Rus Articles Journal

Cesarean section: modern approach of

Part I

operation Technique, postoperative period. The operation course

the Technique of operation of Cesarean section was improved by

for many years. It became for reduction of time of operation, decrease in blood loss, prevention of postoperative hernias.

Fundamental differences of modern techniques of operation concern a section on a forward belly wall and a section on a uterus. The section of a belly wall can pass across the average line (nizhnesredinny) or over a pubis in the cross direction (a section across Pfannenshtil). The last provides the best cosmetic effect, but demands slightly more time for performance, gives less chance for broad access and is followed by bigger blood loss. In the majority of clinics of Russia Cesarean section across Rusakov is applied as the standard. Feature of this kind of operation consists in a section on a uterus. The section across Rusakov is made in the lower segment of a uterus cross. It reduces probability of a gap or divergence of edges of a hem at the following pregnancies. The seam passes parallel to muscle fibers.

the Section along a uterus body, so-called korporalny (from armor. corpus - a body), use seldom now - it is a longitudinal section on a forward surface of a uterus. Indications to it are the cancer of a neck of a uterus and pathological educations in the lower segment of a uterus (myoma); sometimes it is applied at the cross provision of a fruit, insolvency of a longitudinal hem on a uterus after the previous korporalny Cesarean section, and also in need of the subsequent removal of a uterus. It is the simplest and fast section, but at its application complications are frequent: postoperative solderings, bleeding, bad healing of a wound, a hem divergence at the following pregnancy and childbirth.

the Next moment of operation - extraction of the child. The child is carefully taken hands or by means of nippers or vacuum - an extractor. For reduction of blood loss enter the means reducing a uterus into a muscle of a uterus ( Oxytocin , Metilergometrin etc.) .

After the placenta will separate (independently or if the doctor hands separated a placenta from a uterus wall), manual examination of a cavity of a uterus for diagnosis of myoma of a uterus (a benign tumor of a uterus) or for removal of the remains of fetal egg is usually conducted.

Mending of a section on a uterus - very important stage. For this purpose the resolving material is always used. Long time in our country for an ushivaniye of a uterus catgut suture (material from intestines of sheep or cattle) in various options was used. This sutural material had the mass of shortcomings. That somehow to reduce them, the two-storeyed seam was applied. Now the uterus is taken in strong synthetic material which allows to impose one number of seams.

the Following stage of operation - mending of a peritoneum (the thin film covering all bodies and walls of an abdominal cavity), then muscles of a stomach and, at last, skin. On skin impose a continuous hypodermic ketgutovy seam or separate silk seams across Donati.

to

B in technology of carrying out Cesarean section offered the last 4 - 5 years a number of innovations. Several works which are accurately proving, in particular, that not mending of a peritoneum by production of gynecologic operations does not involve any additional postoperative complications became the prerequisite to it and moreover, significantly reduces probability of formation of solderings in an abdominal cavity. Broad application in surgical practice of the synthetic resolving sutural material and, in this regard, more frequent application when mending a section on a uterus at Cesarean section of a single-row continuous seam became other prerequisite.

Duration of operation of Cesarean section is small

- on average 20 - 30 minutes, and the operation stage before extraction of the child takes up to 5 minutes.

the Number of operations of Cesarean section fluctuates over a wide range - in various maternity hospitals from 1 to 27%. Despite application of a cross-section in the lower uterine segment, improvement of methods of mending, preventive prescription of antibiotics of a broad spectrum of activity, percent is purulent - inflammatory complications both in the early postoperative period, and in the remote terms after operation remains high, reaching from 6,6 to 47,7% in separate clinics.

the Postoperative period

the Current of the postoperative period at the patients who underwent an operation of Cesarean section is characterized by two features: on the one hand, they have phenomena characteristic of the postnatal period, and with another - there can be changes connected directly with operation. Therefore the women who underwent an operation of Cesarean section need intensive therapy.

After an operational rodorazresheniye the woman in childbirth within the first days is in special postnatal chamber (or chamber of intensive therapy). Behind it the anestezistka (the nurse of an intensive care unit) and the anesthesiologist carry out continuous supervision. Throughout this time the woman adapts to postoperative existence: to it make blood loss correction, begin antibacterial therapy for prevention of postoperative infectious complications, stimulate work of intestines. Doctors monitor also local manifestations in the field of an operational seam, reaction of a peritoneum, nature of uterine reductions and allocation of lokhiya (postnatal bloody allocations), behind a condition of chest glands and their laktatsionny function.

