Old and new opportunities in optimization of the elective caesarean section (literature review)

This literature review examines the history of caesarean section, as well as the benefits of innovative “natural” caesarean section, which reduce maternal/perinatal morbidity and mortality, early skin-to-skin contact of the mother and newborn, and reviews of foreign authors providing modern data of perinatal outcomes in the modification of elective caesarean section.

“Natural” caesarean section includes elements based on evidence-based medicine of vaginal births, improves the conditions for fetal extraction, quick adaptation of the newborn and early breastfeeding, reduction of birth trauma, postpartum purulent-septic diseases, obstetric hemorrhage and positive effects on psycho-emotional mother's status. There are several terms for this delivery method: natural, slow, gentle, inartificial caesarean section.

Reducing maternal and perinatal morbidity/mortality is currently one of the main tasks of obstetrics. The solution to this problem is connected with the development of rational tactics for the management of pregnant women with various obstetric and perinatal pathologies and the optimization of labor management. A caesarean section is an operation of artificial delivery, when the fetus and afterbirth are removed through an incision of the anterior abdominal wall and uterus. A caesarean section is performed with a live fetus and there are contraindications for a woman for an independent birth and/or to save the mother's life for non-viable fetus and obstetric hemorrhage [1,2].

Previously, the name of the operation caesarean section was mistakenly associated with the legend of the birth of Gaius Julius Caesar. According to literary data, for the first time a caesarean section was performed in the V-VI centuries BC in Ancient Egypt, Mesopotamia, and also ancient Greece. However, this procedure did not set as its goal to save the life of the mother and fetus, since only dead pregnant women were operated on [1].

Rousset (1581) described the corporative caesarean section technique with a side incision of the abdomen and uterus, where uterine closure was not recommended. The results were unsuccessful and in the XVII-XVIII centuries the “anti-caesarean society” was created [1,2].

The first reliably successful caesarean section was performed by the surgeon I.Trautmann (1610). The newborn was taken alive, the postpartum woman died after 4 weeks for a reason not related to the operation [1].

In Russia, the first caesarean section was performed by I. Erasmus (1756) [1,4].

1. Labas (1769) first imposed silk sutures on the uterus during a caesarean section, but the result was unsatisfactory [1].

C. Jory (1806), N. Ritgen (1821) developed a method of extraperitoneal access to the uterus to reduce infection of the abdominal cavity during caesarean section. However, due to unsatisfactory results and due to frequent wounds of the bladder, ureters and heavy bleeding, this method of delivery was temporarily abandoned.

1. I. Stolz (1874), for the first time in Russia, performed a caesarean section with suturing a wound on the uterus, A.E. Schmidt (1883) defended his thesis on the topic “Clinical and experimental research on the uterine suture” [1].
2. E. Rhein (Russia, 1876) and E. Porro (Italy), independently of each other, suggested removing the uterus body after fetal extraction in order to prevent bleeding and infection, which led to a decrease in postoperative mortality to 24.8% [1].
3. Kehrer (1881) made a caesarean section and applied a threerow suture [1].

M. Sanger (1882) theoretically substantiated the classic caesarean section technique with suturing wounds in the uterus. A great contribution to the development of this technology was made by Fritsch and Mueller, which led to a decrease in postoperative mortality to 7% [1,4].

Kronig (1912) and B. Selhei (1928) suggested a retro-vesicular caesarean section with a longitudinal incision in the lower segment of the uterus [4,6].

Caesarean section, as a complete method of delivery, first entered obstetric practice in 1916; however, due to frequent and severe maternal complications, this method of delivery was used as an extreme measure only in a clinically narrow pelvis [1,5].

1. J.B. DeLee, E.L. Cornell (1922), Mr. H. Doerfler (1929) proposed a procedure for the operation of caesarean section in the lower segment by a cross-section [1.6].
2. A. Gusakov and P.V. Zanchenko (1939) improved the technique of caesarean section in the lower segment by a cross-section [1,5].
3. Kaboth (1934), E.G. Waters (1940), J.F. Norton (1946) again attracted the attention of obstetrician-gynecologists to extraperitoneal caesarean section. In Russia, extraperitoneal cesarean section was performed by E.G. Kahn (1909), L.G. Lichkus (1910), D.D. Popov (1912) [1].

Despite the dramatic improvement in caesarean section by the beginning of the twentieth century, postoperative mortality still remained high. The next stage in the development of the history of caesarean section was marked by the development and improvement of the methods of intraperitoneal, retrovesical caesarean section, methods of blood transfusion and pain relief, antibacterial drugs, which led to more favorable outcomes for the mother and fetus. Mortality from septic complications in many obstetric institutions was an exception, the causes of postoperative mortality were associated with the pathology that led to the abdominal delivery [1].

