External obstetric rotation of the fetus. External obstetric rotation in breech presentation: what to discuss with your doctor. Timing of external obstetric rotation

03.11.2019

About 6% of pregnant women during the next ultrasound hear an alarming conclusion - "breech presentation". It is obvious to everyone that nature has provided for the crumbs in the womb a more natural position of the body - head down. Head forward it is easier to move along the birth canal, to be born into this world, it is the head presentation that does not threaten complications.

But what about those who have kids who decide to settle down differently? Is breech presentation always an indication for a caesarean section? Why is it dangerous and is it possible to force a child to change the position of the body? We will try to answer all these questions as fully as possible in this material.

What it is?

Breech presentation is called the abnormal location of the fetus in the uterine cavity, in which not the head of the fetus, but the priest or lower limbs, is facing the exit to the pelvic area. The head is located at the bottom of the uterus. The baby is actually sitting.

Breech presentation refers to the pathological conditions of pregnancy, childbirth during it is also considered pathological. There is nothing natural in this arrangement of the fetus. However, about 4-6% of all pregnancies occur against the background of a breech presentation of the fetus.

For obstetricians, each such case is a real test of professionalism. Pregnancy management in the pelvic location of the baby, as well as childbirth in this location of the crumbs, require a lot of experience and knowledge from the medical staff.

In modern obstetrics, more and more often they offer a woman whose baby is located booty down to do a caesarean section. But you should know that there is an alternative to the operation - natural childbirth. With a breech presentation, the risks of complications in childbirth are higher, but an experienced and well-trained doctor may well conduct the birth process successfully. The baby will be born, of course, legs forward.

Kinds

The concept of "breech presentation" is wider than it seems to expectant mothers. It is not enough for an experienced doctor to know where the baby's head is, he needs to clarify which part of the lower half of the baby's body is located in relation to the small pelvis. Therefore, all breech presentations have a fairly clear and understandable classification.

Gluteal

The buttocks are adjacent to the exit from the small pelvis in this position of the baby. The breech presentation may be incomplete, while only the buttocks are adjacent to the exit from the uterus, and the legs are bent at the hip joints and extended along the body so that the heels are at the very face of the child. Also, the breech presentation can be mixed (combined) or complete, in which the butt fits along with the legs, the baby seems to be squatting.

Incomplete (exclusively breech presentation) occurs in 75% of cases of all breech presentations. Every fifth case refers to a complete or combined (mixed) breech presentation.

foot

This concept means the location of the legs of the fetus towards the exit from the uterus. Foot presentation is much less common than breech presentation. In the full foot position, both legs are adjacent to the exit to the small pelvis, slightly bent at the knees. But such a picture is rather rare. Usually there is an incomplete foot presentation, in which one leg is pressed against the exit from the uterus, and the other is bent at the knee and hip joint and is significantly higher in level than the first.

There are also such resourceful kids who are located at the exit to the small pelvis with their knees. This is also a variant of foot presentation - knee. With it, the baby does not bend the legs at the hip joint, but bends them at the knee joints, it looks as if the baby is kneeling in the mother's womb and both knees are pressed to the exit to the small pelvis.

Foot presentation options are considered the most dangerous in terms of the development of complications during childbirth.

Dangers and risks

Breech presentation in childbirth is dangerous for the development of severe complications. The waters can pour out prematurely, along with them the prolapse of the umbilical cord, its parts and even parts of the body of the fetus is not excluded. Often, women develop weakness of the birth forces, when contractions do not lead to the opening of the cervix. Often, the birth of a child with the pelvis and legs forward leads to acute hypoxia, the death of the baby, and irreversible changes in its central nervous system.

During childbirth, the baby can throw back the arms, chin. The latter is most dangerous by the development of a disabling birth injury associated with fractures, displacement of the cervical vertebrae, brain and spinal cord. For the mother, such childbirth is dangerous with ruptures of the cervix, vagina, and the occurrence of severe bleeding.

For a child, the consequences of breech presentation can be quite unpleasant - this is a congenital dislocation of the hip, pathologies of the gastrointestinal tract, kidneys and urinary system, trauma, development of cerebral palsy.

However, dangers lurk not only in childbirth, but also during pregnancy. In the first half of the gestation period, the breech presentation of the fetus increases the likelihood of miscarriage, hypoxia, and the risks of developing early preeclampsia are also considered elevated. In the second half of pregnancy, a woman whose baby is head up is threatened with premature birth, preeclampsia, including severe, premature placental abruption.

Women with breech presentation of the fetus have a 60% increased risk of developing placental insufficiency and subsequent fetal hypotrophy. In a state of lack of nutrients, vitamins and oxygen, the baby's nervous and digestive systems do not develop well and quickly, there are problems with the endocrine system and the work of the heart and blood vessels.

From the 34-35th week of pregnancy, if the child does not roll over into the head position, the rate of development of the structures of the medulla oblongata slows down, which leads to disruption of the pituitary gland, the adrenal cortex. Negative changes in a child who occupies an incorrect position in space also occur in the genital area - edema and hemorrhage occur, subsequently the girl may develop exhausted ovary syndrome, and the boy may have oligozoospermia or azoospermia. Among children with congenital heart defects, there are many who spent all nine months head up and booty down.

Among congenital cases of pathologies of the musculoskeletal system, about 40% are due to such a cause as breech presentation of the fetus during pregnancy.

The reasons

Physicians and scientists do not fully understand the mechanisms for the development of pathology, it is rather difficult to explain why a baby, who is supposed to be head down by nature, occupies a different position, which is not convenient for him or his mother. Therefore, it is not customary to talk about the reasons as such, rather, we are talking about the prerequisites for breech presentation. And they can be very different.

Pathologies of the uterus and pelvis

This premise is considered the most common. Tumors, uterine fibroids, a narrow pelvis, as well as the presence of postoperative scars on the uterus can prevent the baby from taking the correct head position. Quite often, the prerequisites are the anatomical features of a particular woman - a bicornuate or saddle uterus. The increased tone of the uterine muscles also creates a risk that the baby will take the wrong position of the body.

