External obstetric fetal flip plus. The problem of breech presentation of the fetus. External obstetric rotation of the fetus on the head. What you need to know

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 it is not the head of the fetus that faces the exit to the pelvic area, but the priest or lower limbs. 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. With a 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.

Causes

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 seems to be looking 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.

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

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.

Breech presentation is a fairly common pathological phenomenon in which the child is located with the legs or buttocks down. Why is this happening? Shortly before birth (usually starting from the 32nd week of pregnancy), the fetus takes a certain position that contributes to the easy flow of childbirth. In 90% of cases, we are talking about head presentation, when the child is in the body head down, just above the womb. This means that this particular part of the body, the largest in a newborn, will be the first to be born. It is with her release that the most unpleasant sensations and the most difficulties are associated. The passage through the birth canal of the rest of the body (shoulders, torso, limbs) is usually almost not felt.

However, in some cases, the fetus is pelvis down. This can be determined by visiting the doctor leading the pregnancy through visual examination and palpation. Also, the longitudinal location of the fetus in the uterus is quite easily diagnosed by ultrasound. It makes sense to fix such a position from about 32 weeks of gestation, since at an earlier date the fetus is constantly moving and can repeatedly change position. The forecast of the situation is possible from the 28th week.

Correction of the situation before childbirth

Diagnosing a breech presentation is not a final verdict. At the stage of 32-34 weeks, you can perform special exercises that can provoke the fetus to turn over. This is a tilt of the pelvis, carried out on an empty stomach, specific exercises performed in the knee-elbow position. In the latter case, the pelvis should be above the level of the head. It is recommended to stay in this position for no more than 20 minutes several times a day.

It is also possible to use the force of gravity. Swimming in the pool helps a lot. Here, the pressure decreases, which makes it much easier for the fetus to roll over on its own.

The effectiveness of the described methods with their regular use varies between 65 - 75%. However, we must not forget that there are contraindications for the gymnastics mentioned above:

narrow pelvis;
risk of preterm birth;
malformation of the fetus;
an unsuccessful pregnancy that ended in a miscarriage in the past;
too much or too little amniotic fluid;
pathology of the development of the uterus;
multiple pregnancy;
placenta previa;
preeclampsia;
a number of concomitant diseases in which such loads are contraindicated.

In the last few years, the use of acupuncture, homeopathic influences, has become more widespread. Sometimes suggestion, the use of light, special music helps. However, the degree of effectiveness of these methods has not been fixed by science.

Obstetric coup: pros and cons

With a breech presentation of a child from the 36th or 37th week of pregnancy, an obstetric coup is allowed. We are talking about the implementation of a certain manipulation, in which the doctor can mechanically force the child to take the desired position (head down). It is performed exclusively in a medical institution, in the absence of contraindications, under strict supervision. During the process itself, control is carried out by ultrasonic equipment. Pain relief is usually not required.

Before performing an obstetric coup, appropriate preparation is required. A pregnant woman should not eat anything from the evening before (an empty intestine is important), the bladder is emptied immediately before the start of the procedure itself. Also, the expectant mother is given special preparations that help to relax the internal muscles and uterus. This is intended to facilitate the process of the coup.

The procedure can take from 2 to 3 hours. In total, no more than 3 attempts are made.

The degree of effectiveness does not exceed more than 60%, the fetus may not succumb to manipulation. The child is also able, after the coup, to soon take the same position. It is for the latter reason that in many countries they began to abandon the practice of obstetric coup.

What you need to know

There are contraindications to this procedure:

oligohydramnios, in this case, any impact of this kind can damage the fetus;
extensor position of the head in a child;
multiple pregnancy;
the presence of contraindications in a pregnant woman to drugs that promote relaxation;
individual features of the structure or development of the fetus or uterus.

In most of the cases listed above, an obstetric coup is not possible. Therefore, if the child has not changed position (which is checked by ultrasound, including control - by preoperative ultrasound), a caesarean section is prescribed.

Cesarean section with breech presentation of the fetus

Cesarean section in breech presentation is recommended to minimize the risks to the baby. Especially often it is prescribed if the pregnant woman's pelvis is too narrow, and the baby's head is large. Also, doctors pay great attention to how exactly the fetus lies, what type of pelvic proposal is in question. In male babies, this operation is designed to help prevent problems with the genitals. The latter can be damaged during natural childbirth.

Operative delivery is also indicated if the position of the fetus is complicated by other nuances.

Attention! Foot presentation is considered especially dangerous, in this case there is a high probability of asphyxia and too much trauma to the newborn.

In some cases, there is even a threat of death of the baby. To avoid such situations, doctors prescribe a caesarean section.

