with a burdened gynecological or obstetric history, unpreparedness of the birth canal and the absence of the effect of labor induction.

Extragenital cancer and cervical cancer.

Exacerbation of herpesvirus infection of the genital tract.

Indications for caesarean section in childbirth

Clinically narrow pelvis.

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

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

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

Presentation and prolapse of the loops of the umbilical cord with unprepared birth canals.

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

A state of agony and sudden death of a woman in labor with a live fetus. Caesarean section is often performed according to combined, complex

testimony. They are a combination of several complications of pregnancy and childbirth, each of which individually does not serve as an indication for caesarean section, but together these complications pose a real threat to the life of the fetus in case of delivery through the natural birth canal.

Of considerable interest is the study of the place of caesarean section in preterm birth. The main indications for abdominal

nogo delivery at the last - severe forms preeclampsia, breech presentation of the fetus, premature detachment of the placenta, placenta previa, severe placental insufficiency. To achieve good results, it is necessary to have a highly qualified neonatal service that allows nursing children with low body weight.

Caesarean section during pregnancy is usually performed in planned, less often in emergency(bleeding with placenta previa, failure of the scar on the uterus, etc.), and in childbirth, as a rule, emergency indications. More than half of the operations are performed in a planned manner (54.5%), which indicates a good prenatal diagnosis of the fetal condition, anatomical features of the pelvis, obstetric and extragenital pathology requiring abdominal delivery.

The structure of indications for surgery is different for planned and emergency delivery. Yes, at planned caesarean section most frequent readings- the age of the primiparous over 30 years in combination with obstetric and extragenital pathology; scar on the uterus after caesarean section; pelvic presentation of the fetus; fetal distress.

At caesarean section during childbirth indications are more often fetal distress; anomalies of labor activity; clinically narrow pelvis; bleeding due to premature detachment of the placenta.

It should be emphasized that when deciding on the issue of abdominal delivery, it is necessary to always think about the future generative function of the mother, especially if she has such an operation for the first time.

reserves frequency reduction caesarean section - improving the management of childbirth through the birth canal using modern tracking systems and medications, the development of a method of careful management of childbirth through the birth canal in the presence of a scar on the uterus after cesarean section in the lower segment.

The axiom of E.V. Cragin (1916) "once a caesarean section, always a caesarean section" loses its validity now because it refers to the times when corporal caesarean section was performed, and at present caesarean section is mainly performed in the lower segment of the uterus by a transverse incision, in which conditions scar formation on the uterus is more favorable. It should be taken into account: the frequency of uterine ruptures after corporal caesarean section is quite high and is about 12%.

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

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

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

The question of the method of delivery in conditions of latent or clinically expressed infection with a live viable fetus remains controversial to date. Recently, in the absence of conditions for rapid delivery through the natural birth canal, in the presence of a latent or clinically pronounced infection, a number of authors speak in favor of abdominal delivery. At the same time, it is recommended to use a number of methods for preventing the development of an infectious process in the postoperative period. These include intraperitoneal caesarean section with broad-spectrum antibiotics and wound drainage; temporary delimitation of the abdominal cavity before opening the uterus; extraperitoneal caesarean section; removal of the uterus after a caesarean section.

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

these women for surgery (in the absence of vital indications). 3. Empty bladder (it is advisable to use an indwelling catheter). 4) Absence of symptoms of infection in childbirth.

One of necessary conditions, as with any surgical intervention, is the choice of the optimal time, i.e. such a moment when abdominal delivery will not be too hasty intervention, or vice versa (even worse) - an operation of desperation. This is primarily important for the fetus, but also affects the favorable outcome for the mother.

For the success of the operation, it is important to have an experienced specialist equipped with an operating room with the necessary personnel and sterile kits, as well as a highly qualified anesthesiologist, neonatologist, especially if a caesarean section is performed in the interests of the fetus.

Preoperative preparation. Caesarean section is planned (50-60%) and emergency. When planned the day before, they give a light lunch (thin soup, broth with white bread, porridge), for dinner - sweet tea, an enema is given in the evening, sleeping pills are prescribed at night. In the morning, they also put an enema (2 hours before the start of the intervention), if necessary, produce an elastic bandage lower extremities, and before the operation - auscultation of the fetal heartbeat, catheterization of the bladder.

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

The results of a caesarean section, like many others, depend on timely performance; methodology and scope; the patient's condition; surgeon qualifications; anesthetic support; medical support; the presence of suture material; blood and its components, infusion means; instruments and technical equipment of the clinic; management of the postoperative period.

Despite the apparent technical simplicity, caesarean section should be classified as a complex surgical intervention (especially repeated caesarean section) with a high rate of complications during surgery and in the postoperative period.

Anesthesia method for caesarean section, they are chosen taking into account the condition of the pregnant woman, the woman in labor, the fetus, the planned or urgency of the operation, the presence of a qualified anesthesiologist-resuscitator. In addition, painkillers must be safe for the mother and fetus.

Best for caesarean section conduction anesthesia- spinal or epidural (used in almost 90% of cases). In emergency situations, if rapid pain relief is required, endotracheal anesthesia with nitrous oxide is used in combination with antipsychotics and analgesics. When conducting general anesthesia, it must be remembered that no more than 10 minutes should elapse from the onset of anesthesia to the extraction of the fetus.

Technique of caesarean section.

Abdominal caesarean section (sectio caesarea abdominalis):

Intraperitoneal methods - caesarean section with opening of the abdominal cavity (classic caesarean section, corporal caesarean section, caesarean section in the lower uterine segment with a transverse incision in the modification of Eltsov-Strelkov, Stark; isthmic-corporal caesarean section);

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

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

Vaginal caesarean section according to Dursen (section caesarea vaginalis). Depending on whether or not to open the abdominal cavity, there are intraperitoneal or extraperitoneal caesarean section. The method of operation depends on the specific obstetric situation and the skill of the surgical technique by the surgeon.

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

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

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

2. The whole operation takes place with little blood loss, even when the placental site gets into the incision. In this case, bleeding dilated vessels can be ligated in isolation.

3. With this method, it is possible to make an ideal peritonization of the sutured wound of the uterus due to the vesicouterine fold (plica vesicouterina).