Often, women who have given birth many times face breech presentation - from the uterine muscles are weakened, "stretched", it cannot provide reliable fixation of the fetus. Often with a breech presentation of a baby, women who have had many abortions before are often subjected to curettage of the uterine cavity. The baby instinctively tries to take a position in which his head will be in that part of the uterus, where spasms occur less frequently. For women who have had several abortions, such a section is the fundus of the uterus. Its lower segment is tense.

Fetal pathologies

Quite often in the breech presentation there are children who have gross chromosomal anomalies and malformations. So, according to statistics, up to 90% of babies with microcephaly (reduced brain volume), anencephaly (absence of the brain) and hydrocephalus (hydrocephalus) in the mother's womb are head up.

Breech presentation is often characteristic of one of the twins if the pregnancy is multiple, in which case the position of the child in the uterus may not be associated with any of its pathologies.

Sometimes the incorrect position of the body relative to the exit to the small pelvis is an indirect sign of problems with the vestibular apparatus in a child.

Amount of amniotic fluid

With polyhydramnios, the fetus has more room for coups, somersaults and somersaults. And this sometimes affects the fact that the baby takes the wrong position of the body inside the space of the uterus. With oligohydramnios, the movements of the child, on the contrary, are difficult, and it is difficult to roll over into the correct position.

The umbilical cord and placenta

A short umbilical cord limits the movements of the baby, and too long is often combined not only with the breech presentation of the fetus, but also with entanglement around the neck or limbs. The pathological location of the placenta is also a prerequisite for breech presentation - we are talking about placenta previa or its low location.

Heredity

Obstetricians have long noticed that most often the baby's breech presentation develops in pregnant women who themselves were born in a breech presentation or the mother's entire pregnancy was in this position.

In fairness, it should be noted that the above premises do not always explain this fact. Sometimes a breech presentation is fixed in a baby who does not have any of these prerequisites. Not all cases of breech or oblique breech presentation can be explained, just as it is not always possible to understand why the baby, who was located head up, just a few hours before birth, suddenly does the impossible and rolls over into head presentation. This is rare, but there are plenty of examples in obstetrics and gynecology.

Diagnostics

Until the third planned screening ultrasound, or rather, up to 32-34 weeks of pregnancy, the position of the fetus does not play a big diagnostic role, because the baby still has free space inside the uterus to change the position of the body spontaneously. Therefore, breech presentation at an earlier date is not considered a diagnosis, this is just a statement of fact. The doctor describes the position of the fetus in which he was "caught" during the ultrasound.

After 34 weeks, the chances of a coup are reduced to negligible values. It is at 32-34 weeks that breech presentation already sounds like a diagnosis. The tactics of monitoring a pregnant woman is changing, the question of the method of delivery is decided in advance.

The pelvic position of the baby is first determined by the obstetrician. To do this, he uses the so-called Leopold method. The height of the fundus of the uterus exceeds the norm, probing with the hands of a physician through the anterior abdominal wall of the expectant mother determines a rounded element, quite mobile, slightly shifted to the right or left of the midline passing through the navel. This is the baby's head. To eliminate the error, the obstetrician uses auxiliary methods: the presenting part is palpated in the lower abdomen, if it is a priest, then it is not capable of mobility. The baby's heartbeat is also heard. A tiny heart in the pelvic position usually knocks above the mother's navel, slightly to the right or slightly to the left of it.

By the location of the heartbeat, a woman can determine the presentation of her baby on her own, using a phonendoscope. The points and kicks of the baby, which is head up, are felt more painfully and more tangibly in the lower abdomen, almost above the pubis.

With a vaginal examination, the presumptive diagnosis is specified. Through the anterior fornix of the vagina, the doctor determines the softer presenting part. The head, if the position of the fetus is head, is firmer and more dense to the touch.

After examining the gynecologist, the woman will be offered to undergo an ultrasound examination, which should put everything in its place. Ultrasound will determine not only the position of the baby, but also the nuances that are important for delivery - whether his head is unbent, whether there is an entanglement with the umbilical cord, what is the estimated body weight of the baby, whether he has developmental pathologies, where exactly the placenta is located, what is the degree of its maturity.

The angle of extension of the head in this case is of the greatest importance. If it is unbent and the child, as it were, looks up, then there can be no talk of independent childbirth, because the risks are too great that when passing through the genital tract, the baby will receive serious injuries to the spine.

When establishing on ultrasound the fact that the baby is lying incorrectly, it is imperative to conduct an ultrasound with a Doppler, as well as CTG, in order to have all the data on possible disorders in the baby’s condition caused by hypoxia.

Only at the end of the examination, the doctor will be able to give an exhaustive answer about the prospects for further pregnancy management and the desired method of delivery.

Natural fetal turnover

Until 28-30 weeks, absolutely nothing is required from a woman. Doctors take an observant position and strongly recommend that the expectant mother sleep more, rest, eat normally, take vitamins and drugs to reduce uterine tone in order to prevent fetal hypotrophy and reduce the risks of placental insufficiency. From the 30th week, the doctor may recommend that the woman do corrective exercises.

Exercises according to Dikan, Shuleshova, Grishchenko are aimed at relaxing the muscles of the uterus and pelvis as much as possible, allowing the child to take the correct position while it is still possible. The effectiveness of gymnastic exercises in combination with breathing exercises is estimated at about 75%. In most cases, if the gymnastics has helped, the child rolls over naturally, without coercion, within the first week after the start of classes.

Gymnastics for the coup of the fetus is contraindicated in women with diseases of the cardiovascular system, liver and kidneys. Classes are undesirable for women who have scars on the uterus from surgical operations or a history of caesarean section, for expectant mothers with signs of preeclampsia, the threat of premature birth. With the appearance of discharge from the vagina (watery, bloody) that is atypical for the gestational age, gymnastics is contraindicated.