Types of breech presentation

The incorrect position of the fetus can be different, which affects the decision on how exactly the birth will proceed. The gluteal version is considered a classic. In this case, the child rests on the mother's pelvis with the buttocks. Moreover, the legs can be either bent at the knee joint or extended along the body. In a bent position, the presentation is called mixed. It is determined strictly according to the indications of ultrasound. Visual medical examination is not enough here.

A more complex and rare case is foot presentation (feet facing the entrance). It can be complete, here we are talking about both legs or incomplete, when one is bent and the other is extended. In some cases, the presentation is knee-length, the fetus facing the birth canal with knees bent at the joints. Sometimes the child is turned sideways, obliquely. In the latter case, operative delivery is recommended.

What is the danger of childbirth with such a presentation

The birth process in breech presentation, even in the absence of additional negative factors, will be complicated. The reason is simple: the butt of a newborn is smaller than the head. And the fetus will press with less force on the bottom of the uterus, which causes weaker contractions. This leads to a delay in childbirth, the appearance of a specific weakness. Which is fraught with excessive blood loss, fetal asphyxia, and other unpleasant consequences.

During childbirth, the baby's head may tilt back, which is fraught with injury to the newborn (neck or skull). The process of birth becomes difficult, slows down. There is also a high probability of pinching the umbilical cord between the fetal head and the birth canal.

This causes a weakening of the blood flow to the body of the newborn, sometimes hypoxia develops. Boys are at particular risk. During childbirth with gluteal diligence, significant pressure is placed on the scrotum. Due to compression, injury to this part of the body is possible. That is why, with a breech presentation of male babies in Europe, it is strongly recommended to perform a caesarean section.

What else you need to know about the management of pregnancy and childbirth in this situation

Despite the obvious risk, natural delivery is quite possible if the woman feels well, there are no clinical pathologies of the uterus or fetal developmental disorders. The small weight of the child also contributes to the normal course of childbirth.

Therefore, it cannot be unequivocally said that the incorrect location of the fetus is a "sentence". However, for the best resolution of the situation for a pregnant woman, special medical supervision is needed. A week or two before the approximate date of birth, the expectant mother may be placed in conservation. After all, this presentation is fraught with premature birth. This risk cannot be ignored.

obstetric turn I (versio obstetrica)

an operation with the help of which they change the unfavorable for the course of labor to a longitudinal one. In clinical practice, the following types of A. p. are used: external rotation on the head, external-internal classical rotation on the leg, rotation according to Braxton Hicks.

External rotation of the fetus on the head produced only by external methods (through the abdominal wall) with transverse and oblique positions of the fetus, less often with breech presentations. The operation is performed after the 35th week of pregnancy with good fetal mobility (until amniotic fluid is poured out), normal pelvic dimensions or its slight narrowing (true at least 8 cm), the absence of indications for the rapid completion of labor (, premature detachment of the placenta, etc.).

With oblique positions of the fetus, for external rotation, it is sometimes enough to lay the woman in labor on the side towards which the presenting part is deviated. For example, with the left oblique position of the fetus (head to the left), the woman is laid on her left side. In this position, the bottom of the uterus, together with the buttocks of the fetus, deviates to the left, and the head in the opposite direction, to the entrance to the small one.

With a transverse and persistent oblique position of the fetus, special external manual techniques are used for external rotation. Pregnant or childbirth over 30 min before surgery, administered subcutaneously 1 ml 1% solution of promedol. Must be emptied before operation. The woman is laid on a hard couch on her back, her legs are slightly bent and drawn to her stomach. The doctor sitting on the side on the edge of the couch puts both hands on the woman in labor so that one lies on the head, grabbing it from above, and the other on the underlying buttock of the fetus ( rice. one ). Having clasped in this way, with one hand they shift the head of the fetus towards the entrance to the small pelvis, and with the other they push the pelvic end up, to the bottom of the uterus. These manipulations should be done persistently, but extremely carefully.

In case of breech presentation of the fetus, in case of ineffectiveness of a complex of special physical exercises aimed at correcting the position of the fetus, the doctor may try in a hospital to perform an operation of external rotation of the fetus on the head - the so-called prophylactic rotation. It is usually carried out at the 35-36th week of pregnancy. The general rules for external preventive rotation are as follows: shift towards the back, back towards the head, head towards the entrance to the small pelvis. After turning, it is necessary to systematically monitor the pregnant woman.

When carrying out external rotation (using manual techniques), complications are possible: fetus, premature detachment of the placenta. When the first signs of complications appear, the operation of the external rotation is stopped, according to indications, an operation is performed.