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

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

Corporal caesarean section despite many shortcomings, it is still used with a pronounced adhesive process in the lower segment of the uterus after a previous cesarean section; severe varicose veins in the lower segment or the presence of a large myomatous node in the lower segment of the uterus; the presence of an inferior scar after a previous corporal caesarean section; complete placenta previa with its transition to the anterior wall of the uterus; premature fetus and unexpanded lower segment of the uterus; fused twins; transverse position of the fetus. Corporal caesarean section is currently used in cases where, immediately after caesarean section, it is necessary to perform supravaginal amputation or extirpation of the uterus (according to indications: multiple uterine myoma, Kuveler's uterus). In addition, this method is used in a dead or dying patient with a live fetus. With a corporal caesarean section, the incision of the anterior abdominal wall is made between the womb and the navel, the uterus is not removed from the abdominal cavity; thus, an incision in the uterus and an incision in the anterior abdominal wall coincide with each other, which leads to an adhesive process, and an incision in the body of the uterus leads to an inconsistent scar in subsequent pregnancies.

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

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

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

The incision on the uterus is made according to the method of L.A. Gusakov. In the area of ​​the lower segment of the uterus, a small transverse incision 2 cm below the level of the incision of the vesicouterine fold opens the uterine cavity, then the index fingers of both hands gently stretch the edges of the wound up to 10-12 cm in the transverse direction. In some cases, an incision is used in Derfler's modification: after a small dissection of the lower segment of the uterus (2 cm) is made with a scalpel, the incision is extended to the right and left of the midline arcuate upwards with scissors to the desired size. When performing an incision of the uterus in the lower segment, one should be very careful not to injure the vascular bundle and the fetal head with a scalpel.

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

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

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

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

Extraction of the fetus depends on the presentation and position of the fetus in the uterus.

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

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

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

After removing the child, to reduce blood loss during surgery, 1 ml of a 0.02% solution of methylergometrine is injected into the uterine muscle and 1 ml (5 IU) of oxytocin is started by intravenous drip. In case of violation in the hemostasis system (hypocoagulation), the introduction of fresh frozen plasma is indicated. In addition, it is necessary to capture the edges of the wound, especially in the area of ​​\u200b\u200bthe corners, with Mikulich clamps.

Whether the placenta separated on its own or was separated by hand, in any case, a subsequent revision of the walls of the uterus by hand is necessary to exclude the presence of remnants of the fetal egg, submucosal uterine fibroids, septum in the uterus and other pathologies. Sometimes there is a need for an instrumental (with the help of a curette) examination of the uterus.

In the production of a caesarean section in a planned manner, before the onset of labor and the lack of confidence in the patency of the cervical canal, you should pass it with your finger, and then change the glove.

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

Highly importance have the technique of suturing the uterus, suture material. The correct comparison of the edges of the wound is one of the conditions for the prevention of infectious complications, the strength of the scar.

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

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

It is considered expedient to impose a continuous single-row suture (Vikryl? 1 or 0, Dexon? 1 or 0, etc.) on the uterus with piercing of the mucous membrane and subsequent peritonization of the vesicouterine fold (Fig. 96). Advantages of a single row seam consist in a lesser violation of tissue trophism, a smaller amount of suture material in the suture area, a rarer development of edema in the postoperative period, a reduction in the duration of the operation, and a lower consumption of suture material. Continuous two-

row seam (Fig. 97) is advisable to use with severe varicose veins in the lower segment of the uterus and with increased bleeding.

With a corporal caesarean section (Fig. 98), a two-row continuous suture is usually applied (vicryl, dexon, etc.).

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

Immediately after the operation, on the operating table, the toilet of the vagina should be carried out, which contributes to a smoother course of the postoperative period. It is necessary to pay attention to the color of urine (an admixture of blood!) And its amount.

With a potential and clinically pronounced infection, a live and viable fetus, and in the absence of conditions for delivery through the natural birth canal, it is advisable to use an extraperitoneal caesarean section according to the Morozov method (Fig. 99). With this method, the abdominal wall (skin, subcutaneous adipose tissue, aponeurosis) is opened with a transverse suprapubic incision (according to Pfannenstiel) 12-13 cm long. The rectus abdominis muscles are separated in a blunt way, and the pyramidal ones in a sharp way. Then the right rectus muscle is bluntly exfoliated from the preperitoneal tissue and retracted to the right with a mirror. Expose the right rib of the uterus and the fold of the peritoneum. The detection of this fold is helped by the displacement of tissues (preperitoneal cell

Rice. 96. The imposition of a single-row continuous suture for caesarean section

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

Rice. 98. The imposition of a continuous suture on the uterine incision for corporal caesarean section:

a - muco-muscular suture; b - serous-muscular suture; c - gray-serous suture.

chatki, peritoneum) to the left and up; as a result, the fold is stretched in the form of a "wing". In addition, she has more White color. Slightly below the folds of the peritoneum, the loose connective tissue is bluntly separated to the intrapelvic fascia. To find the place of detachment of the vesico-ma-

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

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

For the best exposure of the lower segment of the uterus, the fingers are spread apart, downwards and especially upwards to the place of intimate attachment of the peritoneum to the uterus. The "bridge" formed by the vesicouterine fold and the top of the bladder is retracted to the left with a mirror and the lower segment of the uterus is exposed. Opening the lower segment of the uterus and removing the fetus is performed according to the method adopted for conventional caesarean section, but before removing the child, the side mirror holding the right rectus abdominis muscle should be removed, and the mirror that holds the vesicouterine fold and the top of the bladder should be left in place , which contributes to better access to the lower segment and less injury to the bladder. A continuous single-row (rarely double-row) Vicryl, Dexon suture is applied to the incision on the uterus. The anterior abdominal wall is restored layer by layer.

Preoperative sanitation of the birth canal (plivasept, furatsilin, etc.) and rational antibiotic prophylaxis during surgery and within 24 hours after it contribute to a decrease in the frequency of postoperative complications.

Most researchers consider the rational prophylactic use of antibiotics for cesarean section only in women in labor with a high risk of infection, as well as preeclampsia, anemia, impaired fat metabolism, etc. The combination of several risk factors increases the possibility of developing infectious complications.

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

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

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

Almost all antibiotics used to treat endometritis after caesarean section are recommended to some extent for its prevention. It:

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

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

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

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

It should be emphasized that only a technically correct caesarean section, regardless of the technique, provides a favorable outcome and a smooth course of the postoperative period.

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

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

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

Pain relief in the postoperative period: on the 1-3rd day after the operation, no narcotic analgesics: analgin 50% - 2.0 ml, baralgin 5.0 ml 1-3 times a day; with inefficiency - narcotic analgesics: promedol 2% 1 ml, omnopon 2% 1 ml.

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

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

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

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

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

To determine the state of the suture, to identify possible inflammatory and other changes in the uterus in the postoperative period, ultrasound is indicated on the 5th day. Women are usually discharged on the 7-8th day after the operation.

