From Big Medical Encyclopedia

CESAREAN SECTION (sectio caesarea; synonym kesarsky section) — a surgical method of extraction of a fruit and an afterbirth through a section in a wall of a uterus. Depending on access to a uterus distinguish abdominal To. the page made by a laparotomy and applied to delivery and vulval To. the page made for the purpose of abortion in natural patrimonial ways. For the purpose of abortion in terms from 16 to 28 weeks it is made also so-called small To. in the abdominal way, especially when extragenital pathology excludes pregnancy and sexual sterilization is necessary for page.

There are contradictory opinions on an origin of the name of operation. It is possible to believe that the origin of the name of operation is connected not with the word the Caesar, and with a name of Guy Julius Caesar who was taken in the abdominal way, for as received the name Caesar. Considering it, Caesarian, but not kesarsky section will be more correct.

Extraction of the child from a belly of the died mother through a section in an abdominal wall and a uterus was made in an extreme antiquity. Each nationality which reached rather high level of a civilization left mentioning of such intervention. From grech, the mythology knows that Dionysus and Eskulap were cut out from a belly of the died mothers — Selema and Karonida. At the end of 7 century BC the Roman emperor H minds Pompily issued the law, on Krom burial of pregnant women without preliminary extraction of the child by a chrevosecheniye was prohibited. This rule was included then almost into all legislations of the European countries.

The first reliable To. the page on the living woman was made in 1610 by the surgeon I. Trautmann from Wittenberg. The child was taken live, and mother died in 4 weeks (the cause of death is not connected with operation). In Russia first operation K. page it was made in 1756 I. Erasmus.

To the last quarter of 19 century results To. pages were, as a rule, unsatisfactory. The infection and bleeding as the wall of a uterus was not sewn up were the reasons of deaths. G. E. Rein and E. Porro's offer in 1876 after extraction of the child to delete a body of the womb — a source of an infection and bleeding — lowered a maternal lethality. However only using a technique of the uterine seam entered

by W. I. Stoltz in 1874 and then an asepsis, antiseptics and an anesthesia there came the new stage of history K. page. Further thanks to achievements of medicine, a high level of the operational equipment K. the page was made with quite favorable results.

Abdominal Cesarean section

Indications and contraindications

To. the page is made when delivery in natural patrimonial ways is impossible or life-threatening mother or a fruit.

To. page — the most frequent operation in obstetrics. In relation to all childbirth, according to literature, To. the page is manufactured by from 1 to 10%, in the USSR — apprx. 2%. In hospitals where pregnant women with high risk of childbirth are concentrated, To. the page is made more often than in usual obstetrical institutions. Since the 70th 20 century frequency To. the page increases; this results from the fact that by means of operational delivery perinatal traumatism and a neomortality decreases. It is more often applied To. page at pregnant women with extragenital pathology and obstetric complications. Improvement of the operational equipment, sovr, an anesthesiology grant, the correct postoperative maintaining women in childbirth later To. villages allow to consider delivery in the abdominal way operation of the choice in certain conditions. It is undoubted that such operations as obstetric nippers, a vakuumekstraktion, the combined outside internal version at full disclosure, extraction of a fruit at one-time presentation, are much more traumatic for a fruit in comparison with correctly and timely made operation K. page.

Indications to To. pages divide on absolute and relative. Existence of absolute indications demands indisputable production To. the page (any other way of delivery is more dangerous to mother), and according to relative indications is necessary for its production weighty justification. Such obstetric situations at which the birth of the living and healthy child is doubtful enter into group of relative indications if delivery is made in the vulval way.

Absolute indications

the pathology excluding a possibility of delivery through a vagina concerns To them: narrowing of a basin when the true conjugate is equal to 7,5 cm and less; other anomalies and deformations of a basin with sharply reduced sizes; the tumors of pelvic bones, myoma of a neck of uterus, a tumor of ovaries and other bodies of a small pelvis blocking patrimonial ways; cicatricial narrowings of a neck of uterus and vagina. Absolute indications to production To. pages also are: full placental presentation and the premature amotio of normally located placenta which is followed by hemorrhagic shock; incomplete placental presentation when massive bleeding takes place, and patrimonial ways are not prepared for vulval delivery. To. it is more preferable to page to make at cancer of a neck of uterus, vagina, vulva, bladder, rectum; urinogenital and enterosexual fistulas in the past and the present; in the presence of a hem on a uterus after korporalny To. page or the sewn-up hysterorrhesis with the complicated postoperative current and signs of inferiority of a hem; in a condition of an agony or the death of mother at a live and viable fruit.