In a natural way, babies can take the head position in 70% of multiparous women and in about a third of pregnant women with first-borns. To achieve the result, they use not only gymnastics, but also swimming in the pool, as well as psychological impact. According to most obstetricians, the child may well "listen" to the persuasion of his mother and roll over. If he does not do this before 35-36 weeks, then with a probability of 99% the baby will remain in the breech presentation until the very birth.

Relying on 1% of his coup already during fights or shortly before them is not worth it.

See below for fetal flip exercises.

obstetrical inversion

If gymnastics, swimming, proper breathing and adherence to clinical recommendations up to 35 weeks did not have any effect on the baby, a forced obstetric coup can be performed. It is also called a coup by the Arkhangelsky method. An external coup is carried out exclusively in a hospital setting. Previously, doctors tried to practice it at 32-34 weeks, now it is considered the most reasonable to turn the baby by hand for a period of 35-36 or 36-37 weeks.

A woman should have a sufficient amount of amniotic fluid, the coup takes place under the constant control of ultrasound. Doctors monitor the baby's heart activity by means of CTG both before the turn and for some time after it. The essence of the method lies in the smooth, careful simultaneous movement of the head and buttocks of the fetus clockwise or counterclockwise (depending on the position of the back). It is not always possible to turn the baby, no one can guarantee that the Arkhangelsky method will give the expected result.

An obstetric coup is contraindicated in women who are at risk of preterm labor, if her pelvis is very narrow, if she is over 30 years old at the time of her first birth. Doctors will not forcibly turn the baby over if there is not enough mobility, if the woman has preeclampsia.

The Arkhangelsky method is not used in cases of multiple pregnancy, in the presence of scars on the uterus, as well as in the absence of amniotic fluid (oligohydramnios) or their excess (polyhydramnios).

If the breech presentation of the baby is due to anatomical malformations of the uterus, a manual overturn is also not carried out. Recently, more and more obstetricians refuse manual coup in principle. It is believed that it increases the likelihood of placental abruption, entanglement and asphyxia of the fetus, violation of the integrity of the membranes. Medicine knows cases when an obstetric coup ended in premature birth, rupture of the uterus and trauma to the fetus.

Considering that there may not be an effect, but there may be side effects, many obstetricians continue observational tactics until the 37-38th week of pregnancy, after which they routinely hospitalize the expectant mother in the maternity hospital and choose the method of delivery.

Caesarean section or natural childbirth?

This is the main question that torments a pregnant woman and haunts her doctor. It is he who has to be solved even before the 38th week of pregnancy. The opinion that you will have to give birth with a breech presentation exclusively through a caesarean section is erroneous. A baby who sits head up in the uterus can be born in different ways:

natural childbirth that began spontaneously;
natural childbirth, stimulated in the DA, a little earlier or a little later than this date;
planned caesarean section.

To choose the appropriate delivery tactics, doctors use a special birth safety scale. If the total score exceeds 16, it is considered that a woman can give birth on her own with a breech presentation. Points are awarded as follows:

gestational age - 37-38 weeks - 0 points;
gestational age more than 41 weeks - 0 points;
gestational age 40-41 weeks - 1 point;
gestational age 38-39 weeks - 2 points;
large fruit (from 4 kilograms) - 0 points;
fetal weight 3500 -3900 grams - 1 point;
baby weight from 2500 to 3400 grams - 2 points;
foot presentation - 0 points;
combined (mixed) presentation - 1 point;
gluteal - 2 points;
strongly extended fetal head - 0 points;
moderately extended head - 1 point;
bent head - 2 points;
immature cervix - 0 points;
insufficiently mature neck - 1 point;
mature cervix - 2 points.

Also, from 0 to 12 points is given for the size of the pelvis - the wider it is, the more points the woman will receive. And only the sum of the points shows whether it is possible to risk and give birth on your own, or is it better to trust the experience and qualifications of the surgical team and give birth by caesarean section.

It should be noted that the statements of many pregnant women that they will not consent to the operation, which are often heard in women's forums on pregnancy and childbirth, are of no particular importance. A caesarean section, if the score is less than 16, is performed for medical reasons and only when there is a high risk of injuring the child during natural childbirth.

The decision on a planned caesarean section in breech presentation should always be weighed.

If it seems to a woman that she was sent for surgery simply because the doctor did not want to “mess around” with problematic pathological childbirth, you need to contact the head of the antenatal clinic and ask for the appointment of a medical expert commission that will once again calculate the risk scores and give their opinion.

For a woman in respect of whom a decision has been made about a possible natural birth, it is important to go to the hospital in a timely manner. You can't wait until contractions start at home. Even the very initial, the first period of the birth process should proceed under the vigilant supervision of a qualified doctor.

At this stage, it is important to prevent premature rupture of the fetal bladder, outpouring of water, especially their rapid outpouring, because along with the waters, loops of the umbilical cord and even parts of the baby’s body can fall out.

As soon as the contractions become regular, and the cervix opens by 3-4 centimeters, the woman is injected with antispasmodic drugs and painkillers to prevent too rapid labor activity. At this stage, the CTG device is connected, the entire process of childbirth will be accompanied by constant monitoring of the state of the fetal cardiac activity. To prevent hypoxia, a woman is given chimes, cocarboxylase, sigetin and halocorbin in injection solutions.

As soon as the waters break, the doctor will carefully assess the baby's condition by CTG, and also conduct an intravaginal examination for prolapse of the umbilical cord loops or parts of the baby's body. If the loops fall out, they will try to tuck them back, but in case of failure at this stage, the woman will be urgently sent to the operating room for a caesarean section.

By the way, about 30% of natural births with breech presentation end with a caesarean section. And both the woman herself and her relatives should be morally prepared for it.

No one can predict the course of childbirth if the baby goes legs or butt forward.