Much attention is currently being paid to adaptation of newborns after caesarean section and timely resuscitation. In children extracted by caesarean section in a planned manner, due to a decrease in adaptive abilities, there may be violations cerebral circulation(encephalopathy), the respiratory system in the form of a syndrome of respiratory disorders, primary atelectasis, aspiration syndrome, transient tachypnea, and conjugative jaundice. The reason is the absence of mechanical and metabolic factors necessary for the fetus during planned abdominal delivery, which affect it during childbirth. In response, a powerful release of stress hormones (adrenaline, norepinephrine, dopamine, etc.) occurs in the fetus's body, helping the child overcome negative influences and more easily endure the process of adaptation to extrauterine life.

Caesarean section is one of the intranatal risk factors for the fetus and newborn. Sometimes the surgical intervention itself is not harmless, since it is possible to injure the fetus during its extraction. Not half-

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

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

Complications, difficulties and errors during the operation of caesarean section are possible at all its stages.

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

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

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

With detachment of the aponeurosis towards the navel and womb, there is often a violation of the integrity a.a. nutricae, bleeding from which leads to the formation of subgaleal hematoma. The frequency of subgaleal hematomas diagnosed by ultrasound and requiring emptying is 0.76%. Therefore, when detaching the aponeurosis to the side, it is necessary to effectively ligate a.a. nutricae. Particularly thorough

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

In all cases of caesarean section, an ice pack is applied to the area of ​​the surgical field within 1.5-2 hours after the operation.

With a longitudinal median incision, bleeding, as a rule, does not happen. Certain difficulties are observed during repeated abdominal dissection, especially when several abdominal dissections have taken place. So, if the abdominal surgery was performed in the past due to intestinal obstruction or other surgical pathology, then intimate soldering of the intestine or omentum to the anterior abdominal wall and their injury during the operation is possible.

Each obstetrician-gynecologist must remember the likelihood of injury to neighboring organs (bladder, ureter, intestines), and if an injury occurs, then diagnose it in time and take appropriate measures. The bladder is usually damaged when opening the peritoneum, especially during repeated abdominal dissections, when dissecting the vesicouterine fold of the peritoneum, separating the bladder from the uterus during adhesions, with extraperitoneal access when trying to hemostasis due to bleeding due to the extension of the incision to the vascular bundles or to the neck uterus.

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

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

Often trauma to the urinary system occurs not during surgery, but during hysterectomy after caesarean section.

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

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

Rational from the anatomical standpoint is a transverse incision of the uterus in the area of ​​the lower segment, in the "avascular" zone, where the anatomical structures of the uterus, including its vascular network, are least injured. However, even with this incision, bleeding is possible due to injury to the coronary artery of the isthmus, as well as damage to the vessels of the varicose venous plexus. If it is impossible to select an avascular site, it is recommended to press the wall of the uterus to the presenting part of the fetus with fingers or a tupfer above and below the intended incision, which results in compression of the vessels and a decrease in bleeding. If bleeding does not allow controlling the depth of the uterine incision, then the uterus should be bluntly perforated at the site of the incision with fingers, which avoids damage to the presenting part of the fetus.

Increasing the incision in the lower segment of the uterus to the lateral sides in a blunt or sharp way can damage the vascular bundle and cause life-threatening bleeding. Sometimes the transverse incision of the lower segment of the uterus is extended not only in the lateral direction, but also downwards, towards the cervix, under the bladder. Most often this occurs during an operation on an emergency basis, with full disclosure of the cervix, with a low incision on the uterus, a low location of the presenting part of the fetus, with a large fetus, during the rotation of the fetus in its transverse position, or if the technique of removing the presenting part is violated, as well as rough handling.

After removing the fetus from the uterus with an unseparated afterbirth, Mikulich clamps are applied to the corners of the incision and bleeding upper and lower edges of the wound on the uterus, 1 ml of methylergometrine is injected into the uterine muscle. If it is impossible to find bleeding vessels, it is recommended to remove the uterus from the abdominal cavity and perform hemostasis under visual control.

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

during incision, uterus; lack of amniotic fluid; violation of the technique of opening the uterus. The danger of such an injury is great when the face of the fetus is turned forward.

With a caesarean section, difficulties and complications may arise in the removal of the fetal head. They are observed when the head is high above the entrance to the small pelvis or very low, especially often when the uterus is dissected by a transverse incision in the lower segment. If the head is located high above the incision, and it cannot be brought down and removed, then it is necessary to find the peduncle of the fetus, carefully turn it and remove it. A significant difficulty is the extraction of the fetus with a low location of the head (a large segment in the plane of entry or in a wide part of the pelvic cavity). If it is not possible to freely remove the head in the usual way, then the surgeon should be assisted by feeding the head from the side of the vagina. This significantly reduces trauma to the fetus, the likelihood of extending the incision to the sides and injury to the vascular bundles.

If it is impossible to extract the fetal head during cesarean section in the lower segment of the uterus with a transverse incision, it is permissible to dissect the uterus upwards in the form of an inverted "T". Difficulties in removing the fetal head are also due to insufficient dissection of the anterior abdominal wall and its insufficient relaxation (when the head is already removed from the uterus), and non-compliance with the removal technique. In such a case, it is necessary to extend the existing or make an additional incision of the anterior abdominal wall.

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

Most obstetricians are supporters of the manual removal of the placenta and the allocation of the placenta during surgery. With manual separation of the placenta, it is possible to identify: its dense attachment and increment; uterine septum; bicornuate or saddle uterus; thinning of the uterine wall or its rupture and other features.

True accretion of the placenta, Kuveler's uterus with a violation of its contractile function - indications for removal of the uterus.

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

The main complication after removal of the placenta is bleeding, which may be due to hypo- or atony of the uterus, a violation of the blood coagulation system.

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

Massage of the uterus;

Removal of blood clots;

The introduction of uterotonic agents into the thickness of the myometrium and intravenously;

Transfusion of fresh frozen plasma;

Ligation of the uterine vessels;

With the ineffectiveness of treatment - removal of the uterus.

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

A serious mistake during the operation is the suturing of the upper edge of the incision of the lower segment of the uterus to its posterior wall. Such an error is possible due to the fact that the lower edge is reduced and goes under the bladder, especially if the incision is made very low. The posterior wall of the uterus contracts and protrudes in the form of a roller, it is taken as the lower edge of the wound. To avoid this, immediately after the extraction of the fetus, even before the removal of the placenta, Mikulich clamps are applied to the corners of the wound and the edges of the incision (upper and lower).