Currently, caesarean section is mainly performed using crossaxillary suture according to J. Pfannenstiel (1887), Joel-Cohen (1972) or a lower median incision. Transverse incisions began to be introduced into obstetric and gynecological practice at the turn of the XIX-XX centuries after a decrease in the incidence of postoperative hernia was noted when using suprapubic incisions. Most researchers consider it expedient to carry out Pfannenstiel laparotomy [1, 16]. The incision of J. Joel-Cohen differs from the incision of Pfannenstiel in a higher level, it is straight and not arcuate, no aponeurosis is detached, the peritoneum is opened in the transverse direction. However, the Joel-Cohen incision loses in cosmetic terms compared to the Pfannenstiel incision.

As M. Stark's (1994) research has shown, this access is performed quickly, is almost not accompanied by bleeding and creates adequate conditions for performing a caesarean section [1]. The principled approach of peritoneal non-stitching at caesarean section was further developed in the works of D. Hull (1991) and M. Stark (1995).

Currently, there are many supporters of caesarean section in the lower uterus segment in the modification of M. Stark (1994), which recommends: dissection of the anterior abdominal wall using the JoelCohen method, after opening the peritoneum dissect the vesico-uterine fold without displacing the bladder, dissect the lower segment of the uterus in the transverse direction, remove the uterus from the abdominal cavity after removing the fetus and removing the afterbirth.

The wound on the uterus is repaired with a single row continuous vicryl suture using the method of J.L. Reverdin. Peritoneal suture on the uterus is not produced. The peritoneum and muscles of the anterior abdominal wall are not sutured, a continuous vicryl suture is applied to the aponeurosis according to J.L. Reverdin. The authors applying this method indicate a decrease in the time of the operation, the amount of blood loss and the severity of postoperative pain syndrome [16].

Subsequently, classical obstetrics became more and more perinatal. Improved methods of caesarean section, anesthesia, suture material, the principles of management of women in pregnancy, childbirth and the puerperal period after a cesarean section. This is facilitated by the development and improvement of obstetric science, anesthesiology, resuscitation, neonatology, the introduction of the principles of "safe motherhood" [5].

According to WHO (1985), at the national level of states, a caesarean section rate of 10-15% is the optimal indicator, provided maternal and neonatal mortality is reduced [5]. However, if the caesarean section rate exceeds 10%, then the current data do not indicate an improvement in mortality rates [5].

According to the WHO, in economically developed countries, the caesarean section rate is close to 25-30% and is accompanied by a decrease in maternal and perinatal mortality, which is one of the criteria for the validity of the growth of its frequency [5].

In the Republic of Kazakhstan, the caesarean section rate varies from 12 to 27% depending on the level of obstetric hospital according to the regionalization of perinatal care [8].

In the Russian Federation over the past 10 years identified the correlation between the increase in the caesarean section rate and the decrease in perinatal mortality from 18.7%, to 14.2%o, although this indicator is high. [5].

According to the national statistics of the United States, over the past 15 years, the caesarean section rate has stabilized at a level of 21-22%, perinatal mortality has decreased from 13.2% to 8.7% [5].

Among the poorest segments of the population in African countries, childbirth by caesarean section does not exceed 2% [4].

According to some authors, the high level of caesarean section is not an absolute indicator of the availability and quality of medical care [5,9].

In view of the progressive development of operative obstetrics, an alternative to the classical caesarean section has emerged “slow”/“natural” caesarean section.

According to official statistics, in the UK, the caesarean section rate is 20-25%. The “slow” caesarean section was first performed more than 17 years ago at the Queen Charlotte's and Chelsea Hospital of the Imperial University in London [10].

To date, there are many studies on the study of this method of operative delivery. At the “Euroanaesthesiacongress” congress (Geneva, 2016), experts argued that the stages of adaptation of a newborn after a “slow” caesarean section, in which the woman is given the opportunity of extended contact with the child, are similar to the stages after natural childbirth. However, this technique is recommended only if there are indications for operative delivery. So, in the future there may be a question about the alternative of a “slow” caesarean section to natural childbirth. In this case, there will be an increase in operative delivery, which may adversely affect maternal morbidity [8].

