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CAESAREAN SECTION
The Caesarean section is a surgical
operation by means of which the delivery is carried out extracting the fetus
through surgical incision on the abdominal wall and the uterus. Currently the frequency of the
Caesarean sections in connection with the total of the deliveries is attested on
figures varying from the 20 to 35% approximately. Until the end of 80 years “the
Caesarean section came usually carried out in general anesthesia. This method
involves the injection of anesthetic/analgesic agents into the epidural or
subarachnoid space to achieve adeguate anesthesia for secarean section while
allowing the parturient to maintain full consciousness. In order to know some more on the
anesthesia you go to the page on the Anesthesia
and Analgesia.
The Caesarean section is indicated in
all those occasions in which a delivery for vaginal way it is impossible or it
introduces risks (for the mother or the child) greater regarding the abdominal
way. The indications of the Caesarean
section can as an example be relative to fetal problems (fetal distress, fetal
malpresentations, etc) or to maternal problems (one or more previous
cesareans section, hypertension, preeclampsia, diabetes, nephropathies, etc).
Often more motivations can coexist simultaneously in the same case.
Those conditions are grouped under
the term of dystocia all that involve one anomaly in the development of the
labor and the delivery. Therefore while a delivery that is carried out normally,
in complication absence comes defined “eutocic” (from the Greek “eu”:
well), a delivery that is carried out with of the complications defines “dystocico”
(from the Greek “dis”: difficult). In the accomplishment of the delivery various
types of problems or “dystocia” can be introduced. We can therefore have of the dystocie consisting
in anomalies of the contractions uterine, characterized from the presence of
irregular contractions for intensities, incoordinate. For effect of such
situation encounter to a slowing down or arrest of the expansion of the uterine
cervix, or to one slowed down or lacked come down the fetal head in the maternal
pelvis is usually gone. Often such problem can be corrected with the drug
employment (as an example the oxytocin) or practicing the artificial breach of
the amniotic sac (if that already has not been taken place spontaneously).
Sometime a suffering slowed down in its evolution for effect of a dystocia can
get better by the peridural
analgesia.
If these procedures have not turned out the accomplishment of the delivery by
means of Caesarean section can become necessary.
A normal presentation is defined by a longitudinal lie, cephalic (the head of the fetus) presentation, and flexion of the fetal neck. All other presentations are malpresentations. “Cephalic” presentation occurs the fetus introduces itself with the head to the income of the maternal
pelvis. This presentation occurs in 95% of the deliveries to term. “Breech” presentation occurs when the fetus introduces itself to the income of the maternal
pelvis with
buttocks. Such presentation verification in 4% of the deliveries to term. In rarer cases to term than pregnancy the fetus
can find itself in "transverse" situation, that is with the head towards a
maternal flank and with buttocks towards the opposite flank. How much the fetus
is found in this situation, its part that is introduced to the income of the
maternal pelvis is one shoulder; therefore in this circumstance it is spoken about
shoulder presentation “”. Of these three presentations (cephalic, breech,
of shoulder) come considered physiological only the cephalic presentation, while
they come considered anomalous the breech presentation and the presentation of
shoulder. In case of shoulder presentation the delivery for
vaginal way is impossible, not being able obviously the fetus to cover the
maternal pelvis in transverse position; therefore the shoulder
presentation is one absolute indication to the accomplishment of the delivery by
Caesarean section. In case of breech presentation the delivery for
vaginal way is not impossible, but it involves greater fetal risks; for this
reason habitually the delivery by Caesarean section is preferred to the
vaginal way.
In the course of the delivery the fetal
well-being comes estimated with the cardiotocographic monitoring. The
cardiotocography (CTG) is a technical means of recording the
fetali heartbeat (cardio-) and the uterine contractions (-toco-)
during childbirth, estimating their frequency and intensity. The appraisal of the fetal
cardiac activity, and above all its behavior in relation to the contractions
uterine, supplies indications on the fetal well-being. In case the cardiotocographic monitoring supplied not reassuring information with regard to
the fetal well-being, revalued all the context of the situation (age of
pregnancy, fetal development, preexistence of eventual pathologies, to es.
hypertension, eventual meconio in the amniotic fluid, entity of the expansion of
the uterine cervix in that moment, etc) could become necessary to accelerate
the times of the accomplishment of the delivery. To second of the situation, to
estimate in every single case, the indication to the accomplishment of the
delivery by means of Caesarean section can be introduced.
