Introduction.
In recent years, cesarean section has played an important role in the management of obstructed labor, pregnancy complications and complications, and in reducing maternal and child mortality and morbidity. With the development of perinatal medicine and the improvement of surgical and anesthetic techniques and pharmacological conditions, the safety of cesarean section has been improving, but at the same time, the cesarean section rate has increased in countries around the world. The cesarean delivery rate in China rose from about 5% in the 1960s to 20% in the early 1990s; and in the past 20 years, it has been on the rise. Reports in the literature show that the cesarean delivery rate in most hospitals in China is between 40% and 60%, and even up to 70% or more in some hospitals.
In a global survey of cesarean delivery rates, the WHO reported that the risk of serious complications and death was significantly higher among pregnant women who had vaginal assisted delivery and cesarean delivery than those who had natural vaginal delivery. In order to standardize the implementation of cesarean section and further improve the indications for cesarean section, preoperative preparation, surgical procedures and postoperative management, an expert consensus on cesarean section in China was formulated based on the clinical guidelines for cesarean section in the United Kingdom and the United States, taking into account the current situation in China.
I. Indications for cesarean section
The indications for cesarean section are pathological or physiological conditions that cannot be delivered vaginally or are not suitable for vaginal delivery.
Fetal distress: acute and chronic fetal distress due to comorbidities or complications in late pregnancy and acute fetal distress during labor that cannot be delivered vaginally within a short period of time.
2, cephalopelvic disproportion: absolute cephalopelvic disproportion or relative cephalopelvic disproportion who failed to deliver by adequate vaginal trial.
Scarred uterus: those who are pregnant again after 2 or more cesarean sections; those who have had previous myomectomy to penetrate the official cavity.
4, abnormal fetal position: transverse fetal position, first trimester singleton breech position (estimated fetal birth mass) and foot previa.
(estimated birth mass) and foot previa.
5, placenta praevia and anterior vessels: placenta partially or completely covering the endocervix and anterior vessels.
6, twin or multiple pregnancies: the first fetus is non-cephalic; complicated twin pregnancies; conjoined twins, three or more multiple pregnancies should be delivered by cesarean section,.
7, umbilical cord prolapse: the fetus has the possibility of survival, and the assessment result is that rapid vaginal delivery is not possible, emergency cesarean section should be performed to save the fetus as soon as possible.
8.Placental abruption: if the fetus is likely to survive, the fetal heart rate should be monitored and emergency cesarean section should be performed as soon as possible to deliver the fetus. In severe placental abruption, the fetus is dead and emergency cesarean section should be performed.
9. Pregnant women with serious comorbidities and complications, such as heart disease, respiratory diseases, severe pre-eclampsia or eclampsia, acute fatty liver in pregnancy, thrombocytopenia and heavy intrahepatic cholestasis in pregnancy, etc., cannot tolerate vaginal delivery.
Those with gigantic pregnancy: pregnant women with gestational diabetes who estimate the birth mass of the fetus
Maternal request cesarean section: The American College of Obstetricians and Gynecologists (ACOG) defines maternal request cesarean section (CDMR) as a full-term, singleton delivery without medical indication at the request of the pregnant woman.
The mere personal request of the pregnant woman is not an indication for a cesarean section, but must be discussed and documented if there are other special reasons.
When a pregnant woman requests a cesarean section without knowing her condition, the overall advantages, disadvantages and risks of a surgical cesarean delivery compared to a vaginal delivery should be detailed and documented.
When a pregnant woman requests a cesarean section because she is afraid of the pain of vaginal delivery, psychological counseling should be provided to help alleviate her fears; labor analgesia methods should be applied during labor to reduce labor pain and shorten the duration of labor.
Clinicians have the right to refuse requests for cesarean delivery without clear indications, but the pregnant woman’s request should be respected and suboptimal advice should be provided.