In the presence of absolute indications To. pages make from the beginning of patrimonial activity or at the end of pregnancy. Absolute indications to To. pages, as a rule, are vital and have no contraindications.

Relative indications

Almost all obstetric complications in a varying degree are relative indications to To. page that is connected with the aspiration to reduce perinatal mortality. This tendency is justified, however difficulty consists that it is impossible to define accurately borders of use To. page according to relative indications. On the one hand, the quick decision of a question can lead to unreasonable production To. page, with another — the overdue solution of a question in advantage To. the page can lead to the birth of the injured child.

Treat relative indications: clinically narrow basin at the normal sizes of a basin, I and II extents of narrowing of a basin or the large sizes of a fruit. At relative (I and II) extents of narrowing of a basin need of the end of childbirth in the way To. the page comes to light in the course of a childbed. At the same time the anatomic sizes of a basin, thickness of pelvic bones of the woman, a form, the place and extent of narrowing of a basin, the sizes of a head of a fruit, ability of a head to change of a configuration and feature of its insertion, the nature of patrimonial activity, the result of the previous childbirth, etc. are considered. Relative indications to To. pages also are: adverse presentations and insertions of a head (frontal, front — a chin of a kzada, a back asynclitism, high direct standing of a head); cross and slanting provisions of a fruit, especially in combination with other complications (narrowing of a basin of I and I of degree, weakness of patrimonial activity, a large fruit, postmaturity, a prolapse of the umbilical cord at insufficient disclosure of a neck of uterus, etc.); the menacing hysterorrhesis, threat of formation of urinogenital fistula; a hem on a uterus later To. page, the sewn-up hysterorrhesis and ginekol, uterus operations without signs of inferiority of a hem and in the presence of additional obstetric complications (e.g., relative extent of narrowing of a basin, the wrong presentations of a head); incomplete placental presentation with moderate bleeding when there are other complicating moments — the wrong provision of a fruit, mortinatality or long infertility in the anamnesis, weakness of patrimonial activity, the menacing pre-natal asphyxia of a fruit, etc.; diseases of mother — the nephropathy and a preeclampsia which are not giving in to conservative methods of therapy; a large fruit at a diabetes mellitus, dekompensirovanny heart diseases, etc.

To. the page is carried out also according to so-called kompleksirovanny indications. These indications call also combined, preventive, combined. They are set of several complications of pregnancy y childbirth, each of which separately does not serve as the indication to To. page, but together they create real threat for life of a fruit in case of delivery in natural patrimonial ways. Refer weakness of patrimonial activity, a dystocia of a neck of uterus, postmature pregnancy, childbirth to them primapara after 30 years, the menacing pre-natal asphyxia of a fruit, mortinatality or usual abortions in the anamnesis; the previous long infertility, pelvic presentations, a large fruit, a prolapse of the umbilical cord, narrowing of a basin of the I degree, late toxicosis. When one woman in labor has 3 — 5 specified complications, for prevention of mortinatality make To. page.

Rare relative indications for performance To. page: malformations of a uterus and vagina, an acute abdomen (torsion of a pregnant uterus, peritonitis, etc.), the extragenital diseases demanding bystry delivery at unprepared patrimonial ways.

During the performance To. the page according to relative indications should consider strictly and possible contraindications. Treat them: pre-natal death of a fruit, deep prematurity, it is long the existing pre-natal hypoxia of a fruit, preliminary attempts to delivery in natural patrimonial ways (imposing of obstetric nippers, version on a leg, etc.); existence hron, and acute infection.

At vital indications to To. the page from mother existence of contraindications loses the value. E.g., at full placental presentation pre-natal death of a fruit is not a contraindication for To. page.