Restoration and maintenance of normal volume of the circulating blood can be reached by the corresponding infusional therapy - in the postoperative period always put droppers. Infusional therapy begins during the first hours after operation.

the preparations improving a myocardium sokratimost (warm glycosides), processes of an exchange in a cardiac muscle (cocarboxylase, ATP, vitamins) increasing a coronary blood-groove ( Eufillin apply To ensuring normal work of heart, the Papaverine ), antiarhythmic means.

Adequate gas exchange is provided to

with early activization of patients (the patient the first time rouse in the first days after operation); an exception of therapy of the narcotic preparations oppressing breath; early purpose of a kislorodoterapiya, respiratory gymnastics, percussion massage (massage during which make percussion on a thorax in order that slime from a bronchopulmonary tree separated better), bronkholitichesky means, physiotherapeutic procedures, and in some cases - artificial ventilation of lungs.

Anesthesia in the postoperative period is carried out by

by application of a combination of narcotic and not narcotic analgetics. All drugs are injected intravenously or intramuscularly.

Prevention of paresis (states at which intestines are not reduced or it is badly reduced) zheludochno - an intestinal path carry out by medicamentous stimulation of motility (PROZERINA solution is hypodermically entered). Therapy comes to an end with a cleaning enema.

Energy needs of an organism in the first 2 - 3 days are satisfied with

due to infusional therapy and parenteral food - introduction of solutions intravenously. In the first days after Cesarean section it is only allowed to drink water with lemon juice. On second day it is possible to indulge himself with the chicken broth scrolled via the meat grinder by boiled meat, skim cheese, yogurt without fruit fillers, a fruit drink without sugar. Completely it is possible to return to a normal diet after the first independent chair (on 4 - 5 - e days). For reduction of a uterus special preparations ( Oxytocin ) several times a day for 3 - 5 days are appointed.

Already on second day mother is transferred to postnatal office where she at once begins to lead active lifestyle - rises and goes, feeds the kid. Mother can constantly be in postnatal chamber with the kid, looking after him independently, more often to women bring kids on feeding.

mother is allowed to Sit down on the second - third day after operation. Within 7 days after Cesarean section (before removal of seams) the procedural nurse daily processes a postoperative seam antiseptic solutions (for example, iodine, “brilliant green“) and changes a bandage. If the wound was taken in by the resolving sutural material, then processing of a wound is carried out in the same mode, but seams are not removed (such threads resolve independently).

the Skin hem is formed by

approximately on 7 - e days after operation; therefore, in a week after Cesarean section it is possible to take a shower absolutely quietly. Only it is not necessary to rub a seam a bast - it can be done in a week.

Besides, the technique of an early extract from maternity hospital for prevention of intrahospital infections practices in our country. For this purpose usually on 5 - e days remove seams, and the patient is written out home.

with

the facts of an extract of women in childbirth for the 4th day after operation do not surprise. On the one hand, it serves one of methods of prevention of a so-called hospital infection. But at the same time it often is followed by the termination of medical supervision over the woman that conceals in itself the increased risk of emergence of postoperative complications. Therefore in different regions and even in different clinics extract terms from a hospital differ enough. A lot of things in this question depend on conditions of accommodation of the patient, on degree of availability of medical care. Of course, doctors consider how pregnancy and childbirth what accompanying pathology was available for the woman before pregnancy proceeded.

the Current and maintaining the postoperative period at patients gestozy and some pathology of internals differs in bigger weight, tendency to complications and demand the purposeful, especially differentiated therapy. Therefore treatment of these patients has to be carried out by the doctor the obstetrician - the gynecologist together with the corresponding experts.

Feeding by a breast

Process of a lactation after Cesarean section actually differs in nothing in

from that after spontaneous childbirth. The only difference is that after planned operation milk can come a bit later: if after spontaneous childbirth milk comes on 3 - 4 - e days, then after Cesarean section - on 4 - 5 - e. It is connected with the fact that when the woman independently enters childbirth, she has an emission in blood of certain hormones which, among other things, stimulate development of breast milk. After planned operation the hormone stimulating a lactation begins to come to blood is delayed, after a rodorazresheniye. But it practically does not affect the weight and a condition of the kid in any way, mother can feed the kid on demand with colostrum in the first several days, without using a dokarmlivaniye.