In the second stage of labor, if everything goes well, the woman begins to inject oxytocin, stimulating contraction and faster opening of the cervix. As soon as it opens enough to let the baby's buttocks through, the medical team performs an episiotomy - a surgical incision in the perineum and posterior wall of the vagina. This will help protect the woman from spontaneous ruptures and facilitate the passage of the baby.

It is considered a favorable sign if the birth of the head occurs no later than 5 minutes after the birth of the baby's torso. In the process of the birth of a baby, an obstetrician can use different methods. With one, the buttocks are supported manually without trying to stretch them or somehow speed up the process, with the other, the baby is carefully removed by one or both legs, by the inguinal fold. There are many options in the third stage of childbirth, it all depends on how the birth proceeds, how the baby himself will be born.

Procrastination or inattentive attitude of the staff towards such a woman in labor can lead to acute hypoxia, death of the fetus, and severe injuries to the child, which will forever make the child disabled.

That is why a woman who is about to give birth in a breech presentation should approach the choice of an obstetric institution, a doctor with great responsibility, once again weigh all the risks.

postpartum period

The postpartum period after such childbirth is not much different from the same period in non-pathological childbirth. A woman should not be afraid that she will spend more time in bed or not be able to take care of a newborn. If there are no complications, bleeding does not open, then the newly-made mother is transferred from the delivery room to the ward where she can rest, and the child is sent to the children's department, where he will be treated with special care.

All babies who were born legs or booty forward, even if there were no visible complications in childbirth, are more closely observed by neurologists, because some consequences of pathological childbirth can be quite remote. It is possible that such a baby will be brought to feed later than other children, often babies after birth with the lower body forward require resuscitation support.

Such newborns need dispensary observation of a neurologist until they reach the age of three.

If pathologies appear, then dispensary registration for a child can become lifelong.

Memo for moms

Pregnancy against the background of breech presentation has its own characteristics, and a woman needs to remember that:

Antenatal bandage, if the baby is positioned head up, can only be worn until the 30th week of pregnancy. If then the baby retains an incorrect position of the body in space, it is impossible to wear a bandage.

Before childbirth or shortly before them, the pregnant woman's stomach drops - the head of the fetus in cephalic presentation is pressed against the exit to the small pelvis. With a breech presentation, the prolapse of the abdomen does not occur until the very birth.

Obstetrician-gynecologists have been using external obstetric rotation to change the presentation of the fetus for several decades. However, not all future mothers who are preparing for the birth of a baby know that the breech presentation, which is considered not the most favorable for natural childbirth, can be changed to a more physiological head one, and this can be done without consequences for the health of the unborn child and the ongoing pregnancy.

Why is an external obstetric turn performed?

The main reason for using external obstetric rotation to change from breech to cephalic presentation is to enable the woman to give birth on her own. After all, breech presentation is almost always a reason for operative delivery.

According to world and Russian statistics, confirmed by the work of the doctors of the Yekaterinburg Clinical Perinatal Center, in nulliparous women, external obstetric rotation is successful in 40% of attempts, in multiparous women - in 60%. According to the doctors themselves, the success or failure of the external obstetric rotation depends on the number of births in the woman in the past, her body weight, gestational age, the size of the fetus and the amount of fluid surrounding it, and the location of the placenta. And, importantly, from the experience of the doctor.

Timing of external obstetric rotation

It makes no sense to carry out an obstetric rotation in the early stages of pregnancy, when the unborn baby is still relatively free to move in the uterine cavity. The optimal gestational age for external obstetric rotation is from 36 weeks for nulliparous women and from 37 weeks for those who have this not their first pregnancy. There is no upper time limit, and the rotation can be done already at the onset of labor, but provided that the fetal bladder is still intact.

Contraindications

As with most medical manipulations, they are divided into absolute and relative.

Absolute contraindications when breech presentation before childbirth cannot or is not practical to correct by rotation:

If a caesarean section is indicated to a woman for reasons other than presentation,

If a pregnant woman has had spotting during the last week,

If there are changes in cardiotocography,

If there are abnormalities in the development of the uterus,

If there was a premature discharge of amniotic fluid,

If there is multiple pregnancy.

Relative contraindications, which the doctor considers along with all other factors of pregnancy, and only after that makes a decision:

If there is a delay in fetal development and impaired placental blood flow,

If a pregnant woman has signs of preeclampsia (preeclampsia is a severe toxicosis of pregnancy with edema, high blood pressure, changes in urine tests),

If oligohydramnios is diagnosed,

If there are fetal abnormalities,

If the fetus in the uterine cavity is still in an unstable position,

If there are scars on the uterus (except for the transverse scar in the lower part of the uterus).

Training

Preparation for external obstetric rotation includes: ultrasound, removal of cardiotocography for 20 minutes, as well as tocolysis (that is, inhibition of possible uterine contractions with the help of medications). Immediately before the rotation, talc or a special oil is applied to the belly of a pregnant woman.

How is an external obstetric rotation performed?

The pregnant woman is laid on her side. With the help of smooth movements with his hands, the doctor lifts the baby from the pelvic cavity and tries to turn it around so as to direct the head of the child towards the pelvis of the mother, and place his gluteal region higher.

The procedure itself without preparation takes no more than 5 minutes. For the expectant mother, the main thing at this time is to relax, breathe deeply and be sure to inform the doctor about any signs of discomfort. If pain occurs or if the baby's heartbeat slows down, which is recorded by doctors, the rotation procedure will be suspended or stopped altogether. It is not scary if the baby could not be deployed on the first attempt, in one procedure the doctor can make up to 3 attempts to externally rotate.

At the end, a control ultrasound is performed and a cardiotocogram is also recorded for at least 20 minutes. If the woman is not bothered by anything, the turn was successful, and there is still time before the birth, then she can go home from the hospital on the same day.

Today, obstetrician-gynecologists do not consider it necessary to fix the position of the baby in the uterus after turning, because bandaging the abdomen of a pregnant woman with various fixing bandages, as time has shown, does not affect the results of the procedure. In other words, if the child is destined to turn around to its original position, he will do it anyway.