The issue of indications for expanding the volume of surgery to hysterectomy during caesarean section and in the postoperative period is complicated. The main indications for removal of the uterus are bleeding that is not amenable to conservative therapy, multiple uterine fibroids (degeneration of myomatous nodes), Kuveler's uterus with a violation of its contractility. The frequency of hysterectomy after caesarean section varies in a fairly wide range - from 2.16 to 9.2%.

The problem of the volume of surgical intervention for uterine myoma, which often accompanies pregnancy, remains debatable. The obtained scientific data and the accumulated clinical experience have made it possible to develop indications for conservative myomectomy during caesarean section. These include subserous pedunculated myoma nodes, the location of the nodes in the area of ​​the proposed incision of the lower segment on the uterus, the presence of intramural large nodes.

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

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

In case of bleeding in the early postoperative period, the chance of stopping bleeding by conservative means should be used, which include timely emptying of the bladder; external massage of the uterus; the introduction of uterotonic drugs intravenously; digital or instrumental emptying of the uterus (with an expanded operating room and under intravenous anesthesia); the introduction of uterotonic drugs into the cervix and intravenously; infusion-transfusion therapy (fresh frozen plasma, etc.). The effectiveness of this therapy is 82.4%. In case of ineffectiveness, relaparotomy and removal of the uterus are indicated.

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

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

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

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

Often, maternal mortality during caesarean section is due to bleeding and untimely, inadequate volume

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

Thus, the reserves for reducing maternal mortality during caesarean section are: prevention of the development of purulent-septic complications; adequate anesthetic support; timely, adequate in volume surgery and replenishment of blood loss in case of bleeding; timely resolution of the issue of abdominal delivery in the absence of the effect of conservative therapy in severe forms of preeclampsia.

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

Primary resuscitation of newborns after caesarean section is important. Often the obstetrician underestimates the importance of placental transfusion and, having raised the removed child high, crosses the umbilical cord. Sometimes misunderstood anesthetic fetal depression becomes an indication for unjustified massive use of resuscitation measures, including aggressive ones.

Transferred caesarean section has a certain impact on the subsequent reproductive function of women: they may experience infertility, recurrent miscarriage, violations menstrual cycle. Therefore, timely and correct technical performance of the operation, proper management of the postoperative period, and dispensary observation in the future are required.

Pregnancy in the presence of a scar on the uterus often proceeds with the failure of the scar, the phenomena of the threat of interruption, placental insufficiency. Pregnant women with a scar on the uterus should be under careful dispensary observation and placed in a hospital in advance (2 weeks before delivery). The choice of method of delivery for these pregnant women should be based on special attention, it is still the subject of debate. Spontaneous childbirth in such patients should be carried out by the most highly qualified specialists, in a hospital with permanently functioning anesthesiology, neonatology and other services.

Despite the relatively large number scientific developments and practical recommendations for the management of pregnancy and childbirth in women with a uterine scar, the problem is very far from a final solution. This primarily refers to the dispensary observation of this contingent of pregnant women, the identification of symptoms of failure of the scar on the uterus at various stages of pregnancy, optimal timing hospitalizations during normal and complicated pregnancy and, finally, to methods of delivery of women with a scar on the uterus (repeated caesarean section or childbirth through the natural birth canal).

When managing pregnant women with a scar on the uterus in the antenatal clinic, special attention should be paid to the following. At the first visit of the patient to the appointment, it is necessary to assess the condition postoperative scar based on anamnesis data, a detailed extract from the maternity hospital (which should indicate the methods of examining the scar in the early postoperative period), get information about the study of the scar outside of pregnancy (hysteroscopic and ultrasound methods). Data on the insolvency of the scar serve as the basis for termination of pregnancy up to 12 weeks. In this case, a woman must be informed about the complications (up to uterine rupture) during the continuation of pregnancy and vital indications for termination of pregnancy.

Almost all obstetricians make a big mistake, already with early dates pregnancy, orienting all women with a scar on the uterus for repeated operative delivery. As studies show, childbirth through the birth canal in such women is not only possible, but also expedient. Repeated caesarean section with a full scar should be an alternative to spontaneous childbirth, and not vice versa.

In addition to conducting a routine obstetric examination during subsequent visits of pregnant women to the antenatal clinic, the obstetrician should pay special attention to the complaints of patients with a scar on the uterus: first of all, pain, its localization, nature, intensity, duration, connection with physical activity; on the nature of the discharge from the genital tract (in the presence of a scar, there is often a low placentation along the anterior wall of the uterus). At each turnout, palpation of the scar on the uterus through the anterior abdominal wall is mandatory. It is easier to determine the condition of the scar in the area of ​​the body of the uterus, it is much more difficult to localize it in the lower segment of the uterus. In the case of pope-

river suprapubic incision of the anterior abdominal wall, palpation of the scar is hampered by cicatricial changes in the skin, subcutaneous tissue, aponeurosis, and the high location of the bladder. However, pain deep palpation in the suprapubic region (in the area of ​​the supposed scar on the uterus), especially the local one, may indicate the inferiority of the scar, and the patient should be immediately hospitalized, regardless of the gestational age, for a more detailed examination and a decision on the possibility of prolonging the pregnancy.

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

With a normal pregnancy, ultrasound in women with a scar on the uterus must be performed at least three times (when registering, at 24-28 weeks and at 34-37 weeks). It is very difficult to assess the viability of the scar on the uterus up to 34-36 weeks of gestation sonographically. However, additional information obtained from echography can greatly help the doctor in choosing further tactics. Attention should be paid to the tone of the uterus, the state of the internal os of the cervix, the place of placentation, the correspondence of the size of the fetus to a given gestational age, the height of the bladder, etc. With the threat of termination in the first half of pregnancy, urgent hospitalization is necessary, where, after a thorough examination of the woman, adequate “saving” therapy is prescribed.

The frequency of the threat of termination of pregnancy in the presence of a scar on the uterus, according to various authors, ranges from 16.8 to 34%. Careful differential diagnostics of this pathology with inconsistency of the scar is necessary. Clarification of the diagnosis should be carried out only in a hospital, with dynamic observation, based on clinical symptoms, ultrasound data, the effect of therapy aimed at prolonging pregnancy. Main clinical symptom failure of the scar on the uterus is a local soreness in the lower segment.

With a positive effect from "preserving" therapy, patients can be discharged from the hospital under the supervision of a antenatal clinic doctor. In the presence of insolvency of the scar on the uterus, pregnant women should be in the hospital until delivery. Ultrasonic control of the scar condition should be carried out every 5-7 days.