Possible complications

As well as any other operation during which the section of fabrics is made and respectively - and blood vessels, Cesarean section is connected with a certain blood loss. Normal blood loss at spontaneous childbirth makes about 200 - 250 ml; such volume of blood is easily restored by the woman`s organism prepared for it. Cesarean section means blood loss much more physiological: average volume makes it from 500 to 1000 ml. Naturally, the organism of the patient cannot independently cope with this problem. Therefore during operation and during the postoperative period intravenous administration of krovezameshchayushchy solutions is made: plasmas of blood, eritrotsitarny weight, and sometimes and whole blood - it depends on amount of the blood lost during operation and on opportunities of an organism of the patient.

by

during operation breaks integrity of a peritoneum - a cover which allows intestines to peristaltirovat freely - to move, advancing food. After surgery, as a rule, there are solderings - unions between loops of intestines and other internals. If adhesive process is expressed slightly, the patient will not feel it in any way if features of an organism mean development of extensive adhesive process, there can be problems with a chair, appear belly-aches, especially in the lower departments. Treatment in that case depends on expressiveness of adhesive process. In not hard cases there are enough physioprocedures, and in heavy the question of expeditious treatment can be raised (for example, of laparoscopic operation with thermocoagulation by “cauterization“ of solderings).

From complications of Cesarean section can note an endometritis - a uterus inflammation. Naturally, in this case it arises more often than after spontaneous childbirth. It is clear, that during operation there is a direct engagement of a cavity of a uterus to air which full sterility cannot achieve. For prevention of an endometritis after operation appoint antibiotics. Short it will be a course or long - depends on associated diseases of the woman.

the uterus is reduced by

After Cesarean section worse, than after the delivery in natural patrimonial ways as during operation the muscle of a uterus is crossed. In this regard there is a subinvolution (reduction violation) of a uterus more often that demands purpose of the additional therapy directed to improvement of sokratitelny ability of a uterus. This therapy is carried out in maternity hospital within 2 - 5 days.

Necessary restrictions

It is frequent patients and their relatives ask whether it is possible to lift weights after operation, to play sports and in general - that is possible and what cannot be done during this period.

the Answer to the first question is ambiguous

. Surgeons, for example, after band operations do not allow the patients to lift more than 2 kg within 2 months. But how to tell it to the woman who should look after the kid? Therefore we do not recommend to women in childbirth after operation of Cesarean section during the first time (2 - 3 months) to lift more than 3 - 4 kg, that is it is more than the weight of child.

to Women after spontaneous childbirth can work as

at once on all muscles of the body (ideally if during pregnancy future mother did it). The patients who transferred Cesarean section can work on an abdominal tension not earlier than a month later after the delivery.

As for renewal of the sexual relations after an operational rodorazresheniye, this term is identical also to the operated patients, and to the women who were giving birth in natural patrimonial ways. After the delivery the uterus represents an extensive wound surface (on the place of an attachment of a placenta and fetal covers). And as it is known, the infection easily “sits down“ on any wound. Process of healing of a wound surface is followed by allocations - so-called lokhiya. At first they bloody, then sanious and mucous. Are allocated to Lokhiya within 6 - 8 weeks after the delivery. The complete recovery of a mucous membrane of a cavity of a uterus is characterized by the termination of these allocations. After that it is possible to renew the sexual relations, but without forgetting about contraceptives that there did not come unplanned pregnancy.

Should remember

that after uterus operation of Cesarean section there is a hem which can exert impact on the course of the subsequent pregnancies. It is proved that the hem reaches an optimum state for pregnancy incubation in 2 - 3 after operation. By this moment and the organism of the woman is restored after the previous pregnancy. Therefore to think of the brother or the sister for your firstborn it is better after this time.

Obstetricians still did not come to a consensus on a possibility of spontaneous childbirth at the patients who underwent earlier an operation of Cesarean section and having a hem on a uterus. As a rule, the hem on a uterus already in itself is the indication to repeated Cesarean section. But exceptions are sometimes possible. Anyway, if you like to give rise independently, this problem is solved individually, depending on a state of your health, from a condition of a hem (it is estimated according to ultrasonography), from a current of the postoperative period and many other circumstances.

Thus, the postoperative period is a responsible stage in recovery of the woman in childbirth on which correct conducting reproductive health of the woman depends.