Caesarean Section

A FREQUENTLY EXPERIENCE

Probably the Caesarean Section (C-Section) is one of the most popular surgical procedures in

caesarean section

Caesarean Section: the moment of cutaneous incision

the world and many women have experienced  C-Section sometimes in dramatic situations to.
The incidence of Caesarean Section has progressively increased in parallel with the development of a modern neonatal and maternal-fetal medicine, the application of semiotic techniques such as ultrasound and fetal cardiotocography; its incidence growth also with the increase of maternal age, medico-legal litigation, use of the reproductive medicine techniques.
Despite some criticism of excessive use, is undeniable that the “Caesarean” has made a great contribution to the safety of pregnancy and childbirth, and many women and children are alive with this surgical technique.

BRIEF DESCRIPTION OF THE TECHNIQUE.

We now analyze the typical technique of Caesarean Section (C-Section). Through a suprapubic abdominal incision very aesthetic (typical is that according to Pfannenstiel with an extension by an average of 6-7 cm)) and uterus in its area less vascularized (lower uterine segment) allows the extraction of the fetus, placenta and membranes .

caesarean section technique

Different moments of c-section: from spinal anaesthesia to cutaneous horizontal incision and fetal extraction.

The average length of a C-section varies on average between 17 and 45 minutes depending on the operator (I performed some C-Section in 12′), the technique used (the Stark is the fastest) but certainly by the technical difficulties that each patient has (eg presence of adhesions, previous interventions, abnormal uterine placental insertion, uterine and adnexal pathology etc.).
At C-Sectio work normally at least two surgeons (first and second operator), an anesthesiologist, an instrumentalist, a midwife, a pediatrician neonatologist, a nurse.
The costs as you can imagine, are high.

EMERGENCY, ELECTIVE, ITERATIVE. INDICATIONS.

A “Caesarean Section” may be necessary for urgent conditions that affect the mother, the fetus or both, but often is programmed outside of labor, in which case we speak of elective caesarean section. When a C-section is repeated after a previous similar action is spoken of Iterative or Repeated Caesarean.
A C-Section can be programmed when you know in advance maternal or fetal conditions that would make the delivery impossible or dangerous such as: abnormal position of the fetus, multiple pregnancies (not all), abnormal placental insertion (placenta previa), uterine malformations congenital or acquired, fetal macrosomia (fetus whose estimated weight exceeds 4100 gr.) or disproportion between the size of the fetus and maternal pelvis bone, abnormalities of the maternal pelvis, severe maternal disease (also concerning the psychic sphere), when it is important to stop the pregnancy and obstetric conditions are not favorable for an induction of labor or when you want to avoid further stress to the fetus or the mother, or when it is preferable that the baby does not come into contact with vaginal secretions (Genital Herpes).
Urgent caesarean section is performed frequently in labor for abnormal dilation of the cervix, the mechanics of childbirth (difficulty in the descent of the baby’s head) or to the occurrence of fetal distress. Indications urgent outside of labor are particularly dramatic and very risky for both mother and fetus: bleeding from placenta previa, cord prolapse, severe fetal distress, the crisis eclamptic that comes to complicate a pre-eclampsia, detachment of the placenta.

AN ANCIENT SURGICAL INTERVENTION.

Many historians attribute the term caesarean birth of Julius Caesar, who according to legend was born this way but it is also true that an ancient Roman law enacted between 715 and 672 BC under Emperor Numa Pompilius and the prescribed Caesarea called lex ‘abdominal extraction of the fetus in all pregnant women who died at the end of pregnancy.
The first documented cesarean section on living woman who died after a few days but dates from 1610, it was only in 1794 that the first woman in Virginia survives the surgery. In 1865, maternal mortality in Britain was equal to ‘85% of the interventions.
The absence of antibiotics, the lack of understanding of the need to suture (close) the uterine wound, the same technique of etching for a long time that occurred longitudinally on the most vascularized uterus, the lack of a suitable anesthesia determined again for a long time high maternal and fetal mortality.

BENEFITS BUT ALSO RISKS. THINK ABOUT IT FIRST.

The Caesarean Section undoubtedly changed history of obstetrics contributing significantly to lowering the maternal and fetal mortality.
It ‘an intervention that has been continuously updated in the technique and is currently considered of great security, but certainly not without risks especially for the mother: anesthetic risks, infection, bleeding, injury of the ureters and bladder, cardio-pulmonary complications and thromboembolic still very small.
It is not a rare event I always feel very important that every pregnant woman is informed already at the time of childbirth preparation classes on the indications and modes of operation of a Caesarean. This will deal with the intervention as greater awareness and with less fear.

