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CAESAREAN SECTION

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Introduction


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.

Indications


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.
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  • Dystocia
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.
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  • Anomalous presentation
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.
  • Fetal distress
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.

  • Previous Caesarean section
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.

  • Pregnancy twin
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.

© 2010 Giovanni Zerlotin