External-internal classical rotation of the fetus on the leg produced by a doctor, in emergency cases -. When it is carried out, one hand is inserted into the uterus, the other is placed on the stomach of the woman in labor. The indications are the transverse position of the fetus, incl. the transverse position of the second fetus from twins, and extensor head presentation of the fetus (for example, frontal), which is dangerous for the mother. In the presence of one fetus, the operation is carried out, as a rule, with a dead fetus. With a live fetus in similar situations, a caesarean section is preferable. Conditions for the external-internal classical rotation: full opening of the uterine os, full fetal mobility, with a live fetus, the size of the pelvis of the woman in labor must correspond to the size of the fetal head. A contraindication to turning is the so-called neglected transverse position of the fetus, in which it is immobile. Before the operation, the woman in labor should empty the bladder, disinfect the external genital organs. The operation is performed on the operating table or on the Rakhmanov bed in the position of a woman on her back. Apply deep ether or intravenous. There are three stages of the operation: the introduction of a hand into the uterus, the search for and capture of the pedicle of the fetus, the actual rotation of the fetus.

With the transverse position of the fetus in the uterus, it is recommended to insert a hand corresponding to the position of the pelvic end of the fetus. In the anterior view of the transverse position (back to the front), the underlying fetal leg should be captured (when the overlying leg is captured, the anterior transverse position can easily go into the rear view, which is unfavorable for labor management). In the rear view of the transverse position (back back), the overlying leg should be captured ( rice. 2, a ), because rear view is easier to convert to front view. Two methods of finding the fetal pedicle are recommended. When using the so-called short method, the hand is carried directly to the peduncle of the fetus; The “long” method consists in moving the hand along the back of the fetus to the buttocks, then along the thigh, lower leg. With the “outer” hand (lying on the abdominal wall), the pelvic end of the fetus is brought down to the entrance to the small pelvis towards the “inner” hand, thus helping to find the leg. As soon as the fetal pedicle is found and grasped (with two fingers or with the whole hand), the "outside" hand is immediately transferred from the pelvic end to the fetal head and the head is pushed to the fundus of the uterus ( rice. 2b ). Traction () for the leg is performed outside, down, towards the perineum until the fetal knee appears from the genital gap. When the leg is brought out to the knee and the fetus has taken a longitudinal position, the turn is completed. Following this, an operation is usually performed to extract the fetus by the pelvic end (see. Pelvic presentation of the fetus).

In the case of head presentation of the fetus, the arm that corresponds to the position of the small parts of the fetus is inserted into the uterus as deeply as possible (up to the elbow). Previously, the fetal head is pushed to the side. After the leg is captured, it is important to transfer the “outer” hand from the pelvic end to the head end. In order not to confuse the fetal leg with a handle, it is necessary to insert the hand deeper into the uterus, and when grasping, turn to the heel tubercle.

With the external-internal classical turn of the fetus on the leg, handles, fetal heads can occur. If the umbilical cord prolapses, it should not be set, because. the reduced part of the umbilical cord usually falls out again; the turn should be continued, trying not to press the umbilical cord. When the handle falls out, a loop is placed on it so that in the future it cannot tip over the head. If the head is infringed, it is necessary first of all to try to gently push it away; if unsuccessful, the second leg should be brought down to create more space in the uterine cavity, and again make an attempt to push the head; with the ineffectiveness of these manipulations and the dead fetus, the heads are shown (see Fruit-destroying operations). A dangerous complication of the operation is the uterus (see Childbirth).

Rotation of the fetus according to Braxton Hicks, or turning the fetus on a leg with incomplete opening of the cervix (4-6 cm), can be carried out with a transverse or oblique position of the fetus, as well as with head presentation in the case of partial placenta previa. Due to the danger to the mother and fetus, it is used extremely rarely, only with a dead or premature non-viable fetus. A necessary condition is the mobility of the fetus. The operation is performed under general anesthesia with the woman in the supine position. Two fingers are inserted into the uterus through, open, grab the fetal leg and, with the help of a hand located on the abdominal wall, turn the fetus onto the leg. Then the leg is removed from the vagina to the popliteal fossa and a weight of 400-500 is suspended from it. G(with placenta previa - no more than 250 G). The expulsion of the fetus occurs spontaneously after sufficient dilatation of the cervix.

Bibliography: Bodyazhina V.I., Zhmakin K.N. and Kiryushchenkov A.P. , with. 443, M., 1986; Grishchenko I.I. and Shuleshova A.E. Prenatal corrections of incorrect positions of the fetus, Kyiv, 1974; Multi-volume guide to obstetrics and gynecology, ed. L.S. Persianinova, vol. 6, book. 1, p. 73, M., 1961.