C-SECTION CAN BE SWEET.

Spontaneous delivery is a ‘beautiful and certainly very rewarding experience for the woman but unfortunately it is not possible when we can make our medical intervention less traumatic as possible from every point of view.
The C-section is lived very differently from patients: some see it as a liberation, others as a salvation, and still others as a failure, however it is a necessary interference, often MANDATORY that interrupts an event not more physiological, a natural event that is to betray the expectations of the mother and her family.
Talk about sweetness of surgery that fits into moments often dramatic and psychological values ​​such complex is perhaps exaggerated but we can certainly do a lot in this direction such as facilitating contact with the relatives of the woman and the newborn (bonding in the operating theater ), reducing the duration of the intervention, the tissue trauma and postoperative discomfort; properly informing and reassuring the patient, facilitating the supply and mobilization within the first 24 hours and discharge within 72 hours.

Anesthetic techniques

Anesthesia in caesarean section should ensure a perfect maternal analgesia without interfering with fetal conditions. The most commonly used technique is that of peripheral type “epidural” that blocks the pain sensations in the lower half of the body, the patient can thus follow every moment of the action, see the newborn baby boy, talk to him, touch him.
When conditions of extreme urgency or contraindications does not allow the back is carried out under general anesthesia.

BREASTFEEDING, SEXUALITY, MY LIFE AFTER C-SECTION.

Sexuality and lactation normally do not undergo any change after cesarean. The recovery of your daily activities will be very rapid. In our center after a first medication within 72 hours recommend a following check after about 7 days, and then after about a month of discharge. Your life will be perfectly normal.

CAESAREAN SECTION ONCE, ALWAYS MEANS C-SECTION?

The subject is delicate and subject of controversy. Giving birth after a previous caesarean section is possible except in cases where the intervention was determined by pelvic or uterine malformations, severe chronic maternal. It is a choice that significantly can increases both maternal and fetal risks; for this reason should be widely discussed before the time of delivery.
Uterine rupture is the most dangerous event in the course of labor and delivery in women who already had cesarean: the old uterine scar can rupture and result in a generous, serious bleeding. This observation is unfortunately not predictable and significant risks to the mother’s life (shock) and fetus (asphyxiation and acute distress) must be recognized and treated with extreme rapidity.
Understand then that a normal birth after previous Cesareo could be dealt with only in centers where it is possible, a close supervision and where there is the immediate availability of a surgical team and neonatology, the presence of a resuscitation and a transfusion center.
Not all hospitals can provide this level of security and not all obstetricians are willing to share an increased risk.

REDUCE caesarean sections, MISSION POSSIBLE.

In recent years, many criticisms have been made regarding the high number of caesarean sections. A high incidence, very varied from region to region Italian, which was affected maternal age, previous pregnancies occurring after infertility, previous cesarean delivery, migration to our country, litigation medico-legal, structural and organizational deficiencies of many hospitals.
At the basis of these criticisms are motivated by economic (C-section costs), but also the desire to put a stop to what could ironically become a “new way to give birth.”
Even today most of the allegations relate to an obstetric omitted or delayed cesarean with stratospheric claims, such that they have led many insurance companies to terminate contracts with physicians or accept new ones; doctors themselves often victims of structural weaknesses which, however, rarely others respond. Many sections are probably determined by excessive caution particularly justified when the structure (in terms of time, organization, neonatal care) does not guarantee adequate levels of security in front of a sudden emergency.
The problem is not easy to understand, help could come from:
– Implementation of national guidelines for the management of pregnancy and childbirth physiological and pathological; guidelines drawn up in precise and detailed, so absolutely unequivocal and accommodating, with a defined period of validity, subscribed by the Medical Associations, from the protection citizens, the Regions and the Ministry of Health;
– Identification of the minimum of structure and organization of the sites devoted to pregnancy and birth and drafting of binding regional protocols for neonatal care;
– Improvement of obstetric and neonatology uniting the resources available and then closing small hospitals where there is a doctor on call midwife, a maternity ward, a Blood Transfusion Centre, a resuscitation;
– Creating an arbitration at the regional level for the management of disputes.
Refresher courses, clarity of guidelines, security assistance, medical-legal and insurance protection are strategically important.

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Filiberto Di Prospero
Medical Doctor, Consultant in Gynecology and Obstetrics, Endocrinology and Metabolism. Director of Gynecologic Endocrinology Unit at Civitanova Marche General Hospital (Italy). Private clinics in Civitanova Marche, Rome and Milan.

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