Placentation plays a significant role in predicting the outcome of pregnancy in women with a uterine scar. When the placenta is located along the anterior wall, especially in the area of ​​​​the scar on the uterus, the risk of failure of the latter is very high. Such women need to be given the closest attention, they are shown planned hospitalization at 24-28 weeks of pregnancy, even with its favorable course. Invasion of the chorionic villi is accompanied by the release of proteolytic enzymes that destroy the connective and muscle tissue, and leads to the development of uterine scar failure. In such pregnant women, the risk of uterine rupture (usually in the absence of symptoms indicating a risk) is very high, abruption of a low-lying placenta, intrauterine growth retardation syndrome, and abortion are more common.

Women need urgent hospitalization if the placenta is located along the anterior wall with increased uterine tone, if there are pulling pains in the lower abdomen, bouts of nausea or weakness, if frequent or painful urination occurs. When conducting pregnancy-preserving therapy, it must be remembered that a number of drugs containing prostaglandin synthetase inhibitors (baralgin, aspirin, indomethacin, trigan, maxigan, etc.) increase pain threshold sensitivity with the threat of uterine rupture along the scar. Frequent complication in pregnant women with the location of the placenta in the area of ​​the uterine scar is the development of placental insufficiency and, as a result, hypoxia and fetal hypotrophy. When examining the fetus, it is necessary to control the compliance of its size with a given gestational age, to perform dopplerometry of blood flow in the vessels of the umbilical cord and aorta.

All pregnant women with a scar on the uterus are scheduled for hospitalization at 37-38 weeks of gestation. Before being admitted to the hospital, each woman is discussed with the question of possible methods delivery. The doctor should explain in detail the benefits and risks of both caesarean section and spontaneous delivery. The decision on spontaneous delivery can only be made with favorable

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

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

b) studies of the scar on the uterus, carried out outside of pregnancy and during this pregnancy;

c) parity (whether there were spontaneous births before the first caesarean section);

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

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

e) the course of the present pregnancy.

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

Methods for studying the condition of the scar on the uterus during pregnancy are practically limited to the only one - ultrasound scanning. Ultrasound acquires the greatest information content and practical significance from the 35th week of pregnancy.

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

The echoscopic signs of insolvency of the scar on the uterus, located in the lower uterine segment, include not so much the total thickness of the scar as its uniformity. Many authors believe that a scar with a thickness of more than 0.4 cm can be classified as full-fledged, less than 0.4 cm - defective. The scar, where there were local thinning, regardless of its total thickness, is recognized as inferior. As studies have shown, “thick” scars are also untenable. With their anatomical usefulness (their total thickness was, as a rule, 0.7-0.9 cm), they were dominated by connective tissue elements (morphological inferiority), and childbirth in such women due to cervical dystocia (functional inferiority) ended with a second operation.

It is very important that a woman agrees to one or another method of delivery, first of all, to spontaneous childbirth, if they are possible.

us. Obtaining the consent of a pregnant woman for a second caesarean section is not very difficult.

Many researchers based on personal experience came to the conclusion that with a wealthy scar on the uterus, a satisfactory condition of the pregnant woman and the fetus, childbirth through the natural birth canal is not only possible, expedient, but also more preferable than a second caesarean section. The most important and difficult task is the selection of pregnant women with a uterine scar for spontaneous delivery.

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

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

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

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

Normal size of the pelvis.

Absence of other scars on the uterus.

Absence of local thinning of the scar.

Absence of local pain in the lower uterine segment.

Placentation outside the scar area.

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

Fruit less than 4000 g.

The absence of extragenital and other pathology, which was an indication for the first caesarean section.

Conducting childbirth in a large obstetric institution by a highly qualified obstetrician.

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

A rich scar on the uterus in the absence of any complications of pregnancy or extragenital pathology (independent indications for caesarean section) gives grounds to resolve the issue of delivery tactics in favor of childbirth through the natural birth canal under careful clinical and monitoring control and with the operating room ready for immediate operative delivery in in the event of any complications during childbirth.

Repeated caesarean section is a technically more complex operation. When it is performed, in some cases, difficulties arise at the time of opening the abdominal cavity, when dissecting the uterus, when removing the fetal head, or when suturing the wound of the uterus. They may be due to the presence of a skin scar on the anterior abdominal wall soldered to the underlying tissues, intraperitoneal adhesions that complicate access to the uterus. Adhesions occur between the uterus and the anterior abdominal wall, between the parietal peritoneum and the omentum, between the omentum, bowel loops and the bladder. After a caesarean section, the bladder is often displaced upward as a result of the features of peritonization or due to the adhesive process. As a result of a change in normal anatomical relationships with repeated caesarean section, injuries of the bladder and intestines are not uncommon.

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

One of the serious complications is ligation or dissection of the ureter during hemostasis in the parametric tissue.

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

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

When studying the long-term results of repeated caesarean section, it was found that women, years after the operation, present various complaints. 25% of them have periodic pain in the abdomen, in the area of ​​the seam, lower back. 4.2% of women had postoperative hernia or the formation of rough adhesions of the skin suture with the underlying tissues.

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

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

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

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

Thus, repeated caesarean section in pregnant women with a scar on the uterus cannot be the method of choice for delivery of these patients. Childbirth through the natural birth canal is preferable. But they must be carried out in a large obstetric institution.

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

childbirth per vias naturales in pregnant women with a scar on the uterus, it is contraindicated in case of a complicated course of the first caesarean section, breech presentation of the fetus, lower median scar on the uterus, large fetus, twins. The risk of uterine rupture at fetal weight >4000 g doubles.

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

Table 21

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

Expectant tactics are advisable with careful monitoring of the nature of labor, the condition of the scar on the uterus and the fetus. For this purpose, external and internal tocography, constant cardiomonitoring of the fetus or pH monitoring are used. The absence of complaints in a parturient woman about local pain in the region of the lower segment of the uterus between contractions or during its palpation, regular labor activity, recorded clinically and with tocography, the normal state of the fetus during monitoring control indicate the viability of the scar.

In the absence of regular labor activity after amniotomy or its weakening in the process of spontaneous childbirth in women with a scar on the uterus, one of the important and not yet fully resolved questions about the possibility of using uterine contracting agents has to be addressed.

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

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

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

Much attention during vaginal delivery in women after caesarean section should be given to adequate pain relief as an important measure aimed at relieving labor stress and allowing the obstetrician to objectively assess the response of the woman in labor to contractions. Epidural anesthesia has become the most widely used for labor pain relief in women with an operated uterus.

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

It's like this surgery, during which the anterior abdominal wall of the woman in labor is first dissected, then the wall of her uterus, after which the fetus is taken out through these incisions.

Caesarean section in modern obstetrics

In modern obstetrics, caesarean section is the most frequently performed operation. Its frequency in recent years reaches 10-20% of the total number of births.