What does the baby feel and is the procedure dangerous for him?

Answering this question, it is worth paying attention to the fact that the external obstetric turn itself is primarily carried out for the baby - so that he avoids a caesarean section or childbirth in a non-physiological breech presentation.

During the external obstetric rotation, the child may have a slow heart rate (bradycardia) - in this case, the doctors will interrupt the procedure. In extremely rare cases, other not entirely pleasant phenomena can occur - for example, the outflow of amniotic fluid or placental abruption. Then a caesarean section will be performed immediately - which is why the external obstetric turn is considered an exclusively stationary procedure, so that the operating room is always ready nearby.

And when in doubt, it is important for the expectant mother to think about this:

The frequency of emergency caesarean sections after external obstetric rotation is no more than 0.5%,

An external obstetric rotation is performed in those terms of pregnancy, when the child is already born full-term in any case,

External obstetric rotation in certain cases is the only way for a baby to be born in the most physiological way and reduce the risk of birth or surgical complications, which after childbirth will have to be compensated for many months and sometimes even years.

obstetrical rotation- an obstetric operation, with the help of which it is possible to change the unfavorable, in a given obstetric situation, for the course of childbirth, the position or presentation of the fetus to a favorable one. Obstetric rotation is carried out by manual techniques (see Obstetric manual techniques).

Obstetric rotation operations include: external preventive obstetric rotation, external-internal classical (combined) obstetric rotation with full opening of the external cervical os and external-internal (combined) obstetric rotation with incomplete opening of the uterine os, the so-called Braxton Hicks rotation.

There are four variations of Obstetric Rotation: pedunculated, pedunculated, gluteal, and glans. The combined turn, as a rule, is made on the leg. Rotation to the head is performed only with external obstetric rotation

General indications

General indications: transverse or oblique position of the fetus; prolapse of small parts and the umbilical cord with cephalic presentation. A number of authors cite some other indications for the production of obstetric rotation, namely: unfavorable insertion of the fetal head (posterior parietal, facial chin backwards, frontal insertion) and maternal diseases requiring immediate delivery, in particular heart defects, eclampsia. However now the majority of obstetricians considers that at similar complications it is more expedient to make caesarean section (see).

External obstetric turn

External obstetric rotation is performed in the absence of the effect of prenatal correction of anomalies in the position and presentation of the fetus by the method of physical exercises proposed by I. I. Grishchenko, A. E. Shuleshova and I. F. Dikan.

External obstetric cephalic rotation produced taking into account the position of the fetus according to the method of B. A. Arkhangelsky or without taking into account the position, considering only the ease of movement of the fetus - according to Wiegand. According to most obstetricians, clarifying the type and position of the fetus is one of the indispensable conditions for external obstetric rotation.

Indications: transverse or oblique position of the fetus, breech presentation. Conditions: pregnancy 35-36 weeks, good fetal mobility, compliance of the abdominal wall, normal size of the pelvis or the absence of a significant narrowing of it, a favorable condition of the mother and fetus.

Contraindications: premature birth and stillbirth in history, postoperative scars on the uterus, toxicosis and bleeding during this pregnancy, anomalies in the development and tumor of the uterus, narrowing of the pelvis (second degree and below), oligohydramnios, polyhydramnios, large fetus, multiple pregnancy.

External (prophylactic) rotation according to Wiegand in the transverse and oblique position of the fetus. The pregnant woman is emptied of her bladder and placed on a hard couch on her back with her legs bent at the knees. The obstetrician places both hands flat on the pregnant woman's stomach in such a way that one hand clasps the head of the fetus, the other - the buttocks (Fig. 1, 1). By simultaneous action on the head and buttocks, guided solely by the ease of movement, without regard to the position of the fetus, the latter is gradually transferred to a longitudinal position. The head is pushed to the entrance to the small pelvis, and the buttocks - to the bottom of the uterus.

External (preventive) turn along Arkhangelsk with transverse and oblique position of the fetus. A pregnant woman is injected under the skin with 1 ml of a 1% solution of promedol, the bladder is emptied, laid on a hard couch, and her legs are asked to bend. The doctor sits down on the right facing the pregnant woman, accurately determines the position of the fetus, after which he grabs the head from above with one hand, and the pelvic end of the fetus from below with the other. In the anterior view of the transverse position of the fetus, when its back is turned to the bottom of the uterus, with careful movements the head is shifted to the entrance to the small pelvis, the pelvic end of the fetus is to the bottom of the uterus (Fig. 1, 2). In the case when the back of the fetus is facing the entrance to the small pelvis, the rotation is made by 270 °, for this, the buttocks are first displaced to the entrance to the small pelvis, and the head - to the bottom of the uterus. Then, from the breech presentation, the fetus is transferred to the head.

The general rule of external rotation according to Arkhangelsk for all types and positions (with oblique and transverse positions) of the fetus is the displacement of the buttocks towards the back, the back towards the head, and the head towards the abdominal wall of the fetus.

When performing these techniques, the fetus, after turning, is in the anterior view. Arkhangelsky believes that with this technique, the fetus, while maintaining the correct articulation and shape of the ovoid, remains in a flexion position, which is most favorable for its rotation in the uterine cavity.

External prophylactic rotation of the fetus on the head in breech presentation. An unfavorable prognosis for breech presentation for the mother and fetus served as the basis for the use of prophylactic correction of pelvic presentation during pregnancy by external rotation to the head.

Conditions and contraindications for rotation from breech presentation to the head are the same as for rotation in the transverse position.

A pregnant woman is emptied of the intestines, immediately before the operation - the bladder and laid on a soft couch on her back. The doctor sits down to her right. Determines the position and type of fetus in detail.

