II-199
TEHNIKA CARSKEGA REZA PRI PLODOVIH
Z IZJEMNO NIZKO PORODNO TEŽO
TECHNIQUE OF CESAREAN SECTION IN EXTREMELY LOW BIRTH WEIGHT INFANTS
Andreja Štolfa-Gruntar1, Živa Novak-Antolič2, Ivan Verdenik3
1 Klinični oddelek za ginekologijo, Ginekološka klinika, Klinični center, Šlajmerjeva 3, 1525 Ljubljana
2 Klinični oddelek za perinatologijo, Ginekološka klinika, Klinični center, Šlajmerjeva 3, 1525 Ljubljana
3 Služba za raziskovanje, Ginekološka klinika, Klinični center, Šlajmerjeva 3, 1525 Ljubljana
Key words: cesarean section technique; transport in utero;
extremely low birth weight
Abstract – Background. The Department of Perinatology in
Ljubljana is a third level perinatal centre. Since the introduc-
tion of transport in utero (TIU) in Slovenia in 1984, two thirds
of Slovene extremely low birth weight infants are delivered in
Ljubljana, where pregnant women with suspected preterm de-
livery are transferred from other maternity units. As TIU is
well established, postnatal transport of extremely low birth
weight infants from other maternity units to Neonatal Inten-
sive Care Unit in Ljubljana became an exception.
Material and methods. By means of the National Perinatal
Information System of Slovenia it was found that 816 infants
weighting less than 1000 g were born in Slovenia from 1. 1.
1990 to 31. 12. 1999, among whom 144 (17.6%) by a ce-
sarean section. We made a survey among 20 gynecologists at
the Department of Perinatology in Ljubljana on the technique
they apply in a cesarean section with extremely low birth we-
ight infants, and reviewed the labour records of extremely
low birth weight infants, delivered by a cesarean section in
the Department of Perinatology in Ljubljana from 1. 1. 1990
to 31. 12. 1999.
Results. Due to TIU, 529 (64,8%) out of the 816 extremely low
birth weight infants were born at the Department of Perina-
tology in Ljubljana, 113 (21.4%) of them by a cesarean secti-
on. In 42% of cases cesarean section was performed after a
spontaneous onset of labour because of fetal distress, in 4% it
was performed in induced labours, and 54% were elective
cesarean sections (the leading two indications being pre-
eclampsia and IUGR). With a planned cesarean section in
extremely low birth weight infants the preoperative evalua-
tion of fetal condition and an ultrasound examination deter-
mining the position of the fetus and the placenta are of
utmost importance in order to perform a cesarean section
with the minimal trauma to the infant (the most frequent are
injuries of skin and muscles, neural plexus injuries, bone frac-
tures and intracerebral hemorrhage), and the minimal mor-
bidity of the mother. Cesarean section does not entirely solve
the problem of delivery because of thick lower segment of the
uterus, frequent malposition of the fetus and frequently diffi-
cult extraction of the tiny little malpositioned fetus with head
circumference much greater than abdominal circumference.
Conclusions. The key steps in the technique of a cesarean sec-
tion in extremely low birth weight infants are the following:
larger laparotomic incision in order to have enough place
for a gentle extraction of the fetus, incision of fascia above
the skin incision, miometrial incision in the upper part of
lower uterine segment, with the J-extension if needed, fetal
extraction »en caul«, i.e.delivery of the intact gestational sac
together with unruptured membranes and the placenta.
POSTERJI
Ključne besede: tehnika carskega reza; transport in utero;
izjemno nizka porodna teža
Izvleček – Izhodišča. Porodnišnica Ljubljana je perinatalni
center tretje ravni. Od leta 1984 dalje, ko je bil v Sloveniji
uveden transport in utero (TIU), se dve tretjini slovenskih plo-
dov z izjemno nizko porodno težo rodi v porodnišnici Ljub-
ljana, kamor ob sumu na prezgodnji porod premestijo nosečni-
ce iz drugih porodnišnic. Ob dobro uveljavljenem TIU je pre-
voz otrok z izjemno nizko porodno težo (tj. po rojstvu) iz dru-
gih porodnišnic na oddelek za intenzivno nego in terapijo
novorojenčkov postal izjema.
Material in metode. Po podatkih Nacionalnega perinatalne-
ga informacijskega sistema Slovenije se je v Sloveniji od 1. 1.
1990 do 31. 12. 1999 rodilo 816 plodov s porodno težo pod
1000 gramov, med temi 144 (17,6%) s carskim rezom. V raz-
iskavi smo anketirali 20 ginekologov v porodnišnici Ljublja-
na o tem, kako izvajajo carske reze pri plodu z izjemno nizko
porodno težo, in pregledali popise porodov ploda z izjemno
nizko porodno težo s carskim rezom v porodnišnici Ljublja-
na od 1. 1. 1990 do 31. 12. 1999.
Rezultati. Ker je TIU dobro uveljavljen, se je v porodnišnici
Ljubljana rodilo 529 (64,8%) od teh 816 plodov z izjemno
nizko porodno težo, od tega 113 (21,4%) s carskim rezom.
Pri 42% carskih rezov je šlo za dokončanje poroda pri spon-
tano začetem porodu zaradi fetalnega distresa, 4% je bilo s
carskim rezom končanih induciranih porodov, 54% prime-
rov pa je bilo elektivnih carskih rezov (vodilni indikaciji pre-
eklampsija in IUGR). Pri načrtovanju carskega reza pri plo-
du z izjemno nizko porodno težo je bistveno, da pred opera-
tivnim posegom ocenimo plodovo stanje in z mislijo na izved-
bo carskega reza naredimo ultrazvočni pregled, pri katerem
ocenimo položaj ploda in posteljice, zato da poteka operacija
čim nežneje za plod (najpogostejše so poškodbe kože in mi-
šičja, živčnih pletežev, zlomi kosti in možganske krvavitve)
in da je obolevnost mater po carskem rezu čim manjša. Car-
ski rez ne reši popolnoma problema travme pri porodu, ker je
spodnji segment uterusa debel, ker je vstava ploda pogosto
nepravilna in je ekstrakcija drobnega ploda z večjim obse-
gom glavice kot trebuha v nepravilni vstavi pogosto težka.
Zaključki. Bistvene razlike pri tehniki carskega reza pri plo-
du z izjemno nizko porodno težo so: večja laparotomija, da
pridobimo dovolj prostora za nežno ekstrakcijo ploda, incizi-
ja fascije nad incizijo kože, incizija miometrija v zgornjem
delu spodnjega segmenta uterusa, po potrebi podaljšana v
obliki črke J lateralno navzgor, to je ekstrakcija ploda z in-
taktnimi ovoji skupaj s posteljico (tj. en caul).