Abnormalities of the birth canal: e.g. high vaginal complete diaphragm, post artificial vaginoplasty, etc.
Vulvar diseases: e.g. those with severe varicose veins in the vulva or vagina.
Severe infectious diseases of the genital tract: e.g. severe gonorrhea, condyloma acuminata, etc.
Pregnancy combined with tumor: such as pregnancy combined with cervical cancer, huge cervical fibroids, lower uterine fibroids, etc.
Timing of cesarean section
The choice of the timing of cesarean section is very important and is an important factor affecting the prognosis of mother and child.
1.Elective cesarean section: It is an elective operation with indications for cesarean section, good condition of pregnant woman and fetus, and planned and prepared before delivery. Because the risk of respiratory infection complications in newborns is higher in cesarean section before 39 weeks of gestation, elective cesarean section is not recommended before 39 weeks of gestation except for twin or multiple pregnancies and placenta praevia.
2.Emergency cesarean section: It refers to the cesarean section under emergency conditions that threaten the life of mother and child. It should aim to end the delivery in the shortest possible time. It also requires the cooperation of the mother and her family, as well as the communication and cooperation of medical and nursing staff of obstetrics, neonatology and anesthesiology.
Pre-operative preparation for cesarean section
(I) Pre-operative talk content
The preoperative conversation should take into account the cultural background, education level and choice of delivery method of the pregnant woman and her family. The obstetrician should fully inform the pregnant women and their families about the possible adverse outcomes during and after the operation, and should explain clearly about CDMR.
1. Indications and necessity of cesarean section: explain to the pregnant woman and her family in detail about her condition, explain the risks of vaginal delivery and the necessity of ending the pregnancy by cesarean section, and obtain the consent of the pregnant woman and her family.
2. Possible complications for mother and child before, during and after cesarean section.
Effects of surgery on the mother: ① persistent postoperative incisional discomfort; ② incisional infection, fissure, fat liquefaction, subcutaneous hematoma, delayed incisional healing, etc.; ③ postpartum hemorrhage, shock, DIC; ④ hysterectomy; ⑤ amniotic fluid embolism; ⑥ postoperative thromboembolic disease; ⑦ ureteral, bladder and other peripheral organ damage; ⑧ maternal death; ⑨ due to different maternal comorbidities and complications, a targeted description of the related risks of occurrence, such as the possibility of complications such as eclampsia and heart, liver and kidney failure during and after surgery for pregnant women with severe pre-eclampsia, and cardiac arrest during surgery for pregnant women with combined heart disease.
Effects of surgery on neonates: (1) neonatal respiratory distress syndrome; (2) increased risk of neonatal hypoglycemia, sepsis, and neonatal hospitalization beyond Sd; (3) occurrence of neonatal birth injuries. (3) Effects of cesarean delivery on recurrent pregnancy and childbirth: (1) increased likelihood of cesarean delivery in recurrent pregnancy and delivery; (2) risk of uterine rupture in recurrent pregnancy or delivery; (3) risk of placenta praevia, placental adhesion or even placental implantation in recurrent pregnancy; (4) risk of pregnancy in the scarred area of the uterus in recurrent pregnancy. (4) Long-term complications: endometriosis and uterine diverticulum, etc.
(3) Sign the informed consent form: signed by both spouses and the physician in charge.
(II) Pre-operative preparation
1.The following laboratory tests should be available before surgery: (1) routine blood and urine, blood type; (2) coagulation function; (3) screening for infectious diseases (hepatitis B, hepatitis C, HIV infection, syphilis, etc.); (4) electrocardiogram; (5) biochemical examination (including electrolytes, liver and kidney function, blood glucose); (6) fetal ultrasound; (7) others, depending on the needs of the condition.
2.Prepare the skin as appropriate: shave the abdominal sweat hair and pubic hair on the day before surgery. Note that the operation should be gentle to prevent damage to the skin, and skin infections and boils should be treated first before skin preparation.