Turning technique: very carefully manipulating both hands simultaneously, move the buttocks away from the entrance to the small pelvis to the bottom of the uterus, towards the back of the fetus, and the head - to the entrance to the pelvis, towards the abdominal wall of the fetus (Fig. 1, 5).

After external rotation surgery, the possibility of recurrence is not ruled out, so it is necessary to fix the longitudinal position of the fetus. To this end, Arkhangelsky proposed a special bandage in the form of a tape 10 cm wide, which is fixed on the pregnant woman's abdomen at the level of the navel or slightly below it; this contributes to an increase in the vertical and a decrease in the horizontal diameter of the uterus. The bandage should not be removed for 1-2 weeks to exclude the possibility of the fetus moving into a transverse position.

Holding the longitudinal position of the fetus after external rotation to the head can be done using two rollers rolled from sheets placed on both sides of the fetus, followed by bandaging the abdomen.

External-internal rotation

External-internal classical (combined) rotation of the fetus on the leg. Indications: transverse position of the fetus, prolapse of the umbilical cord and small parts in head presentation, complications and diseases that threaten the condition of the mother and fetus. Unfavorable insertion of the head (posterior parietal, frontal, facial chin posteriorly) does not serve as an indication for obstetric pedicle rotation.

Conditions: full opening of the external os of the cervix, the fetal bladder is intact or the water has just poured out, the mobility of the fetus in the uterine cavity is completely preserved, the correspondence between the size of the fetus and the size of the pelvis.

Contraindications: neglected transverse position of the fetus, discrepancy between the size of the mother's pelvis and the head of the fetus, threatening, begun and completed uterine rupture.

Before surgery, you should empty your bladder. The operation is performed under anesthesia on the operating table or on the Rakhmanov bed. It consists of the following points: 1) introduction of the hand; 2) finding a leg; 3) capturing the leg; 4) actual turn.

1. Introduction of the hand. The right hand is usually inserted into the uterine cavity. Some obstetricians recommend inserting a hand of the same position. So, at the first position of the transverse position (head to the left) and the first position of the head presentation (back to the left), the left hand is inserted, at the second position - the right hand.

Rice. 2. External-internal (combined) obstetric rotation of the fetus on the leg: 1 and 2 - the introduction of the hand into the birth canal, the "outer" hand on the fundus of the uterus (2); 3 - capture of the anterior leg in cephalic presentation; 4 - the leg is captured with the whole hand; 5 - the leg is captured by two fingers; 6 - bringing the legs down through the vagina, the "outer" hand pushes the head of the fetus upward; 7 - the turn is over, the leg is brought out to the knee; 8-10 - according to Boyarkin: 8 - the head is captured by the brush, the "outer" hand is at the bottom of the uterus, 9 - the head is abducted to the bottom of the uterus, 10 - the leg is captured and brought down; 11-13 - with incomplete disclosure of the uterine os according to Braxton Gicks: 11 - the head is moved towards the back, the "outer" hand brings the pelvic end closer to the entrance to the pelvis, 12 and 13 - the leg is captured with two fingers and reduced

After thorough disinfection of the external genital organs and the hands of the obstetrician, the genital gap is pushed apart with the “outer” hand; the hand chosen for rotation (“internal”) is lubricated with vaseline oil, the brush is folded into a cone, inserted into the vagina and advanced to the cervix of the uterus (the rear of the hand should be turned towards the sacrum). As soon as the ends of the fingers have reached the pharynx, the "outer" hand is transferred to the bottom of the uterus (Fig. 2, 1 and 2). After that, the fetal bladder is opened and the hand is inserted into the uterus; in cephalic presentation, before inserting the hand into the uterus, the head is pushed towards the back.

2. Finding a leg. When turning from a longitudinal position, one should find and grab the peduncle of the fetus facing the anterior wall of the uterus (Fig. 2, 3). In the transverse positions of the fetus, the choice of the leg depends on the type: in the anterior view, the underlying leg is captured, in the posterior view, the overlying one, since it is easier to transfer the posterior view to the anterior one.

To find the legs, they feel for the side of the fetus and slide their hand from the armpit to the pelvic end and further along the thigh to the lower leg and grab the leg. During the search for the legs, the “outer” hand moves the pelvic end of the fetus downward, towards the “inner” hand.

3. Capturing the leg is done in two ways: a) the shin is captured with the whole hand - with four fingers they wrap around the shin in front, the thumb is located along the calf muscles, its end reaches the popliteal fossa (Fig. 2, 4); b) grasp the fetal leg in the ankle area with the index and middle fingers (Fig. 2, 5), the thumb supports the foot.

4. The actual rotation of the fetus. After capturing the legs, the “outer” hand is transferred from the pelvic end of the fetus to the head and pushed upwards, to the bottom of the uterus; at this time, the “inner” hand lowers the leg, bringing it out through the vagina (Fig. 2, 6).

The turn is considered complete after the leg is removed from the genital gap to the knee (Fig. 2, 7). Immediately after the rotation, the fetus is removed (see Childbirth).

External-internal (combined) obstetric rotation according to S. Ya. Boyarkin. The introduction of the hand into the uterine cavity and the rupture of the fetal bladder are performed as described above in the classic obstetric turn. The "outer" hand fixes the fundus of the uterus and promotes the reduction of the buttocks. At the same time, the "inner" hand goes to the head of the fetus, grabs it and gently moves it to the bottom of the uterus (Fig. 2, 8 and 9). Thus, the actual turn is made. As soon as it is produced, the “inner” hand is carried along the body, along the side of the fetus or its back, and then along the buttocks, thigh and lower leg, grab and lower the leg (Fig. 2, 10). With this method of lowering the leg, it can be easily captured and cannot be mistaken for a handle, since the latter, during the abduction of the head, rose up to the bottom of the uterus. However, most obstetricians prefer the classical method as less traumatic for the fetus.

External-internal (combined) turn on the leg according to Braxton Geeks. Indications: partial placenta previa and dead or non-viable premature fetus, transverse (oblique) position of the fetus with early outflow of water and dead premature fetus.