Conditions for performance of Cesarean section — existence of a live and viable fruit; timeliness of operation, i.e. definition of an optimum span when surgical delivery is not too hasty or, on the contrary, overdue intervention (in the first case To. the page will be made at quite favorable opportunities for vulval delivery, in the second — there is a real danger of a still birth or even death of mother). Along with strict observance of all rules of an asepsis and the antiseptics accepted in surgical practice during the performance To. the village needs to pay special attention to a possibility of existence of a horioamnionit (an inflammation of amniotic covers). Arises horioamnionit at long childbirth, an anhydrous interval more than 12 hours, the infection preceding childbirth. Clinically horioamnionit it is shown by fever, headaches, putreform allocations from patrimonial ways. The general condition of the woman in labor originally remains satisfactory, symptoms of intoxication join later, bacterial shock can develop. Gematol, indicators change, as at inflammatory process. At a horioamnionita To. the page cannot be made, by way of exception perhaps extra peritoneal To. page.

For performance To. the page is necessary the consent of mother to operation that is reflected in the history of childbirth.

Preoperative preparation and anesthesia

the Volume of preoperative preparation usual for laparotomies (see). In case of an immediate surgery empty intestines and the crowded stomach. Just before operation surely a catheter lower urine.

Anesthesia has the features since by the time of operation, in addition to a condition of the woman, it is necessary to take a condition of a fruit and influence on it of various anesthetics into account. The placenta is not a barrier to one of them irrespective of a method of introduction them in an organism of mother. Late toxicosis, anemia, a depressed case at mother, long childbirth, prematurity, postmaturity, disturbance of uteroplacental blood circulation cause a pre-natal hypoxia of a fruit or high degree of order to the slightest decrease in delivery of oxygen to it.

The anesthetics applied at To. pages, shall not lead to oppression of sokratitelny activity of a uterus in order to avoid hypotonic bleeding during operation and after it.

At To. pages most often apply endotracheal inhalation anesthesia (see). In 15 — 20 min. prior to operation intravenously enter 0,5 mg of Atropini sulfas. In most cases apply Propanididum (Sombrevinum, Epontolum) or viadril to an introduction anesthesia. The introduction anesthesia by Propanididum is carried out with obligatory inclusion in premedication of antihistaminic drugs and calcium chloride. At pregnant women with tendency to allergic reactions use of Propanididum is contraindicated. It is possible to apply barbiturates in combination with antipsychotic and sedative drugs to an introduction anesthesia that allows to reduce a dose of barbiturates and to avoid a narcotic depression of a fruit. At acute blood loss at the woman in labor and a hypoxia at a fruit barbiturates do not apply.

The high level of cholinesterase of a placenta does use of the depolarizing muscle relaxants harmless to the newborn. It is better not to apply ether, Ftorotanum, Trilenum, cyclopropane to the main anesthesia until extraction of a fruit, and to use nitrous oxide with antipsychotic drugs.

After extraction of a fruit technique neyroleptanalgeziya (see) does not differ from that at surgeries.

Considering fiziol, the hyperventilation at women in labor providing normal diffusion of oxygen to a fruit, artificial ventilation of the lungs (see. Artificial respiration ) in time To. the page is recommended to be carried out with a minute volume of breath not less than 14 l. More vigorous ventilation (from 18 to 20 l/min) can lead to sharp falling of a uterine blood-groove that will cause a hypoxia of a fruit.

Technology of operation

Depending on the place of opening of a cavity of the uterus To. the page can be korporalny (classical) and in the lower segment of a uterus.

Korporalny Cesarean section

Korporalny Cesarean section should be made when after operation it is necessary to make a hysterectomy (see. Hysterectomy ), in the presence of the expressed destructive changes in area of the lower segment of a uterus or when very bystry delivery for the benefit of mother and a fruit is required (e.g., at profuse uterine bleeding).

At korporalny To. pages after a nizhnesredinny laparotomy bring a uterus out of an abdominal cavity in an operational wound; on its front surface a scalpel make midsection in the direction from a bottom not less than 12 cm long from top to bottom. Then open a bag of waters, take a fruit, capturing him for a leg or for a head, between clips cut an umbilical cord and transfer the child to the midwife. After that delete an afterbirth and take in a section on a uterus a two-row knotty catgut seam — muscular and muscular and serous and muscular. After a toilet of an abdominal cavity the abdominal wall is sewn up tightly.

