Monday, July 30, 2012

His Majesty, cesarean section

Cesarean section is obstetric surgery to cut through the abdominal wall and lower uterine segment extraction of the fetus is in an advanced stage of pregnancy and childbirth within the abdominal route.Because of its importance is one of the most important procedure performed in gynecology and obstetrics.

The origin of the term cesarean section is obscure - wrongly associated with Caesar, and by its Latin etymology is probably the origin (sectio = cutting caesareus = cut). In European medicine it is mentioned in the sixteenth century when the lethal finishing operations required by a woman, the nineteenth century is a milestone for the introduction of principles of asepsis, and the current modifications and operating principles are based on the experiences of the twentieth century.

Cesarean section is one of the ten most common major surgery, with appreciable difference in incidence between different regions in the world and among certain hospital institutions. Factors that contribute most to the frequency of this operation are: dystocia (inadequate uterine activity), previous cesarean delivery, breech fetal position, fetal distress (suffering), intrauterine growth retardation, pregnancy is transferred, multiple pregnancy, late parity, reduced use of forceps and vacuum, more information and so on. The frequency is now 10-25% - in our clinic, about 14%.

The traditional division includes:
absolute indications
Relative indications
expanded indications
Absolute: Absolute narrow pelvis, genital abnormalities and diseases that constitute an obstacle to the birth, the transverse position of the fetus, central placenta previa, uterine rupture predecessor, serious cases of premature detachment of normally inserted placenta, severe preeclampsia-eclampsia, previous CR classical medial incision was made, vulvovaginal herpes.

Relative: Feto-pelvic disproportion, placenta previa lateralis, osteomalatična pelvis, preeclampsia, intrauterine fetus, acute fetal distress, diabetes mellitus, twin pregnancy with an unfavorable fetal positions, primary uterine inertia, dystonia, conization.

Extended: Early placental abruption (lower surface), pelvic presentation, deflection presentation of the fetus and abnormalities of rotation, dropping the umbilical cord and vasa praevia velamentozna insertion of the umbilical cord (this), a scar on the uterus, pelvic joint ankylosis, malformations of the fetus, genito-urinary fistula, recto-vaginal fistulas, varices genital warts expressed a pointed, psychosis, certain heart diseases, retinal detachment, laryngeal tuberculosis, hyperthyroidism, the age of primiparae over 35 years, a history of infertility, previous losses, etc. intrapartal. One can say briefly that the indications for CR: Distress (suffering) of the fetus, maternal distress, previous CR and pelvic presentation.

The main contraindications could be the lack of indications that would be acceptable. In our country the CR is not based on wishes of the patient or the team that takes delivery (reasons of comfort), but based on medically justified Indications.

The surgical technique
Incision on the abdomen may be:
medial (central)
suprapubic (cross over the symphysis)
The medial incision is technically the easiest, it can be extended and provides good visibility of the abdominal cavity and rapid extraction of the fetus. The aesthetic is less acceptable and is now used only in emergency (emergencies or specific indications).
The low transverse incision (at low transverse Pfannenstiel) is made across the 2 cm above the symphysis.Cosmetic advantage of this cut is so obvious that most of CR's work on this cut incision on the uterus may be a corporal-classical istmiko-cervical, ekstraperitonealni. In our country it is a horizontal incision at istmikocervikalni Dorfler.

CR is not a safe operation, but the maternal and fetal morbidity (illness) and mortality (death) small.According to the literature is considered acceptable maternal mortality 1-2 / 1000 women and the most common causes of death were: unsatisfactory preoperative preparation, faulty surgical technique, anesthesia complications, hemorrhage, sepsis, peritonitis, pulmonary embolism, heart failure, errors in determination of blood groups, inadequate antibiotic therapy and so on. Leading causes of death were: pulmonary embolism, cardiopulmonary arrest (standstill), bleeding and sepsis. Early and late postoperative complications are bleeding, sepsis, ileus, renal failure, trombophlebitis, urinary infections, anemia, uterine subinvolucija, endomyometritis, peritonitis, wound infection, loosening of the uterine incision (sava), mastitis, stress ulcer, endometriosis of the cut and so on. In the subsequent pregnancy was more common occurrence of placenta praevia, loosening the scar on the uterus and re-CR and infertility. The most common complications are: puerperal sepsis, urinary tract and wound infections.

Pregnancy after a CR-
Pregnancy after CR has some specific characteristics. Previously savetavolo to pause after the first pregnancy ended with CR-be three years, and today is the attitude that it is sufficient for 18 months. There are some risks associated with this pregnancy: placenta praevia (placenta, which leads) 15 times more common in these pregnancies in two of the three cases are expected and placenta acreta (ingrown).

Vaginal porđjaj after CR
Previously applicable rule: always a CR CR is no longer current. The fact is that re-CR is more than one third of all CR's, and that vaginal delivery after previous CR-born and 18-44% of women if they are allowed a trial labor. Institution consultation and personal decisions about the patient's way of delivery after a previous CR-there is so decided by the treating physician regardless of the wishes of the patient. Data from the literature favoring vaginal delivery after a CR, but because of the few not very serious complications that accompany such births is the only valid ethical principle of respect for each individual case.

Up to 50% in patients with previous CR can successfully give birth vaginally. Thanks to advances of perinatal medicine, surgery, anesthesia, transfusion, and of course the pharmaceutical industry today CR is a safe procedure. The surgery for the mother and child is extremely useful if the indications are set correctly. Suspicious indications are not used by the patient.

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