In the past 10 years it is a lot increased
the number of Caesarean sections. In
Italy in many hospitals the number of the Caesarean sections exceeds 30% of the
total of the deliveries. That involves that more and more often there are women
who have already give birth by means of Caesarean section, and that therefore in
occasion of the successive delivery they are found of forehead to the crossroad:
vaginal delivery or repetition of the Caesarean section? The previous Caesarean section, also not being
of for himself an absolute indication to the repetition of the Caesarean section,
represents, with to the dystocia, the cause more frequent than Caesarean section. Given
the complexity of the problem, in this page it is limited to us to consider some
of the more important aspects, remembering that every single clinical case goes
estimated to himself being in its clinical context.
It goes held account that the uterus of the woman
whom it has already endured a Caesarean section introduces a scar that has smaller elasticity in comparison to healthy
tissues. Therefore the woman who has already had a previous Caesarean section,
in a successive pregnancy introduces, at least on the theoretical plan, a risk
of uterus breach. Such risk is greater in case of previous Caesarean section with longitudinal
incision on the body of the
uterus; in nearly the totality of the cases one execute a transverse low incison.
In case of previous cesarean section, the existence of the uterine scar,
considered this like a point of minor resistance, in case the way of a vaginal
delivery is chosen, usually is abstained to us from a pfarmacologycal induction of
the delivery, in order to avoid one eventual excessive stimulation of the
contractions. Therefore in the woman with previous Caesarean section it is
preferred to attend the insorgence spontaneous of the labor. Generally the vaginal delivery is adviced against
if the estimated fetal weight is advanced increase to the average, being
able itself in this case to preview the possibility of a difficult vaginal
delivery. Also advices against the vaginal delivery if in the past they have
been at least two Caesarean sections. They are at last from considering two fundamental
permittent conditions for being able to follow the choice of the vaginal
delivery: 1 - considered the greater probability of a
Cesarean section urgent during the labor,, the structure
hospital worker must be in degree (for structure and staff) to execute a
Caesarean section in emergency; 2 - consent of the patient to the vaginal
delivery.
The pregnancy twin represents 1% of all
the pregnancies. In the past few years there is one tendency to
the increase of the number of the twin pregnancies, and that as a result of
the greater spread of the techniques of assisted fecondazione. In the event of pregnancy twin, with both
the fetus in cephalic presentation, and a gestational age at least 34
weeks, generally is permitted the vaginal delivery,
while the TC would have proposed to the cases of pelvic disproportion or fetal
distress. In the event in which the first fetus it was
in breech position, the Caesarean section is indicated. In the event of breech or transverse presentation of
the second fetus, with the first one in cephalic presentation, today is
preferrede the Caesarean section.
In fact after the birth for vaginal way of the first it is possible complications for the birth of
the second fetus in anomalous
presentation. In order to avoid such complications it is today preferred the delivery by
Caesarean section in all the
pregnancies twin in which the children they are not both in cphalic presentation. Beyond to the described indications up to now (that
they are most frequent), can it are to you numerous other indications to Caesarean section: placenta praevia,
abruptio placenta, maternal infections, cardiovascular pathologies, renal
pathologies, respirator, pathologies, diabetes, etc. Demanding the exposition of these arguments
every a detailed scientific deepening for single case, and exceeding therefore
the simple informative aim of this website, is thought to postpone to their
exposition, being invited who was interested to a single argument to address to
just the gynecologist of confidence. In order to know some more the Links consults than
Gyneconline.net and in particular: ·
Vaginal Birth After to Cesarean Guidlines, American
College of Obstetricians and Gynecologists
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Pagina redatta a cura del Dott. Giovanni Zerlotin |
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