In the applied modifications of this method the uterus is not removed from an abdominal cavity; subsequent stages K. pages carry out in the same sequence. Other modifications korporalny To. page (with ground cross section across Frich, with a ground and sagittal section according to Müller, with a slit of a back wall of a uterus across Konstein — Half-ANO etc.) are not applied and have only historical value.

At abdominal To. the village after a section of a wall of a uterus sometimes can find the placenta (placenta caesarea) prelying to a wound. At the same time it is necessary to be afraid not so much of severe uterine bleeding how many blood loss at a fruit, edge can be at a section or a rupture of a placenta. In these cases the hand entered into a cavity of the uterus otslaivat a placenta and, having reached covers, break off them then take the child in the regular way. During To. page blood loss, according to some authors, makes 800 — 1000 ml therefore during operation hemotransfusion and blood substitutes is carried out.

On a nek-eye to indications after abdominal To. pages make supravaginal amputation or a hysterectomy. The hysterorrheses excluding a possibility of its mending belong to such indications; uteroplacental apoplexy (Kuveler's uterus); true increment of a placenta; cervical placenta; an atony of a uterus if bandaging of vessels does not lead to a stop of bleeding; seldom infection of a uterus; cancer of a neck of uterus; hysteromyoma.

Cesarean section in the lower segment of a uterus

At To. pages with cross section of the lower segment of a uterus make a longitudinal nizhnesredinny laparotomy or cross section but Pfannenshtilya. The abdominal cavity is carefully fenced off napkins in order to avoid hit in it amniotic waters. In the place of the greatest mobility open with scissors a vesicouterine fold in the middle, to-ruyu cut up to both round ligaments of a uterus in transverse direction. In the stupid way otslaivat a bladder and displace from top to bottom. Level of a section of the lower segment of a uterus varies depending on an arrangement of a head of a fruit and shall correspond to its largest diameter. Scalpel make small cross section up to opening of a bag of waters; the section is expanded with index fingers of both hands to extreme points of the periphery of a head. Then enter the left hand into a cavity of the uterus, take a head of a fruit, turn it a nape (or the person) kpered and make extension (or bending) thanks to what the head is brought out of a uterus. Then a pandiculation both hands for a head serially take one and other shoulder, then a trunk.

Fig. 1. The diagrammatic representation of some stages of Cesarean section in the lower segment of a uterus: 1 — cross section of a wall of the lower segment of a uterus; the peritoneum is opened along an uterovesical fold; 2 — expansion of a section of a wall of the lower segment of a uterus index fingers to extreme points of the periphery of a head of a fruit; 3 — imposing of the first (on the right) and the number of noose catgut muscular and muscular sutures second (at the left) on a wall of a uterus: 4 — a continuous catgut suture on a vesicouterine fold of a peritoneum (peritonization).

In the presence of pelvic presentation the fruit is taken for a leg, and at the cross provision of a fruit after preliminary version for a leg; the head out of a cavity of the uterus is brought the reception identical to Morisso's reception — Levre (bending of the subsequent head at extraction of the child in case of pelvic diligence). The umbilical cord is cut between clips and the child is transferred to the midwife. Enter oxytocin then delete with a pandiculation for an umbilical cord an afterbirth into a wall of a uterus; the cavity of the uterus is checked the big curette or a hand. Uterus wound is sewn up with knotty catgut seams in two ranks without capture of a mucous membrane; the first stitches are put on the unimpaired sites of a uterus on both sides otstupya on 1 cm from a corner of a section of a uterus. The third row of seams — continuous catgut — recover integrity of a vesicouterine fold (fig. 1).

If after extraction of the child and an afterbirth there is uterine bleeding which is not giving in to conservative therapy bandaging of the main vessels is made, and at inefficiency of this action supravaginal amputation or a hysterectomy depending on the reason which caused bleeding. After a toilet of an abdominal cavity the abdominal wall is sewn up tightly.

To. page with a slit of the lower segment of a uterus (istmiko-korporalny To. the page) on the immediate and long-term results considerably concedes to the above described technique. In these cases often the section is extended on a body of the womb (at difficulties with extraction of the child) and To. the page in essence becomes korporalny.