Conditions: opening of the external os of the cervix by at least 4-6 cm, fetal mobility, no significant narrowing of the pelvis, no indications for immediate delivery.

Contraindications: live full-term fetus, complete placenta previa.

The technique of the operation consists of three points: inserting a hand into the vagina and two fingers into the uterine cavity, finding and grasping the leg, and actually turning.

The operation is performed on a Rakhmanov bed or on an operating table under anesthesia.

Having parted the labia with one hand, the second brush, folded cone-shaped, is inserted into the vagina in the same way as when turning with full disclosure of the external os of the cervix. The index and middle fingers are inserted into it. If the fetal bladder is intact, the membranes are torn apart by the holder of the bullet forceps. If the turn is made with a head presentation, then the head is pushed towards the back with the fingers. At the same time, the “outer” hand presses on the bottom of the uterus and brings the pelvic end of the fetus closer to the “inner” hand (Fig. 2, 11). With the transverse position of the fetus, the “outer” hand produces pressure on the lateral surface of the uterus, where the pelvic end is located. With two fingers they grab any leg above the ankle, pull it down (Fig. 2, 12 and 13) into the pharynx, then into the vagina and, finally, remove the leg from the genital gap. At the same time, the “outer” hand is moved to the head, pushing it upwards. The turn is considered complete when the fetal leg is removed from the genital gap to the popliteal fossa, and the head is at the bottom of the uterus. In the future, childbirth is carried out expectantly; a load of 200-400 g is suspended from the leg (see Childbirth). After turning the fetus on the leg according to Braxton Hicks, it is impossible to extract the fetus. This can lead to significant bleeding due to rupture of the cervix and lower uterine segment, especially with placenta previa, and in some cases be fatal.

Possible Complications

During the production of an external obstetric turn, the following complications are possible:

1. Beginning asphyxia of the fetus. The operation should be terminated. Treat intrauterine fetal asphyxia.

2. Premature detachment of a normally located placenta. Obstetric rotation should be stopped, carefully monitor the condition of the pregnant woman and the fetus. With an increase in phenomena - an urgent caesarean section.

3. The appearance of signs of uterine rupture. Manipulation must be stopped. When establishing a diagnosis of uterine rupture, an urgent abdominal surgery is indicated.

When performing an external-internal (combined) rotation of the fetus, complications are also possible:

1. When opening the fetal bladder, a loop of the umbilical cord may fall out. With this complication, the turn is continued, trying not to press the umbilical cord. Following the turn (with full opening of the pharynx), the fruit is immediately removed.

2. The introduction of the hand into the uterine cavity prevents spasm of the internal pharynx. This complication can also occur after the hand is inserted into the uterus. In this case, it is necessary to leave the hand in the uterus without movement, deepen the anesthesia and inject 1 ml of a 0.1% solution of atropine sulfate under the skin of the woman in labor. If these measures do not help and the spasm continues, the obstetrician should remove the hand from the uterus and abandon further attempts to rotate.

3. Instead of a leg, a handle has been removed. In this case, a loop of gauze bandage is put on the dropped handle. The assistant moves the handle with the loop towards the head, and the obstetrician re-enters the hand into the uterus, searches for and grabs the leg and makes a turn.

4. The rotation is not made due to insufficient mobility of the fetus. In this case, all manipulations are stopped in order to avoid uterine rupture, and childbirth is carried out in the future, depending on the characteristics of their course.

5. The most dangerous complication during the production of an obstetric turn is uterine rupture (see Childbirth), which usually occurs when the operation is performed with insufficient fetal mobility or when it is removed when the external cervical os is not fully opened. Prevention of this serious complication should be in the exact observance of the conditions necessary for the production of the rotation operation.

Bibliography:

Bodyazhina V. I. and Zhmakin K. N. Obstetrics, M., 1970; Gritsenko I. I. and Shuleshova A. E. Prenatal corrections of incorrect positions and pelvic presentation of the fetus, Kyiv, 1968; Zhordania I. F. Textbook of obstetrics, M., 1964; Multi-volume guide to obstetrics and gynecology, ed. L. G. Persianinova, vol. 6, book. 1, p. 73, Moscow, 1961; Yakovlev I. I. Emergency care for obstetric pathology, L., 1971.

G. M. Savelyeva.

It is known that in some pregnant women the fetus is in a breech presentation. There are many opinions about what kind of help such women need. And at the same time, there is a single position supported by all the leading obstetricians in the world and voiced by the World Health Organization. We came to a consensus because it was formulated on the basis of high-quality scientific research, and not on the opinion of individual experts. In this article, I will try to talk about the help that should be offered to a pregnant woman according to international recommendations.

Why obstetricians do not like breech presentation of the fetus?

Births in breech presentation have a greater risk to the health of the fetus.

What is known about the effectiveness of treatment for breech presentation?

Firstly, you should not worry about how the fetus is located in the uterus until 36-37 weeks. It is likely that he can completely independently take the head presentation before this time. Gymnastics, which is often offered to pregnant women, turned out to be ineffective (the frequency of fetal rotations in those who perform and do not perform special exercises is the same). As a method of delivery, a caesarean section is usually offered, but independent childbirth is also possible (this can only be said after an ultrasound on the eve of childbirth and an analysis of the clinical situation by an experienced obstetrician).
Many clinics in the world have completely abandoned independent births in breech presentation, delivering such pregnant women by caesarean section. However, the argument often offered in the Russian Federation that breech birth in boys leads to male infertility has no scientific evidence. This story about male infertility is a topic exaggerated in Russian obstetric literature, and it was not heard about outside the USSR.