Indications for caesarean section

A caesarean section is performed only in situations where vaginal delivery is fraught with a serious danger to the life and health of the fetus or the woman herself.

Distinguish between absolute and relative indications for surgery

Absolute readings to caesarean section - these are clinical situations in which childbirth through the natural birth canal poses a danger to a woman's life.

To the group relative readings includes diseases and obstetric situations that adversely affect the condition of the mother and fetus if childbirth is carried out in a natural way.

As you can see, most of the indications for caesarean section are due to concern for the health of both mother and child. In one case, already at the very beginning of pregnancy, during examination, a woman reveals the prerequisites that she may not give birth on her own (for example, a strong narrowing of the pelvis, or a scar on the uterus from a previous operation). In another, indications for delivery by caesarean section appear as the gestational age increases (for example, the fetus has a transverse position in the uterus or placenta previa was determined by ultrasound). The doctor warns the pregnant woman about this fact immediately, explaining to her the reason. In both of these cases, the woman is prepared for a caesarean section at planned, that is, when she enters the maternity ward, they begin to prepare her not for childbirth, but for surgery.

Of course, the psychological aspect of "rejection" by future mothers of a caesarean section is understandable. Few people feel "thrust" for surgical interventions in the affairs of their own body. But cesarean section is an everyday reality (judge for yourself: on average, 1 out of 6-8 pregnant women give birth this way). Therefore, the doctor always tries to explain all the pros and cons of the upcoming operation and reassure the woman.

But, sometimes, when nothing seemed to portend danger throughout the pregnancy and the woman began to give birth on her own, emergency situations arise (for example, the threat of uterine rupture or oxygen starvation of the fetus, persistent weakness of labor activity) and childbirth ends after urgent indications cesarean section operation.

What clinical situations are considered a contraindication for caesarean section?

1. Intrauterine fetal death (fetal death before birth).
2. Deep prematurity of the fetus.
3. Fetal deformities.
4. Prolonged oxygen starvation of the fetus, in which there is no certainty in the birth of a live child.
5. infectious and inflammatory diseases mother.

What conditions are considered the most favorable for the operation?

1. The optimal time for the operation is the onset of labor, since in this case the uterus contracts well and the risk of bleeding decreases; in addition, in the postpartum period, the discharge from the uterus will receive a sufficient outflow through the ajar neck.
2. It is better if the amniotic fluid is intact or after their outflow, more than 12 hours should not pass.
3. A viable fetus (this condition is not always feasible: sometimes, when the life of the mother is in danger, the operation is performed even with a non-viable fetus).

What is the preparation of a woman for a planned caesarean section?

When preparing a pregnant woman, a detailed examination is carried out, including a study of blood counts, electrocardiography, a study of vaginal smears, an examination by a general practitioner and an anesthesiologist.

In addition, a comprehensive assessment of the condition of the fetus (ultrasound, cardiotocography) is mandatory.

The night before the operation, the pregnant woman is given a cleansing enema, which is repeated in the morning on the day of the operation. At night, as a rule, sedatives are prescribed.

What are the methods of anesthesia for caesarean section?

Endotracheal anesthesia - this is general anesthesia with artificial ventilation of the lungs; is currently the main method of anesthesia for caesarean section. It is done by an anesthesiologist and during the entire operation controls the condition of the woman.

Operation steps

An incision of the skin and subcutaneous adipose tissue is carried out along the lower fold of the abdomen in the transverse direction.

The incision on the uterus is made carefully (so as not to damage the fetus) in the lower uterine segment (the thinnest and most stretched place on the uterus). The incision is made initially small also in the transverse direction. Then the surgeon gently stretches the incision with his index fingers to 10-12 cm.

The next and most crucial moment is the extraction of the fetus. The surgeon gently inserts a hand into the uterine cavity and brings the fetal head out, and then removes the entire baby. The umbilical cord is then cut and the baby is delivered pediatrician and a nurse.

The placenta with membranes (afterbirth) is removed from the uterus, the uterine incision is carefully sutured, the surgeon checks the condition of the abdominal cavity and gradually sews up its wall.

What unpleasant moments are possible after the operation?

Possible discomfort during the recovery from anesthesia (and even then not for everyone). It can be nausea and dizziness, headaches. In addition, the surgical wound can also be a source pain at first time. The doctor usually prescribes drugs that reduce or eliminate pain (taking into account the effect of drugs on the newborn if the mother is breastfeeding).

Troubles also include the need for bed rest for the first time (1-2 days, on the 3rd day after the operation it is allowed to walk), the need to urinate through a catheter inserted into the bladder (not for long), more than usual, the number of prescribed drugs and tests , constipation and some hygiene restrictions - a wet toilet instead of a full shower (until the stitches are removed).

How is the postpartum period different for women after a caesarean section?

Mainly because it will take more time before a woman feels like before pregnancy, as well as the sensations and problems associated with a postoperative scar.

These patients need more rest and help with household chores and with the baby, especially in the first week after discharge, so it is helpful to think ahead and ask family members for help. By discharge, there should be no particular pain in the area of ​​the postoperative suture.

The suture area may be tender for a few weeks after the operation, but this will gradually disappear. After discharge, you can take a shower and you should not be afraid to wash the seam (with subsequent processing of it with brilliant green).

In the process of healing the seam, a feeling of tingling, tightening of the skin or itching may occur. These are normal sensations that are manifestations of the healing process and will gradually disappear.

A feeling of numbness of the skin in the area of ​​the scar may persist for several months after the operation. If there is severe pain, reddening of the scar, or brownish, yellow, or bloody discharge from the suture, you should consult a doctor.

Complications after caesarean section and their treatment

Peritonitis after caesarean section occurs in 4.6 - 7% of cases. Mortality from peritonitis and sepsis after caesarean section is 26 - 45%. The development of peritonitis causes infection of the abdominal cavity (from complications of caesarean section - chorionamnionitis, endometritis, suppuration of the suture, acute inflammatory processes in the appendages, infections penetrated by the hematogenous or lymphogenous route - with paratonsillar abscess, with abscess of soft tissues, pyelonephritis).

Risk factors for the development of sepsis and peritonitis are similar in clinical and management tactics:

• sharp infectious diseases during pregnancy
• chronic infectious diseases and existing foci of chronic infection.
• All vaginosis (nonspecific) and specific colpitis.
• Age: under 16 and over 35.
• A long anhydrous period (more than 12 hours), that is, an untimely caesarean section.
• Frequent vaginal examinations (more than 4).
• Peritonitis after chorionamnionitis or endometritis in childbirth

Therapy program and treatment

Diagnosis is always late, but so is treatment. Developed tactics of surgical treatment (with removal of the uterus, as it is the primary source of peritonitis). Operate most often on days 9-15, rarely operate on days 4-6. Severity should be assessed by the progression of symptoms.