To. the page in the lower segment of a uterus in comparison with korporalny has indisputable advantages: at korporalny To. the page an over-all mortality is higher, incidence ginekol. to a thicket, a thicket are made by diseases repeated To. page at the subsequent pregnancy and childbirth (because of inferiority of a hem on a uterus); there are hysterorrheses on the Hem more often. To. the page in the lower segment of a uterus is proved also from the anatomo-functional point of view: at it the arrangement of muscular layers and vessels, features of functions of various departments of a uterus in labor are considered.

Repeated To. pages make in the lower segment of a uterus (even in cases of sterilization) since at korporalny To. pages in the postoperative period meet various complications more often, in particular peritonitis (see).

Extra peritoneal (ekstraperitonealny) Cesarean section it is applied during the developing of an infection in labor to the prevention of postoperative peritonitis. It is shown at a long anhydrous interval (more than 12 — 14 hours), at pregnant women with chronically and ostroprotekayushchy diseases and at allergic reactions to antibiotics. This operation is reasonable if operational delivery is shown and there is an essential risk of postoperative peritonitis. Technically extra peritoneal To. page — more difficult operation in comparison with intraperitoneal To. page also it has to be carried out by the most experienced obstetrician-gynecologist. Before operation for the best orientation the bladder is filled by 150 — 200 ml of solution of Furacilin or boric to - you. Make abdominal section on the white line or on Pfannenshtil's way to a peritoneum. Direct muscles move apart in the stupid way and take to the parties, otseparovyvat a peritoneum up, bare a bottom of a bladder, then remove a bladder to the right, otseparovyvy it from the lower segment of a uterus in the stupid way. Having emptied a catheter a bladder, open the lower segment of a uterus, delete a fruit and an afterbirth, then sew up a section on a uterus, return into place a bladder and sew up with a usual way an abdominal wall.

A postoperative current and leaving

Later To. pages transfer the woman in labor to chamber of an intensive care where make correction of water and electrolytic balance, blood gases etc. Reasonablly monitor overseeing by indicators of a hemodynamics (pulse, the ABP, the volume of the circulating blood, minute volume of blood circulation, etc.) and behind breath (a respiration rate, minute volume of breath, blood gases, etc.). Blood losses) on 2/3 fill with donor blood, enter the solutions improving rheological properties of blood — reopoliglyukin, Polyglucinum, Haemodesum. Infusional therapy is supplemented with solutions of glucose and sodium chloride. Total quantity of the entered liquid varies depending on basic data of volume of the circulating blood, but there should not be less than 1500 — 2000 ml. Along with infusional therapy enter diuretic means, amount of the entered liquid korrigirut depending on a diuresis. Apply anesthetics, vitamins, antihistaminic drugs. Antibiotics are appointed only in case of an immediate surgery; use of semi-synthetic penicillin or cephalosporins is reasonable. For the 2nd days carry out correction of electrolytic balance, apply prozerin and glyukozonovokainovy mix to prevention of paresis of intestines. Careful overseeing by involution of a uterus, character of lokhiya is necessary. If there are signs of an endomyometritis later To. pages, perform intensive antibacterial, infusional and fortifying care.

In several hours after operation recommend to turn in a bed, to move hands and legs, the next days to sit down, and on the 2nd days to go on chamber. Feeding by a breast of the child can be allowed on 3 — the 5th day after operation, and at good shape of mother and child earlier. On 6 — the 8th Days remove seams from an abdominal wall; on 10 — the 12th days after operation the woman in childbirth can be written out home under observation of the doctor of clinic for women.

Such maintaining the postoperative period is carried out at almost healthy women who transferred an uncomplicated operative measure with a smooth postoperative current. If at the patient in time and after operation complications (shock, a collapse, posthemorrhagic anemia, late toxicosis, inflammatory processes etc.) are observed, then the specified actions supplement with a package of measures, directed to their elimination.

The immediate and long-term results

Achievements of medicine, right choice of a method of delivery and method K. pages, the accounting of indications and contraindications to operation, timeliness of its production and other actions allow to reduce perinatal and maternal mortality later To. page to a minimum.

The reasons of maternal mortality can be divided into two groups: connected with operation K. page (peritonitis, a thrombembolia, complications of anesthesia, sepsis, impassability of intestines, bronchial pneumonia, etc.) and not connected with operation K. page (prenatal bleedings, eclampsia, diseases of cardiovascular system, other extragenital diseases).

