Cesarean section or C-section is a surgical method of delivering a baby. A cut is made across the belly just above the pubic area. A horizontal incision is made in the lower uterine portion. LSCS - Lower segment Cesarean section is the preferred type of Cesarean surgery today as it allows the uterus to remain strong for future childbirth. The uterus is opened along with the amniotic sac and the baby is delivered. This is resorted to when a vaginal delivery is not possible; either because of risk to the mother or baby. Typical cases where Cesarean section is opted for are fetal distress, breech baby, uterine rupture, prolonged labor, hypertension in mother, tachycardia in mother or child or contracted pelvis. In cases of twin pregnancy or triplets, Cesarean section is opted. When the baby's heart rate is abnormally high or the baby has developmental problems, the obstetrician might suggest a c-section. But being a surgical procedure, Cesarean section carries some amount of risk. There can be chances of hemorrhage leading to anemia or need for blood transfusion. There is risk of infection at incision site or injury to other organs. The recovery time is longer than a normal vaginal delivery.
Fetal surgery refers to the surgical treatment of the developing baby in the womb to rectify congenital defects. Surgery of the fetus is performed to fix the prenatally diagnosed anomalies. However fetal surgery is a complicated procedure and comes with lot of risks to both mother and the baby. Yet, doctors recommend fetal surgery, if the risks associated with continuing the pregnancy, without surgical intervention, outweighs the risks that come with fetal surgery. Certain abnormalities, if left to progress in the womb, may turn fatal and infant may die soon after the birth. However fetal intervention is initiated only after taking the safety of the mother into consideration. The common risks that are associated with fetal surgery are premature delivery, infection of the uterus, leaking of amniotic fluid through the membrane, potential infertility and the risk of anesthesia.
There are various techniques followed to diagnose fetal anomalies. The diagnostic method can be non invasive such as ultrasound, fetal echocardiography, MRI, Radiography, Measuring MSAFP (maternal serum alpha-fetoprotein) and Measuring maternal serum beta-human chorionic gonadotropin (HCG) or invasive procedure such as amniocentesis, Chorionic villus sampling and Percutaneous umbilical blood sampling (PUBS) are used to detect the birth defects.
Types of Fetal Surgery
Depending on the incision level, fetal surgery is classified into three types.
Open Fetal Surgery
Open fetal surgery is almost similar to cesarean section and involves a total opening of the uterus. In this type of surgery, a long incision is made in the mother's abdomen and then on the uterus to reach the fetes. Once the surgical correction is performed on the fetus to treat the birth defect, the uterus and abdominal is closed back leaving the fetus intact. Open fetal surgery is performed under general anesthesia. Surgery is performed using special instruments containing staples to prevent bleeding from uterus. During the operation, warm saline water is infused to maintain the position of placenta and umbilical cord and surgeon will keep a vigil on the pulse and heart rate of the baby with the help of the oximeter. After the surgery, the mother is hospitalized for close to a week to facilitate close monitoring. One should remember that, with open fetal surgery, mother will forgo the option of vaginal delivery for the present and future deliveries. She can deliver the baby only through C-section. She may be given some medication to avoid pre term labor. Open fetal surgery is followed for the conditions like chest mass, neck mass, spinbifida, myelomeningocele and Sacrococcygeal teratoma (SCT) (a tumor at the base of the child's tail bone).
There is one more variation to the open fetal surgery called the EXIT (Ex Utero Intrapartum Treatment) Procedure. EXIT surgery is performed at the end of the full term and just before the delivery. In this method the baby is partially delivered by bringing out only a part of the fetes from uterus and keeping rest of the fetes attached to placenta and umbilical cord to allow blood circulation. Once the defect is rectified, the baby is delivered fully. Exit procedure is essentially followed to correct the airway blockage in the baby.
Fetoscopic surgery is minimally invasive and unlike open fetal surgery, fetes remains inside the uterus while operating. Surgeon uses special instruments such as laser and makes a small incision with the help of the fetoscope to correct the birth defects. Fetoscopic surgery has shown high success rate in conditions such as Twin-Twin Transfusion Syndrome (TTTS), Twin Reversed Arterial Perfusion (TRAP), Amniotic band syndrome, and Tracheal occlusion for CDH. Fetoscopic surgery does not pose a risk of pre term labor and also eliminates most of the risks associated with open fetal surgery. This is essentially why fetoscopic surgery is the preferred choice, yet one should note that few complicated birth defects can be corrected only through open fetal surgery.
Fetal image guided surgery
Fetal image guided surgery is the least invasive of all wherein surgery is performed with the guidance of images of fetus produced on the external screen by ultrasound. Very thin instruments are inserted through a small opening in the abdomen and the correction is made without any endoscopic view and the whole procedure is guided by the sonogram images.
Various congenital conditions treated through fetal intervention
Congenital diaphragmatic hernia (CDH): Congenital diaphragmatic hernia (CDH) refers to the opening in the diaphragm through which the contents of the abdomen enter the chest cavity leaving no space for the lungs to develop properly. This is a serious condition and may lead to respiratory failure after birth. This condition, depending upon its severity, is treated through fetal intervention.