Plaat, J. Smith, N. Fisk (2008) described the technique and steps of the “slow” caesarean section. The first stage of the “slow” caesarean section operation is identical to the classical caesarean section before the incision in the uterus and the removal of the head to the surface. At the time of removal of the head of the fetus in the wound, the screen is lowered, the head end of the woman in labor is lifted to ensure the possibility of observation and participation in the process of childbirth. After removing the head, a pause of 3 to 5 minutes is maintained to allow the fetus to adapt to the environment, the fetal body remains in utero, still attached to the placental circulation, which imitates the process of vaginal delivery. According to the biomechanism of labor, the head is rotated to the side, the surgeon releases the hanger and subsequently transfers the newborn mother, which allows for early skin-to-skin contact.

“Slow” caesarean section includes elements based on evidencebased medicine of vaginal births, which contribute to the rapid adaptation of the fetus, early adhesion to the breast and the satisfaction of the mother, which is not seen in the classical caesarean section [7, 11].

A survey conducted in the UK by the Obstetric Anesthetists' Association (2010) showed that only 2.5% of postpartum women were offered a “slow” caesarean section, and in 55% of cases one or more elements of this technique were suggested. Nearly half of the respondents were aware of the “slow” caesarean section operation [13].

Initially, a “slow” caesarean section was proposed only to women with a physiological pregnancy, only in a planned manner, due to the incorrect position of the fetus, a caesarean section in history and other obstetric indications, which accounted for about 3035% of all caesarean sections.

According to the position of the National Institute of Health and Maternity Protection in the UK, it is believed that if a pregnant woman is fully informed and consulted about the risks and complications of a caesarean section, provides informed consent, then a caesarean section without testimony is not prohibited, because they believe that the refusal may have a negative impact on the mental health of pregnant women and potentially lead to the long-term need for postnatal psychological support [13].

A comparative study of the classical and "natural" caesarean section in the UK showed that during the "natural" caesarean section, the duration of the operation exceeded the classical caesarean section by 4 minutes 42 seconds. However, recovery after the “natural” caesarean section was much faster, infectious complications were 61% less frequent than with the classical one. Newborns after surgery of “slow” caesarean section were admitted to intensive care units less frequently than after classical caesarean section [14,15].

According to a number of specialists, this caesarean section technique carries with it less risks for the newborn than the classical one. Children born with the classical caesarean section are more likely to suffer from cardiovascular maladaptation syndrome, impaired formation of effective pulmonary ventilation due to rapid removal from the uterus.

At delivery by the operation of “natural” caesarean section, newborns adapt better due to the tested “catecholamine surge” characteristic of newborns during natural vaginal delivery. In addition, the participation of the woman in labor with the “natural” caesarean section and the visualization of the newborn from the first seconds of his life causes her positive emotions, which is impossible with the operation of the classical caesarean section. In women in labor who have undergone a “natural” caesarean section, there are fewer postpartum complications [14,15].

To date, a randomized, controlled study has been conducted at the Charite Clinic (Berlin, 2000), where the results of the classical and “natural” caesarean section are compared. The study showed that the “natural” caesarean section improves a number of breastfeeding indicators, reduces the incidence of complications in the mother and newborn, and increases satisfaction with the outcome of labor [12].

Also, colleagues from America conducted a meta-analysis of articles from the Cochrane Database of Systematic Reviews. 46 studies were included with 3,850 women and their children; 38 studies with 3472 women and babies provided data for analysis. Tests were conducted in 21 countries. All babies born by the “gentle” caesarean section were healthy, and most of them were full-term. Women from the first group with early skin-to-skin contact were more prone to breastfeeding than women with standard contact. Women from the first group breastfed their children longer.

The obtained data prove the use of early contact “skin to skin” of mother and newborn allows to improve a number of breastfeeding indicators [23].

For the first time, the “natural” caesarean section in the Republic of Kazakhstan was conducted by the Department of Obstetrics and Gynecology No. 1 of the Kazakh National Medical University named after S. Asfendiyarov on 14.06.2016 on the basis of the city clinical hospital No. 1 in Almaty.

Thus, in recent years, the frequency and structure of operative delivery has changed, the technique of caesarean section has been optimized. The possibilities of “natural” caesarean section include elements based on evidence-based medicine of vaginal births, improve the conditions for fetal extraction, early breastfeeding, quick adaptation of the newborn, reduction of birth injury, postpartum purulent-septic diseases, obstetric hemorrhage and positive effects on psycho-emotional status of the mother, which is not observed in the operation of the classical caesarean section.

Analysis of the literature shows that researches on the effectiveness of "natural" caesarean section are often fragmented. It remains relevant to study the effect of "natural" caesarean section on the frequency of perinatal / postnatal complications in the mother and newborn / infant, the development of lactation of breastfeeding, as well as on the quality of life of women in labor and their satisfaction with the outcome of labor.

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24. URL: https://www.ncbi.nlm.nih.gov/pubmed/22592691