The analysis of the reasons of perinatal mortality at abdominal delivery shows that it hl. obr. it is connected with placental presentation and premature amotio of normally located placenta, late toxicosis of pregnant women, extragenital pathology, and also with complications of childbirth which led to death of a fruit in connection with untimely performance of abdominal delivery (clinically narrow basin, weakness of patrimonial activity, anomaly of situation and presentation). When the pathology of mother influencing a condition of a fruit, no perinatal mortality is lower and is caused by prematurity, uglinesses, a hemolitic disease of newborns, bronchial pneumonia of newborns.

Ginekol, incidence after postponed To. the page meets more often after korporalny To. the page is also shown by hl. obr. disturbances of menstrual function and hron, inflammatory processes.

The obstetric forecast for the women who transferred To. the page, is not absolutely favorable since in considerable percent of cases after korporalny To. the page is observed infertility. In developing of infertility the crucial role is played by not operation, and inflammatory processes developing after it in genitalias.

Delivery of the women who transferred in the past To. the page, is an important problem sovr, obstetrics. The analysis of data of literature shows that repeated operation K. the page is carried out to 55% of cases. Indications to repeated To. the page can be divided into three groups. The first is made by so-called stable indications which were the basis for production of the first To. page (e.g., anatomically narrow basin, cicatricial deformations of a vagina and neck of uterus). Indications which arose at this pregnancy and childbirth irrespective of postponed earlier To concern to the second group. page (e.g., placental presentation, prolapse of the umbilical cord). Adverse effects previous enter into the third group To. page, hl. obr. in connection with insolvency of a hem on a uterus. Potentiality of a hysterorrhesis on a hem later To. the village, especially later korporalny, at the subsequent pregnancy and childbirth demands dispensary observation for such women. The interval between surgical delivery and the subsequent pregnancy shall be not less than 2 years. During the definition of the forecast repeated To. the page, in addition to the general and obstetric data, is important clarification of a method postponed earlier To. page, indications, on the Crimea it was carried out, a current of the postoperative period, character of a hem on a uterus and an abdominal wall. The gisterografiya is applied to the characteristic of a uterine hem (see. Metrosalpingografiya ), edges it is made before pregnancy in a side projection and not earlier than 6 months later To. page.

During repeated To. the page quite often rises a question of sterilization since danger of a hysterorrhesis on a hem at the following pregnancy and childbirth increases. At the uncomplicated course of pregnancy of women in labor it is necessary to hospitalize for 2 weeks before childbirth, and in the presence of a defective hem on a uterus for 4 — 5 weeks in such obstetrical establishment where obstetric care in the necessary volume can be given them.

Vulval Cesarean section

Vulval Cesarean section (a synonym a vulval hysterotomy) is applied to abortion on medical indications in terms from 16 to 28 weeks.

Operation is offered by J. A. Duhrssen in 1896. In obstetric practice the modification developed by Yu. A. Leybchik in 1924 and irrespective of it a bit later F. Heinsius is applied.

Indications and contraindications

belong To indications: toxicoses of pregnancy (nephropathy, eclampsia, etc.), heart diseases, lungs, kidneys and other bodies.

Treat contraindications: ginekol, the diseases creating an obstacle for free access to the lower segment of a uterus (a new growth, cicatricial deformation of a vagina or neck of uterus, a trachelectomy, etc.); cervical pregnancy; placental presentation at rather big duration of gestation (20 weeks and more); acute inflammatory diseases of pelvic bodies (e.g., paraproctitis).

Preoperative preparation and anesthesia

Training of the patient for operation does not demand preliminary restriction of meal. The night before and empty intestines in the morning. Apply an endotracheal anesthesia or peridural anesthesia to anesthesia (see. Anesthesia local ).