Treatment

1. Surgical intervention. The earlier it started surgery after the diagnosis of peritonitis, the less organ damage will be observed after surgery. Removal of an organ as a focus of infection (uterus with peritonitis after cesarean section) is etiologically directed. The uterus with tubes is removed, the ovaries are usually left if there are no inflammatory phenomena in them. Extirpation of the uterus is more often performed than amputation. The lower segment is close to the cervix, so supravaginal extirpation of the uterus is performed with removal of the fallopian tubes with revision of the abdominal organs.
2. Antibiotic therapy: cephalosporins and antibiotics acting on gram-negative microorganisms - gentamicin in maximum doses, preferably intravenously. Preparations of the metronidazole series - metragil intravenously (acts on gram-negative flora, fungal flora). The spectrum of sensitivity of microorganisms to antibiotics must be done.
3. Treatment and relief of intoxication syndrome. Infusion therapy with drugs that have detoxification properties: reopoliglyukin, lactasol, colloidal solutions. The introduction of solutions improves the patient's condition. Also prescribe drugs that increase oncotic blood pressure - plasma, amino blood, protein preparations, amino acid solutions. The amount of liquid is 4-5 liters. The therapy is carried out under the control of diuresis.
4. Restoration of intestinal motility: all infusion therapy with crystalloid solutions, antibiotics improve motility. Also use agents that stimulate intestinal motility (cleansing, hypertonic enemas), antiemetics, prozerin subcutaneously, intravenously; oxybarotherapy). The first 3 days should be a constant activation of intestinal motility.
5. Antianemic therapy - fractional blood transfusion (preferably warm donor blood), antianemic drugs.
6. Stimulation of immunity - the use of immunomodulators - thymolin, complex, vitamins, UV blood, laser blood irradiation.
7. Care and struggle with physical inactivity is important, parenteral nutrition, then complete enteral nutrition - high-calorie, fortified - dried apricots, cottage cheese, raisins, dairy products. The fight against hypodynamia consists in breathing exercises, early turning in bed, massage

wounds of the abdominal wall with a wide suprapubic mirror and a retractor, the movable part of the vesicouterine fold, loosely connected to the uterus, is found (preferably with tweezers). In the middle between two tweezers that lift the fold of the peritoneum, it is dissected with scissors (or a scalpel). Then one branch of the scissors is inserted under the peritoneum and the vesicouterine fold is dissected to the side, parallel to the upper border of the bladder, 2 cm away from it. The peritoneum is dissected in the same way in the other direction. This point of operation is essentially exactly the same as for a retrovesical caesarean section.

Abdominal delivery rate

Speaking about the frequent use of caesarean section, one should not consider only the data of individual institutions, as well as comparing them, criticize certain scientists and cite the authority of others as evidence. Numerous factors influence the number of cases of this surgical intervention: the level of hospital management of pregnancy and childbirth in a given area or in the republic, the proportion of obstetric inferiority among hospitalized women who are preparing to become mothers and giving birth to women in a specific maternity ward, generally accepted therapy instructions, qualifications of doctors, workload obstetric institution, its profile, etc. In addition, it is desirable to understand the fact that the development of a system for organizing and providing affordable medical care to the population, for example, providing medical care in the process of childbirth, reflects the stage of the national economic upsurge of the republic. In foreign countries, some other factors are added to these factors: the affiliation of the maternity ward to the city authorities, and maybe to the subject of individual entrepreneurship, mercantile positions and, possibly, the racial affiliation of the puerperas. From this follows the diversity in the indicators not only for some countries, but also within a particular country.

Why the given figures cannot describe the situation about the real frequency of cases of artificial delivery today. The method of studying the huge number of birth processes in a large developed region, solely based on statistical data, can in a certain way level out such differences and determine an approximate figure that reflects cases of artificial delivery as a delivery technique for a given historically important period of time.

Still, it is also not necessary to completely ignore the frequency of abdominal surgery in childbirth in any individual maternity hospital. In favor of the organizers of childbirth, one should remain not indifferent when in a large, adequately equipped hospital with qualified medical staff, the frequency of artificial delivery becomes the same as in a small maternity ward.

Likewise, both abroad and in our country, the press draws attention with some concern to the increase in the frequency of caesarean section over the past decades, due to a significant improvement in the personal results of such a procedure for a woman in labor. In the event that a comparison of the corresponding figures is made, this assurance will remain only partially true. Since the time when abdominal delivery was firmly included in medical activity, the frequency of this operation in the European republics and the United States turned out to be traditionally large, in the republics Soviet Union- insignificant.

Regardless of the direction of the incision, the initial stage of the classical caesarean section is the release of the lower segment from the peritoneal cover with the formation of a flap of the vesicouterine fold, which is subsequently used to peritonize the uterine wound. For the purpose of this, the peritoneum of the vesicouterine fold is captured with forceps in the place of its free mobility (2-3 cm above the place of attachment to the bladder or 1-1.5 cm below the level of its dense attachment to the anterior wall of the uterus), and then with scissors open in the center.

Through the hole formed with scissors, possibly at the end of the preliminary formation of the channel between the peritoneum and the wall of the uterus with their folded branches, the vesicouterine fold is dissected in the transverse direction, almost close to the round ligaments of the uterus.

Opening the peritoneum of the vesicouterine fold with scissors in the transverse direction

The corners of the cut direct the steam up, so that the cut has a crescent shape, convex downwards.

The length of the peritoneal incision should be sufficient, taking into account the subsequent opening of the myometrium and extraction of the fetus. With a small extent, it is unrealistic to ensure adequate displacement of the bladder, the formation of a flap of the vesicouterine fold sufficient for peritonization, when the fetus is removed, the incision will continue into the gap, which may cause additional bleeding or injury to the bladder. At the same time, excessive continuation of the incision of the peritoneum should be avoided due to the risk of injury to the veins passing along the ribs of the uterus in broad ligaments.

At the end of the opening of the vesicouterine fold, the peritoneum with the bladder is lowered down so that the lower segment of the uterus is exposed. In most cases, it is not necessary to deflate the bladder more than 5 cm, since the possibility of bleeding from the venous plexus is great. In addition, in women in childbirth with a flattened cervix, the risk of a too low subsequent incision (at the level of the cervix or vagina) increases (Cunningham F.G. et al. 1997).

