1ST CITY CLINICAL HOSPITAL

Author: obstetrician-gynecologist (head) of the highest qualification category of the obstetric physiological department of the health care institution "1st City Clinical Hospital", Dvornik E.V.

Date: 03/10/2023

In the 21st century, there is a trend towards an increase in the frequency of cesarean section (CS), which is currently the most common delivery operation. The rate of caesarean sections worldwide has tripled in the last decade and continues to rise.

The frequency of CS, according to literature sources, in recent years is 21-29%, while the frequency of planned cesarean section is also steadily increasing.

At the same time, the position of the global expert community in the field of healthcare is that the optimal number of cesarean sections is 10-15% of all births.

It has been found that when 10% of all births in a country are performed through surgery, the mortality rate for newborns and mothers decreases because it means more women have access to this life-saving operation.

The high proportion of births by cesarean section in modern obstetrics has objective reasons related to:

• the onset of the first pregnancy at a late reproductive age (over 35 years);
• an increase in the number of women with high perinatal and obstetric risk, including somatic diseases, and, accordingly, an increasing frequency of pregnancy complications;
• an increase in the number of pregnant women after in vitro fertilization, often with a history of multiple attempts;
• an increase in the number of patients with a uterine scar after CS, myomectomy performed by laparoscopic access;
• expansion of indications for CS in the interests of the mother and fetus, which is argued by three goals: reducing perinatal mortality, child, and, in the opinion of some obstetricians, maternal injuries.

To a certain extent, overdiagnosis, based on information about the condition of the fetus obtained using additional research methods (fetal cardiotocography, fetal ultrasound with Doppler), and improved surgical techniques, contribute to an increase in the frequency of CS.

In addition, women themselves increasingly prefer caesarean section to natural childbirth. The World Health Organization (WHO) says the trend is global, with different causes everywhere. Probably the main one is the desire to avoid pain during vaginal birth, as well as speed up the process of giving birth to a child.

Of course, at present, a caesarean section is of great importance, since in case of complications during pregnancy and childbirth that cannot be corrected, it allows preserving the health and life of both mother and child. According to WHO, modern surgical approaches, effective painkillers and antibacterial drugs allow surgery to be performed with minimal risk to the mother and child.

However, CS is classified as a complex operation: compared with vaginal birth, CS in women experiences a high incidence of postoperative complications (3.3-54.4%), and mortality increases 3 times (from 0.9 % to 2.7%). Surgical delivery without indications increases the risk of maternal mortality, the likelihood of blood transfusion, hysterectomy, vascular ligation: planned surgery - by 2.7 times, emergency - by 14.2.

Like any surgical intervention, cesarean section can have complications that are possible at all stages of the operation, as well as in the early and late postoperative periods:

■ formation of hematomas: in the subcutaneous fat, under the aponeurosis, in the parametrium, in the prevesical tissue;

■ injury to neighboring organs: bladder, ureter, intestines;

■ bleeding may occur when the uterus is dissected if the incision is prolonged and the vascular bundle is injured. A very serious complication is bleeding caused by hypotension or atony of the uterus, a violation of the blood coagulation system;

■ amniotic fluid embolism, pulmonary embolism;

■ development of purulent-septic complications in the postpartum period: endometritis, thrombophlebitis, wound suppuration, peritonitis.

According to modern literature, women after surgical delivery are more likely to suffer from prolonged postpartum depression. In addition, a caesarean section can lead to difficulties with breastfeeding.

The consequences of CS for children are also ambiguous: it has been proven that in the majority of newborns extracted by CS, the adaptation period is disrupted, which is manifested by hypoxic-ischemic damage to the central nervous system, hypothermia, hypertension, a pronounced decrease in body weight, and disruption of the formation of intestinal microbiocenosis. Moreover, according to psychologists, children born by cesarean section have perinatal psychotrauma caused by the unexpectedness and unpreparedness of the child for the transition to extrauterine existence, characterized as a state of shock and causing neuropsychic and intellectual deprivation, which is extremely difficult to treat.

Long-term negative consequences described in foreign retrospective studies were also identified. Thus, the likelihood of obesity in 3-year-old children is increased by 2 times, and in adulthood – by 26%; the likelihood of type 1 diabetes mellitus and bronchial asthma is 20% higher; the frequency of respiratory distress syndrome increased from 3.8 times at 37 weeks and 1.9 times at 38 weeks.

In addition, CS can have a negative impact on the further reproductive function of women: the development of menstrual irregularities, recurrent miscarriage, infertility, placenta previa, and true placenta accreta may develop during a subsequent pregnancy.

Despite the possible complications of CS, the frequency of this operation is steadily increasing throughout the world, which causes reasonable concern for obstetricians in all countries.

In this regard, it is necessary to carefully substantiate the indications for surgical delivery, especially during the first operation, which is dictated by concern for the future generative function of the mother.

If there are indications for CS during pregnancy, it is preferable to carry out the operation as planned, since it has been proven that the number of complications for the mother and child is significantly less than for those undergoing emergency interventions.

The reserve for reducing cesarean sections is high-quality preconception preparation, effective psychoprophylactic work with pregnant women in antenatal clinics, and an increase in the number of vaginal births in pregnant women with a uterine scar.