Technology of operation

Position of the patient typical for vulval operations. After processing of external genitals and a vagina and bladder emptying by a catheter the neck of uterus is bared mirrors and taken bullet nippers (or two-teeth) for front and back lips. The channel of a neck of uterus is probed, then expanded with Hegar's dilators to No. 13 — 15. The neck of uterus is reduced to an entrance to a vagina, the elevator bared and pull the front arch. In it do a cross semi-lunar section of a wall of a vagina 4 — 5 cm long, camber turned towards a neck of uterus, otstupya from an outside pharynx of a neck of uterus on 2 — 2,5 cm. The upper edge of a semi-lunar section of a vault of the vagina is taken and raised surgical tweezers, the bladder is separated in the stupid way from a front surface of an isthmus of a uterus to the parties and to a vesicouterine fold. Connective tissue crossing points between a bladder and side parts of a neck of uterus cut scissors, and the bleeding vessels alloy a catgut. Enter a mirror elevator into a wound of a front vault of the vagina and bare a front surface of an isthmus of a uterus. Into the canal of a neck of uterus enter a dilator No. 13 — 15 or the flat metal pallet and on it a scalpel make a median slit of a supravaginal part of a neck of uterus. On edges of a section on both sides through all thickness of a neck of uterus impose on one provisional catgut ligature then delete buzh or the pallet and bullet nippers. Tightening for ligatures handles, under protection of a mirror elevator and under control of sight scissors continue a section of an isthmus (the lower segment of a uterus) up to a vesicouterine fold of a peritoneum; at the same time in a section the amniotic bubble is shown. Open an amniotic bubble, delete vaginal speculums. Enter a hand into a vagina, an index and long finger get into a cavity of the uterus, find and take a leg of a fruit, make turn and take a fruit to a head. Again enter vaginal speculums and under protection of the elevator perforate sharp-pointed scissors a head of a fruit, make excerebration then the fallen-down head of a fruit is taken. If after opening of a bag of waters in a wound there is a prelying head, she is captured bullet nippers, perforate and after emptying take a pandiculation for bullet nippers. The afterbirth is deleted, sipping for an umbilical cord hemorrhoidal nippers or the fingers entered into a uterus. At small durations of gestation fetal egg entirely can be otsloyeno and is removed in the manual way. After removal of fetal egg the cavity of the uterus is scraped out a big blunt curette. Previously in thickness of a uterus or intravenously (slowly!) enter 1 ml of oxytocin, and to women with cardiovascular pathology — methylergometrine.

Fig. 2. Diagrammatic representation of some stages of operation of vulval Cesarean section: 1 — capture of the upper edge of a rag of tissue of vagina after a semi-lunar section in a front vault of the vagina for the subsequent separating; 2 — the neck of uterus is cut on a metal dilator of Hegar; 3 — through a section of a front wall of a neck of uterus on which edges provisional ligatures are imposed begin extraction of a fruit a leg; 4 — the final stage of operation — suture on a semi-lunar discission of the cervix.

Closing of a section of a wall of a uterus is begun with an upper corner of a wound, putting separate knotty catgut stitches to one floor; the mucous membrane should not be taken in a seam. On a rag of a front vault of the vagina also put knotty catgut stitches — the first in the center for its symmetric recovery, and then serially in each party (fig. 2). Without taking vaginal speculums, in front and the side arches enter a gauze tampon which is deleted in 4 — 6 hour.

At vulval To. the page is possible wound of a bladder, a cut most often and arises because of fear it to injure. At a superficial section of a wall of a vault of the vagina in the place of its transition to a neck of uterus further amotio of a bladder is carried out not in friable cellulose between a bladder and an isthmus of a uterus, and within a wall of a bladder by stratification of muscle fibers. Check of integrity of a bladder is carried out by catheterization (blood in urine) and filling by its solution of methylene blue. Defect in a wall of a bladder is sewn up with knotty catgut seams. At duration of gestation the insufficient section of a supravaginal part of a neck of uterus and the lower segment during extraction of a fruit can lead more than 20 weeks to continuation of a section on a uterus. After emptying of a uterus of border of an artificial opening in it shall be accurately defined before mending.

The postoperative current and leaving

the Patient appoint a bubble with ice to a bottom of a stomach, means reducing a uterus, antibiotics (in case of inflammatory process). On 2 — the 3rd days it is allowed to sit down in beds, on 3 — the 4th — to rise, and on 8 — the 9th — the woman can be written out from a hospital if the basic disease allows. At an uncomplicated current of the postoperative period vaginal examonation and vaginal speculums examine in 2 — 3 weeks after an extract as control survey.