Spina bifida: Spina bifida refers to a condition wherein spinal column of the baby does not close properly around the spinal cord and the nerves start to protrude through the opening. Spina bifida can range from mild to severe form, and the severe cases lead to serious neurological problems after the birth. Only the severe form of spina bifida like Meningocele and Myelomeningocele call for fetal intervention through open fetal surgery.
Neck masses: Neck masses are the tumors of the neck that may obstruct the airway and esophagus of the child and also increase the level of amniotic fluid surrounding the baby. Typically, tumors of any kind are treated after birth. In rare cases they grow very large and may even cause heart failure. In such cases fetal intervention becomes necessary to remove the tumors.
Lung lesions: Lung lesions refer to the abnormal growth of lung tissue and these lesions can be cystic (fluid filled) or solid. There are various types of lung lesions and treatment depends upon their size and location. During pregnancy, continuous monitoring is necessary to keep vigil on the size of the lesion. Most often lung lesions shrink and make way for normal development. Lesions of smaller and moderate size are best treated after delivery. But if the size of the lung tumor is abnormally huge and poses a risk of hydrops (excess accumulation of fluid in the fetus) fetal intervention is initiated. Cystic lesions are normally removed through needle aspiration under the constant guidance of ultrasound images, but solid lesions require more elaborate procedure such as EXIT.
Congenital heart diseases: Not all congenital heart defects call for fetal intervention. Sometimes the septum (wall separating the right and left side of the heart) of the heart develops a hole while in the womb. However septum defects are typically treated after the birth of the child and rarely require fetal surgery. But if the heart develops severe obstructive cardiac disorders such as aortic stenosis, pulmonary stenosis and coarctation of the aorta,a fetal image-guided procedure may be necessary to open or enlarge the narrowed valve. This procedure involves placing a balloon catheter by inserting it through the uterus and into the fetal’s heart.
Amniotic Band Syndrome: This is a condition where fetus is entrapped in fibrous amniotic bands in the womb, restricting blood flow to the affected portion of the fetes. It normally affects legs, arms, toes and fingers. In utero surgery may be performed to rectify the condition if there is risk of amputation of the limb after the birth.
Twin-to-twin transfusion syndrome (TTTS): TTTS is a condition that occurs in identical twins wherein unbalanced exchange of blood takes place between the twins. One receives higher amount of blood whereas the other receives less amount. The fetus with less blood supply may become anemic and the one with excess blood supply may suffer heart failure due to excess fluid. Fetal surgery through laser fetal intervention is the preferred option to correct the condition. This procedure involves inserting a laser along with small telescope into the uterus and separating the blood vessels on the placenta that are connected to both twins.
Congenital high airway obstruction syndrome (CHAOS): Congenital high airway obstruction syndrome (CHAOS) refers to the blocking of fetal airway resulting in enlarged lungs, windpipe and bronchial tube. A complete or near to complete blockage may lead to a heart failure. Though congenital high airway obstruction syndrome (CHAOS) is treated after birth, in severe cases where fetes is at high risk such as hydrops, fetal surgery is performed.
By 8 months, the baby in the womb positions itself as it does not have much place to move about. Most babies position themselves head-down otherwise known as cephalic position during this time. In very few cases the baby positions itself feet-down or in breech presentation.
By the beginning of the third trimester, the medical practitioner will physically feel the mother's abdomen and will be able to tell the positioning of the baby. This is usually done using Leopold's maneuver. Location of the heart beat, position of the baby's bottom and head helps the doctor determine the position of the baby. About 25% babies are positioned breech during this time but they turn to normal position on their own within the next couple of months.
When the mother is approaching full term and the baby is still positioned breech, the medical practitioner may conduct a pelvic examination or an ultrasound to confirm the positioning of the baby. At 37 weeks about 3-4% babies are in breech position. Even after 37 weeks if the baby is presenting breech position then it might not turn on its own to the cephalic position. In general breech babies are delivered through a cesarean section. Generally normal delivery is not advised for a breech position baby when:
Frank breech: Bottom first with feet up near the head (feet straight up).
Complete breech: Bottom first with legs crossed in Indian style.
Footling breech (incomplete breech: One or both feet are positioned to come out first.
Stargazers: When the baby is in any one of the above mentioned positions but is extending its neck completely as though it is watching a star it is called as stargazer. Babies positioned like this are usually delivered using c-section.
Helping baby from breech to cephalic
ECV: External Cephalic Version is a procedure wherein pressure is applied to the mother's abdomen for manual manipulation of the baby's position. The pressure helps the baby take a head-down position. ECV has its own limitations and many a times the baby moves back to the breech position. Women with pregnancy complications like low amniotic acid, bleeding and twins cannot undergo this procedure.
Tilt position: The Breech Tilt inversion technique is used to help a breech baby flip to a head-down position. The mother is asked to lie on a couch placing her feet up on an ironing board. The head is positioned down while the feet are placed up. 20 minutes a day is the recommended duration. This exercise needs to be done only after approval from the authorized medical personnel or midwife.
Chances of having a breech baby
A mother who has had one or more of the following conditions may have a breech baby: multiple pregnancies, excessive amniotic fluid, baby having anomalies, placenta lying low, uterus anomalies and Placenta previa.
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Bibliography / Reference
Collection of Pages - Last revised Date: June 17, 2019