The Main Types of Obstetric Operations

CESAREAN SECTION. It is an operation whereby the fetus is delivered through the incision in the abdominal and uterine wall. There are a lot of types of cesarean section. It may be large and minor, according to term of pregnancy. Minor cesarean section means the operation in term of 16-22 weeks of pregnancy. Thus, it is done by methods of urgent termination of pregnancy due to a severe complication, when there is no possibility to do therapeutic abortion or there is no time to induce the uterine contractions. Minor cesarean section may be performed by two methods: by dissecting the abdominal wall and by dissecting the vagina in the area of fornix. Most operations are performed by the abdominal access.

The operation which is performed in term of over 22 weeks of pregnancy is named a large cesarean section. Most operations of cesarean section are a large cesarean section.

The types of cesarean section may be subdivided into the following groups:
- intraperitoneal
- extraperitoneal

The first group of operations means those performed through the incision of the peritoneum.

There are some types of such operations:
- Classical method or upper segment operation: the uterus is dissected in the area of corpus (corporal cesarean section).
- Lower segment operation: the uterus is dissected in the retrovesical area, behind the bladder.
- Operations with the temporary or constant protection of the abdominal cavity.

Extraperitoneal cesarean section is the type of operation which is performed in the lower segment without incision of the peritoneum, in the area of vesicouterine pouch.

The operations with protection of the abdominal cavity and extraperitoneal operation are called protective types of cesarean section.

Cesarean section may be performed according to plan, or it may be urgent.

Indications for cesarean section. Nowadays these are divided into maternal and fetal.

· Fetal indications include:

· Conjoined twins

· Giant fetus

· Intrauterine fetal hypoxia

· Postmaturity (post-term pregnancy)

· Malpresentations (vertex, brow, face presentations)

· Transverse or oblique lying of the fetus

· Active maternal herpes simplex virus infection

· Fetal anomalies, such as hydrocephalus, that would make successful vaginal delivery unlikely

· Prolapsed umbilical cord in cephalic presentation

· Intrauterine hemolytic disease of the fetus

· Prolapse of the umbilical cord

· Maternal agony and a viable fetus (a healthy fetus may remain alive in 10-15 minutes after mother’s death)

· Maternal indications include:

· Extreme degree of pelvic contraction (the 3^rd and 4^th with true conjugate < 7 cm)

· Cephalopelvic disproportion (clinically contracted pelvis)

· Total placenta previa, vasa previa

· Abruptio placentae in case of no possibility for urgent termination of labor through the maternal passages

· Threatened rupture of the uterus

· Blockage of the pelvis by large or impacted tumors

· Extreme cicatricial deformation of the cervix

· Cancer of the cervix

· Pelvic tumors

· Pathological changes in the uterine wall (scar tissue in case of its incompetence)

· Hemorrhages due to incomplete placenta previa

· Severe preeclampsia

· Cervical rigidity

· Abnormalities of labor pains, without any effect of medicamental treatment

· A compromised history (cesarean section, antenatal intrauterine death of the fetus, infertility, extracorporal fertilization, the first labor at the age of over 30, etc.)

· Rectovaginal and vesicovaginal fistulae

· Decompensated extragenital diseases (or high risk of decompensation)

· Previous extensive pelvic floor repair (after the third-degree of tear)

· Varicosis of the vulva.

Sometimes the combined indications are also distinguished. These include indications, which are separately not sufficient enough to be an indication for the operation, but in case of their combination the better way of delivery for mother and her fetus is abdominal. For example:

· Premature rupture of amniotic membranes and expulsion of fluids, inefficiency of inducing the uterine contractility.

· Aged primipara with complicated anamnesis (primary infertility, mortinatality, etc).

· Aged primipara and breech presentation, or post-term pregnancy, etc.

· Breech presentation (or transverse lying) of the 1st fetus when there is multiple pregnancy.

· Contraindications for cesarean section include the following:

· When the child is dead or in such danger that there is very little chance of its survival.

· When there is gross infection of the maternal passages (endometritis, high temperature, any inflammation, more than a 6-hour period of ruptured water bag, more than 5 vaginal examinations during labor.

· Mother (or family) does not agree to the operation.

· Unskilled operators.

It is necessary to know that contraindications are of no importance in case of absolutely indicated operation (for example, severe hemorrhage, threatened rupture of the uterus, etc.).

In case of high risk of inflammation after cesarean section (long period of ruptured membranes, a lot of vaginal examinations) one should choose one of the protective methods of operation.

Anesthesia. General anesthesias with pulmonary ventilation, segmental epidural anesthesia are commonly used. Local infiltrative anesthesia may be applied but very rarely nowadays.

Prerequisites for operations are:
- Child is alive and viable. (In case of severe hemorrhages, or absolutely indicated operation they are of no importance).
- Maternal agreement to operation (if there are no vital indications).
- Evacuated maternal bladder.
- Absence of any signs of infection.

Preparation for the operation. If cesarean section is going to be performed according to plan, it is necessary to give the patient light lunch the day before and only tea with some sugar overnight. Guidelines recommend a minimum preoperative fasting time of at least 2 hours from clear liquids, 6 hours from a light meal, and 8 hours from a regular meal. However, patients are usually asked not to eat anything for 12 hours prior to the procedure.

In the evening before the operation evacuant enema should be done to empty the rectum, and then sedatives are usually administered.

In the morning the enema should be repeated 2 hours before the operation. The bladder should be catheterized just before the operation.

The operation should be performed with the rules of asepsis and antisepsis.

Risks. The patient should be counseled about the standard risks of surgery, such as discomfort, bleeding that may require transfusion, infection, and damage to nearby organs.