The immediate and long-term results vulval To. pages are quite favorable; menstrual and genital function do not suffer.

Cesarean section on dead and dying

In literature there are messages about To. page on dead for the purpose of rescue of the child. The result of these operations long time was unsatisfactory. On combined statistics of Lange up to 20 century from 141 K. the page is received only 3 living children. But already from 22 operations described in 1934 — 1960, 20 children were taken live. On results of similar To. to page the great influence is exerted by time which passed from the moment of the death of mother before extraction of the child and the nature of a disease, from to-rogo the woman died. The forecast is more favorable for a fruit in cases of sudden death of mother and is adverse in cases of death from hron, diseases and intoxications. According to P. Ya. Garfunkelya, the maximum time necessary for extraction of the living child after the death of mother, makes 21 — 23 min. To. pages on dead make more than 28 weeks at duration of gestation. To. the page shall be made by a korporalny method since it is the most bystry.

To. the page on dying is carried out when the disease of mother is fatal and inevitability of near death is undoubted, and the fruit is viable. Before operation it is necessary to be convinced that delivery in natural patrimonial ways is impossible. If the patient is in consciousness, her consent to operation is necessary, and in case of unconsciousness it is necessary to receive (whenever possible) the consent of her relatives. The decision of a question of operation is made whenever possible ex consilio.

Operation K. pages on dying make with observance of all rules of an asepsis and equipment by a korporalny method.

Bibliography Z. Ya Gendonum. Interruption of late durations of gestation by operation of vulval Cesarean section, Akush, and ginek., M 1, page 58, 1970; Zverev V. V., Persianinov L. S. and Rasstrigin H. H. Anesthesia at operation of Cesarean section using antipsychotic and analgetic means, in the same place, No. 7, page 21, 1972; L and E. A. N-tsev and d river. Long peridural anesthesia at Cesarean section, Vopr. okhr. mat. also it is put., t. 20, No. 3, page 75, 1975; Malinovsky M. S. Operational obstetrics, page 328, M., 1974; Persianinov L. S., Kastru-bin E. M. and Rasstrigin N. N. Elektroanalgeziya in obstetrics and gynecology, M., 1978; Persianinov L. S., the P e r N at x and E. A. both To about m and with about are about in and L. M. Ekstraperitonealnoye Cesarean section, Akush, and ginek., No. 5, page 34, 1977; Pokrovsk V. A. and Markin V.P. Cesarean section in the lower uterine segment with suprapubic cross section of an abdominal wall, Voronezh, 1968, bibliogr.; Blind A. S. Abdominal Cesarean section in modern obstetrics, M., 1968, bibliogr.; Chipev of X., Balabanova S. and Ivanov of E. Protichaneto on burden-nosta and razhdaneto a trace prekarano sectio caesarea, Akush, and ginek. (Sofia), t. 15, page 415, 1976; Frankenberg H. W. Die Wandlung der Kaiserschnitt-Indikationen, Geburtsh. u. Frauenheilk., Bd 35, S. 265, 1975; Hibbard L. T. Changing trends in cesarean section, Amer. J. Obstet. Gynec., v. 125, p. 798, 1976; Martius H. Die gebur-tshilflichen Operationen, Stuttgart, 1962; Frosts H. Nova is operational the equipment for ekstraperitonealno sektsio, Akush, and ginek. (Sofia), t. 13, page 263, 1974; P e k-s and And. i. i. Kliniczne aspekty ciecia cesars-kiego, Ginek. pol., t. 46, s. 145, 1975; P a-x and m of Uakhib And. Histerografiya trace repeatedly tsezarovo section, Akush, and ginek. (Sofia), t. 15, page 332, 1976; Hibbard L. T. Changing trends in cesarean section, Amer. J. Obstet. Gynes., v. 125, p. 798, 1976; Johnell H. E., Ost-bergH. WahlstrandT. Insre-asing cesarean section rate, Acta obstet, gynec, scand., v. 55, p. 95, 1976; Uher M. aj. Akutni stavy po sectio of a sayevagyo, Cs. Gynek., sv. 39, s. 736, 1974; Weber of Page E. Postmortem cesarean section, Amer J. Obstet. Gynec., v. 110, p. 158, 1971,