3.Insertion of catheter: Insert a retained catheter according to the aseptic catheterization method, usually a Foley double-lumen balloon urinary catheter.
4.Blood preparation: Blood is drawn for the patient for blood cross-checking on the day before surgery, and an appropriate amount of fresh blood is prepared through the blood bank for application during surgery. In case of placenta abruptio, uterine rupture, placenta praevia, multiple pregnancy, etc., which may bleed more than 1000ml during the operation, it should be performed in a medical unit with sufficient blood supply.
5. Infection prevention: The use of antibacterial drugs is in accordance with the Ministry of Health antibacterial drug use standard. The use of antimicrobial drugs for cesarean section (type II incision) is prophylactic and can reduce the occurrence of incisional infection after surgery.
6. Pre-operative assessment: make adequate pre-operative assessment for seriously ill pregnant women, make pre-operative discussion and record, and decide the anesthesia and surgical mode (such as whether a pregnant woman with severe pelvic infection should have extraperitoneal cesarean section, etc.).
Choice of anesthesia and its precautions
The decision should be made according to the status of the pregnant woman and the fetus, the conditions of the medical institution and the anesthesia technology. The anesthesia methods for cesarean section include intraspinal anesthesia (combined anesthesia of subarachnoid anesthesia + epidural block, or continuous epidural block); general anesthesia; local infiltration anesthesia, etc.
1.Pre-anesthesia talk with pregnant women and their families: introduce the necessity of anesthesia, anesthesia mode and possible complications, and sign the informed consent for anesthesia.
2.Fast food and water: fasting water 6-8 h before anesthesia.
3.Vital signs monitoring before anesthesia: monitor the respiration, blood pressure and pulse of the pregnant woman, monitor the fetal heart rate, etc.
V. Important steps in the lower uterine segment cesarean section
1.Selection of abdominal wall incision.
Transverse abdominal wall incision: compared with longitudinal incision, the incidence of maternal incisional discomfort after transverse incision surgery is lower and the appearance is more beautiful.
Transverse abdominal wall incisions include: ① Joel-Cohen incision. The incision is located bilaterally below the line of the anterior superior iliac spine at approximately
The incision is made in a straight line. The disadvantage is the high position and the less aesthetic appearance. (ii) Pfannenstiel incision. The incision is located 2 fingers above the pubic symphysis
or slightly above the level of the skin folds of the lower abdomen, the incision is shallow and curved toward the anterior superior iliac spine on both sides. The low incision position is more aesthetically pleasing, the incision is less tense, the postoperative reaction is mild, and the incision heals more easily.
Longitudinal incision of the abdominal wall: located at the white line between the umbilicus and shame, about 10~300 px. Its advantages are good pelvic exposure, easy to grasp and operate, and short operation time; its shortcomings are heavy postoperative pain, longer healing time of the incision, and less beautiful appearance.
2, treatment of the bladder: in general, when the lower segment of the uterus is well formed, it is not recommended to cut the peritoneal reflex of the bladder and push down the bladder; except in the case of poorly formed lower segment of the uterus or adhesions between the bladder and lower segment of the uterus.
3. choice of uterine incision: mostly choose a transverse incision in the upper middle third of the lower uterine segment, about 250 px long. blunt separation to open the uterus is recommended when the lower uterine segment is well formed, which can reduce blood loss and the incidence of postpartum hemorrhage. Pregnant women with anterior placenta or placental implantation avoid the placental attachment site and choose the incision location as appropriate.
4, the application of forceps: when the fetal head is difficult to deliver, can consider the application of forceps to assist delivery.
5.Application of contractin: After delivery of fetus, give 10~20U of contractin and (or) contractin directly to myometrial wall.
Add 500ml crystalloid into intravenous drip. It can effectively promote uterine contraction and reduce postpartum bleeding.