In full-term pregnancy and in the absence of adhesions, the peritoneum of the vesicouterine fold is well mobile. As a result, this stage of the operation is easy to perform with a blunt method, using fingers or a small tupfer on the clamp. Along with this, creating a detachment of the peritoneum, direct the instrument to the wall of the uterus, and not the bladder, in order to avoid damaging it.

If there are difficulties in detaching the peritoneum (in most cases, with an adhesive course at the end of the previous cesarean section), first of all, you need to make sure that the level and layer in which the surgeon operates are correctly selected, after which the peritoneum is cautiously separated with a sharp method using narrow scissors. The formed flap of the vesicouterine fold with the bladder is placed behind a wide suprapubic speculum, which, on the one hand, protects them from injury, and, on the other hand, leaves the lower segment of the uterus free for manipulation.

For more reliable fixation of the vesicouterine fold, some authors advise to preliminarily apply 2-3 provisional sutures to its vesical edge, which are captured on clamps and placed behind the mirror (Blind A.S. 1986). These sutures may also be necessary for the rapid clarification of topographic relationships in an urgent situation after the end of the birth of the fetus with a sharply thinned lower segment, the occurrence of massive bleeding, or spontaneous extension of the incision into a rupture of the lower segment of the uterine wall.

Determining the level of the transverse incision in the lower segment of the uterus with the cephalic presentation of the fetus, first of all, aim to aim so that it, if possible, falls on the projection area of ​​the largest diameter of the head. Along with this, the removal of the head into the wound and its birth occur smoothly. If the incision is made too low, then apart from the risk of damage to the vaginal wall and bladder, it will be difficult to extract the fetus, since most of its head will be significantly higher than the level of the incision, which prevents it from eruption into the wound.

At a high level of the incision, on the contrary, the majority of the head is significantly below the opening of the wound. In this situation, the hand inserted behind the head should be brought to the incision, exerting dosed pressure in the direction of the fundus of the uterus. Whether the incision is too low or large, the need for additional effort can lead to trauma to the uterus and fetus, increased time to extraction, hypoxia, and blood loss.

In a normal situation, the incision of the wall of the uterus is not less than 4 cm above the base of the bladder and not less than 1 cm from the beginning of the vesicouterine fold. To ensure adequate operational access to the lower segment, a suprapubic speculum is used.

Exposure of the lower segment through the suprapubic speculum

The anterior wall of the lower segment of the uterus, with caution, so as not to injure the fetus or the loops of the umbilical cord, is opened in the transverse direction for 2-3 cm.

When large vessels enter the incision (in most cases with an unformed lower segment, premature pregnancy), the surgical field may be filled with blood, which prevents the reliable completion of the incision. In this situation, if drainage with gauze swabs or through vacuum suction is ineffective, the assistant should be directed to press the upper and lower edges of the incision with gauze swabs on clamps or fingers, which helps to reduce or stop bleeding and allows penetration into the uterine cavity without injuring the presenting part of the fetus.

To reduce the risk of fetal injury and reduce blood loss, N.S. Shetapp (1988) recommends making a prudent incision in layers. The purpose of this method is to cut the wall of the uterus without damaging the membranes, which are opened at the end of its full completion. When using such a layered technique, the pressure of the fetal bladder on the lower segment and the edges of the incision helps to reduce blood loss. But this method is applicable only with whole amniotic fluid.

Since the opening of the uterine wall by 2-3 cm, two methods of continuing the incision are currently used. The first option (according to Derfler) involves increasing the incision in the lateral directions under the control of the index and middle fingers of the surgeon introduced into the wound. The incision at the corners should be slightly raised (semilunar), which corresponds to the course of the muscle fibers and allows you to expand access to the uterus for easy delivery of the fetal head without damaging the vascular bundles. For reliable delivery of the fetus during a caesarean section in full-term pregnancy, the length of the uterine incision should be 10-12 cm.

According to L.A. Gusakov (1939), a caesarean section is made with an incision at the level of the vesicouterine fold without separation and displacement of the bladder. At the end of the transverse incision of the lower segment of the uterus, the expansion of its wounds is achieved by blunt dilution through the index fingers.

This method is quite reliable and fast. Thus, Mudapp et al. (2002) demonstrated a reduction in blood loss with the blunt dilution of the uterine wound during caesarean section. S.I. Kulinich et al. (2000) over the past 5 years have noted an increase in the frequency of using a renal incision according to L.A. Gusakov from 85% to 91%. IN AND. Kulakov et al. (1998) suggest that in a situation of heavy bleeding in the incision area, to prevent injury to the fetus with a scalpel, first perforate the uterus with your fingers, then apply the blunt wound dilution technique.

At the same time, some obstetricians prefer a semilunar incision with scissors (according to Derfler), believing that it is this method that allows you to correctly calculate its size and movement, avoid additional ruptures, and the formation of clusters of displaced muscle fibers, which are not well matched when suturing the wound (Krasnopolsky V. I. et al. 1997; Jovanovic R. 1985). On the basis of morphological studies of biopsy specimens, V.A. Ananiev et al. (2004) concluded that when cut with scissors, dystrophic and necrobiotic transformations of the myometrium are less pronounced.

To compare two options for increasing the uterine incision, A.I. Rodriguez et al. (1994) conducted a study in 296 women delivered by caesarean section. The continuation of the incision into the gap was considered to be situations when the planned size of the uterine incision at the end of the fetal extraction was found to be 2 cm larger. The results of the study did not find differences in the frequency of extension of the incision into the gap, as well as in other indicators (duration of surgery, blood loss, postoperative complications). According to the authors' point of view, the risk of extending the incision into the gap largely depends on the thickness of the lower segment and increases from the state of pregnancy to the first, and after that the second stage of labor, amounting to 1.4%, respectively; 15.5%; 35%.

The choice of uterine dissection technique should be determined by the specific obstetric setting. The technique of blunt dilution of the wound in the lower uterine segment is preferable in full-term pregnancy and childbirth with a well-formed lower segment, while in preterm pregnancy and a non-deployed segment, a scissor incision.

At the end of the opening of the uterus and membranes, the fetus is removed, after which the placenta, fenestrated clamps are applied to the bleeding corners of the incision and proceed to restore the integrity of its wall.

In a caesarean section in the lower uterine segment, which is created at term pregnancy or childbirth, the incision is made in a stretched, thinned part of the wall containing a relatively small number of blood vessels. As a result, in a simple situation, it is not necessary to resort to ligation until the wound is closed, at which a complete stop of bleeding is achieved. In the presence of a separate bleeding vessel, an additional clamp is temporarily applied (fenestrated, Kocher or Mikulich).

A.N. Strizhakov, O.R. Baev