To avoid caesarean section in all industrialized countries, pregnant women are encouraged to perform an external rotation of the fetus on the head. The obstetrician, by light pressure on the abdomen, rotates the fetus, and it becomes head presentation. This is the safest and most frequently performed procedure in obstetrics, which is practiced throughout the world. The method of turning is different from previously performed, and most importantly, it is carried out under the control of ultrasound and CTG, which means that the obstetrician has a good idea of what is happening inside.
There is a lot of speculation about this manipulation that I hear from both patients and medical professionals. For many years of practice (I have been performing turns since 2001), I have not observed any complications of this manipulation. Although there is a risk of some complications, and it is negotiated with the pregnant woman before manipulation, the risk of such complications is extremely small. This risk is not comparable to the risk of a caesarean section or a breech birth.

The most common fear expressed by a pregnant woman is that the fetus can be injured or damaged. It is impossible to injure the fetus during the rotation, it is in a state of hydroweightlessness and is protected by amniotic fluid, and the rotation is carried out with light movements. No such complication has been reported in the world, although the manipulation is performed in large numbers.

Time manipulation lasts from a few seconds to several minutes. Although the whole process will take about 2-3 hours, because. ultrasound is preliminarily performed, CTG is recorded before and after the rotation. After the turn, the pregnant woman goes home. We usually ask to visit the maternity hospital in 1-2 days. If the rotation is successful, then the woman will have a normal birth.

In about 30-40% of cases, the turn fails. The longer the gestation period, the more failures. Most often, the failure lies in the fact that in the process of examining a pregnant woman before turning, there are contraindications to its implementation. Less often, the rotation is carried out, but it is not possible to rotate the fetus. For those who want more scientific information, the World Health Organization Reproductive Health Library can be consulted. Fortunately, in 2008 her resume was translated into Russian.

You know that I am used to sharing many things with you: my successes, joys, and defeats. In this article I will tell my story about the external obstetric turn.

This question came up during my . Everything was going great until I was diagnosed with a breech presentation by ultrasound at 30 weeks. There was plenty of time for the baby to roll over and also for me to think about the matter. What if not? And I realized that I really do not want a caesarean section. In Russia, breech presentation is most often considered as (and many patients are kind of glad about this, I must admit), but I knew that I wanted to give birth naturally! Yes, this is probably somewhat presumptuous, but I really didn’t want to end up with two kids (the eldest child is not yet three years old) and with a scar on my stomach.

I will make a reservation right away, natural birth in a breech presentation is fraught with more risks than a caesarean section!

This is a responsible decision that is made on the basis of a combination of factors together with the attending physician in the absence of any restrictions / doubts / indications for a caesarean section.

There is such a technique: external obstetric rotation (when the obstetrician mechanically turns the baby from the breech presentation to the head presentation with his hands through the abdomen in late pregnancy). I read a lot about it, but to be honest, I did not meet doctors who would do it in Moscow. And I began to search. While chatting with a friend who is an OB/GYN doctor in the US, I asked her if they performed this procedure. It turned out that yes, without fail (in their clinic) to all women with a breech presentation of the fetus. It is not always possible to succeed (in about 60% it is possible to make a turn), but in the remaining 40% we do not lose anything, just the fetus remains in the breech presentation.

I waited for an ultrasound at 36 weeks (the rotation is performed at 37 weeks and beyond), which confirmed the breech presentation of the fetus.

And I started asking obstetricians I know. I got different answers. All, as one, were against this idea. But I had doubts. None of those who tried to dissuade me, did not turn before. My husband asked me to stop bullying the child. My natural stubbornness did not allow me to calm down.

I was even advised an osteopath on this thorny path. And I even went to him (no, I don't recommend going to osteopaths! I was a) pregnant, b) ready to try all the ways), but, of course, without effect.

And now - oh, a miracle! - I found doctors who know how to make this turn! And I made an appointment (these are excellent doctors working in a Moscow maternity hospital, not shamans and not chiropractors!). I must say, breech presentation is quite rare, but just the day before my visit, they successfully turned the kids in two pregnant women.

The evening before the visit, my blood pressure rose to 150/90 mm Hg. (And I followed him quite closely, because in I was diagnosed with preeclampsia with a pressure reaching 180/110 mm Hg) In the morning I measured the pressure again, I saw 145/90 mm Hg. and I realized that my usual attack overtook me, and no one would perform any manipulations on a pregnant woman with such pressure. Since the appointment with the doctor was already scheduled, I went to it to discuss the next course of action for my pressure (so as not to self-medicate, hee hee). At the hospital, my blood pressure was measured (120/70 mmHg), they did an express test for protein content in the urine (negative) and took me for an ultrasound scan.

And only being on the ultrasound, I realized that everything, now they will make a turn! I'm healthy!

With pressure and urine, everything is OK, but I came around the corner! So they all gathered (4 doctors) to make it for me! My moms!!! Good thing I was in bed! I had a panic (well hidden, really)! I remembered all the horror stories that I had heard (rupture of the umbilical cord, abruption of the placenta), I realized that I was a real egoist, not listening to my husband and not caring about my unborn child ( “Well, why these experiments??? Well, it would look a little like a seam, it would be your problems, not the baby! I said to myself at that moment.) But the process was started, and I could not stop it. She lay down and panicked. She panicked and lay down. The doctors were extremely attentive and careful. The procedure was carried out under constant ultrasound control (and under the gun of two camera phones). Turn failed (40%, remember?). But there were no complications. They did a control ultrasound with doppler, CTG. Both me and the baby felt great. There was no turning, but the gestalt was closed. I tried. I should have tried it. Colleagues, thank you very much for this!

I thank the doctors of the perinatal center of City Clinical Hospital No. 24 (Kuznetsov Pavel Andreevich, Dzhokhadze Lela Sergeevna, Shogenova Maria Zamirovna) for my chance and Bondarenko Karina Rustamovna for their support and for not fainting!

P.S. Olga Roaldovna, if you are reading this, please forgive me for my amateur performance! But you know these pregnant women! If they got something into their heads, it is impossible to convince them))

P.P.S. I am writing this text in the evening after an unfortunate turn. But do not think that this story has an unhappy ending. The next one will be about childbirth! I will tell her for sure!