6. Placenta delivery method: It is recommended to deliver the placenta by controlled and continuous pulling instead of freehand stripping, which can reduce the amount of bleeding and the risk of endometritis. It is not recommended to deliver the placenta immediately after delivery unless there is significant active bleeding or no sign of abruption after 5 min. Check carefully after delivery for the integrity of the placenta and membranes.
7.Suturing the uterine incision: The safety and effectiveness of the single-layer suture method of closing the uterus is unclear. At present, double-layer continuous sutures are recommended to close the uterine incision. Pay attention to the suturing of the lateral corners of the uterine incision on both sides; the suturing should be started outside the lateral corners of the incision.
The suture should be started outside the lateral corners of the incision; the first layer is sutured continuously in a full layer, and the second layer is sutured continuously or intermittently with mattress sutures to embed the incision; attention should be paid to the stitch distance, the distance of the suture from the incision edge and the tightness of the suture.
8, suture the abdominal wall: (1) To clean the abdominal cavity, check for active bleeding, count the gauze and instruments. (2) Suture the dirty and mural peritoneum as appropriate. (3) Continuous or interrupted suturing of fascial tissue. (4) Suture subcutaneous tissues as appropriate. (5) Interrupted or continuous intradermal sutures to the skin.
9. Management of the newborn: umbilical cord weaning, warmth, airway cleaning and other routine treatments.
Postoperative management of cesarean section
1.Routine postoperative monitoring items.
Vital signs monitoring: postoperative
Monitor heart rate, respiratory rate and blood pressure once every 30 minutes in the postoperative period, and once every hour thereafter until the maternal condition is stable. If the vital signs are not stable, the number and duration of monitoring should be increased. For women with epidural block analgesia pump, respiratory rate, sedation and pain score should be monitored every hour until 2 h after discontinuation of the drug.
Contractions and bleeding: 15 min, 30 min, 60 min, 90 min, postoperatively
The uterine contractions and vaginal bleeding should be monitored, and the number of monitoring should be increased if there is more bleeding, and blood routine, urine routine, coagulation function and liver and kidney function should be monitored if necessary until the bleeding is stabilized at normal condition.
2. Prevention of thrombosis: Prevention of deep vein thrombosis is something that must be paid attention to. The risk of maternal deep vein thrombosis increases after cesarean section, so preventive measures are recommended. Encourage early bedtime activities. Measures such as wearing elastic stockings, prophylactic application of intermittent inflatable devices, hydration and subcutaneous injection of low molecular heparin can be selected individually according to the presence or absence of maternal risk factors for thrombosis.
3. Timing of feeding and water intake: The timing of maternal feeding and water intake should be arranged according to the anesthesia mode as appropriate.
4. Timing of urinary catheter removal: Remove the indwelling catheter as appropriate on the next day after cesarean section.
5.Management of postoperative incisional pain: postoperative analgesic pump containing opioid analgesic drugs can relieve postoperative incisional pain after cesarean section.
6.Application of postoperative contractin: postoperative contractin is routinely applied.
Review of blood and urine routine: Routine review of blood routine and urine routine as appropriate.
7.Discharge criteria.
Good general condition and normal body temperature.
Basic normal blood and urine routine.
Good healing of incision.
Good uterine regeneration and normal malignant dew.
VII. Measures to reduce cesarean section
1. Pregnancy education: understand the advantages and disadvantages of vaginal delivery and cesarean section, the process of delivery and precautions, simulate delivery before delivery, enhance the confidence of pregnant women in natural delivery, which can reduce CDMR.
2.Humanized care measures during labor: guided accompaniment with continuous support may reduce the cesarean delivery rate.
3, timing of labor induction: pregnant women without pregnancy complications up to 4’1 weeks of pregnancy should be given induction of labor treatment, which is conducive to reducing perinatal mortality and cesarean delivery rate.
4, labor analgesia: it can reduce labor pain and enhance the confidence of vaginal delivery.