II Obstetric turn (versio obstetrica)

Obstetric twist classic(v. obstetrica classica; . A. p. combined external-internal) - A. p., in which the fetus is turned on the leg with the full opening of the cervix with two hands - one inserted into the uterus and the other acting through the anterior abdominal wall.

Obstetrical rotation combined external-internal- see Obstetric turn classic.

Obstetric turn external(v. obstetrica externa) - A. p., produced with the help of hands only through the abdominal wall.

1. Small medical encyclopedia. - M.: Medical Encyclopedia. 1991-96 2. First aid. - M.: Great Russian Encyclopedia. 1994 3. Encyclopedic dictionary of medical terms. - M.: Soviet Encyclopedia. - 1982-1984.

The indication for surgery is the breech presentation of the fetus.

Preparation for the operation. The operation is performed on an empty stomach, after cleansing the intestines with laxatives or an enema (the night before). The bladder is emptied just before the operation.

The pregnant woman is laid on a hard couch, on her back, dressed only in a shirt. The doctor sits down to her right. The position, position, type and presentation of the fetus are established by external methods. Narcosis is not shown.

Operation technique. Very carefully, manipulating both hands at the same time, they move the buttocks away from the entrance to the pelvis high up - above the iliac crest, and the head - down. The turn is considered complete when the head is located above the entrance to the pelvis, and the buttocks are in the bottom of the uterus.

At the end of the operation, small soft rolls of diapers are placed on both sides of the uterus and the entire abdomen is not tightly bandaged with a long towel to keep the fetus in the uterus in the position reached.

The outcome of the operation. Not in all cases, even with a successful external rotation, the achieved longitudinal position of the fetus is preserved.

In modern conditions, the operation of the external prophylactic rotation is practically not used due to the lack of effectiveness and the significant incidence of serious complications (PONRP, uterine rupture, premature onset of labor, etc.).

Combined obstetric rotation with full opening of the uterine os

Indications: transverse (and oblique) position of the fetus; unfavorable presentation of the head - frontal insertion, anterior view of the facial insertion (chin backwards) high straight standing of the swept suture; prolapse of small parts of the fetus and umbilical cord - in the transverse position and head presentation; threatened conditions of the woman in labor and the fetus, requiring the immediate end of childbirth.

Conditions: complete or almost complete opening of the uterine os; absolute mobility of the fetus; accurate knowledge of the position of the fetus; the condition of the uterus and solid parts of the birth canal, allowing the birth of the fetus through the natural birth canal; good condition of the fetus.

The first two conditions are absolute ; with incomplete opening of the uterine pharynx, it is impossible to penetrate with the whole hand into the uterine cavity, with limited fetal mobility, and even more so with incomplete immobility, the production of a classic turn on the leg in order to avoid inevitable uterine rupture in such cases contraindicated.

Preparation for the operation. Preparing for surgery is the usual for vaginal surgery. Deep anesthesia is indicated to relax the uterus and abdominal wall. The position of the fetus and the state of the birth canal are studied in detail by external techniques and vaginal examination. The doctor performs the operation while standing.

Operation technique consists of three stages:

hand selection and insertion into the uterus;

finding and capturing the legs;

actual turn.

The first stage of the operation - the choice and insertion of the hand

When performing the first stage, you should pay attention to the following three points.

The rotation can be done with any hand inserted into the uterus. However, it succeeds if an easily remembered rule is observed: they introduce a hand of the same position.

The arm is inserted with the hand folded conically. To do this, all five fingers of the hand are pulled out to failure and brought together one with the other in the form of a cone. The fingers of the second ("outer") hand push the labia apart, after which the brush, folded with a cone, the back surface of which is turned backwards, can easily be inserted through the vaginal opening into the uterine cavity, pushing the perineum backwards. The hand is introduced necessarily outside the fight. If the fetal bladder is intact, it is opened in the center, and the brush is immediately carried out into the uterine cavity. In this case, if possible, prevent the rapid outflow of water from the uterus.

The hand should be held past the cape. If the presenting head interferes with the advancement of the brush into the uterine cavity, then it is pushed up with the inner hand and taken away towards the back with the outer hand. In the same way, the presenting shoulder of the fetus is pushed aside in a transverse position.

External obstetric rotation of the fetus is one of the oldest methods used in obstetrics. Over the years, obstetricians and gynecologists have changed their attitude towards this method. In the last decade, interest in external obstetric fetal rotation has grown significantly. This is due to the introduction into obstetric practice of the recommendation indicating the greater safety of caesarean section in breech presentation of the fetus. External obstetric rotation has become a safe alternative to caesarean section. We publish a review of the literature and the results of our experience with this manipulation.

external obstetric rotation of the fetus

breech presentation of the fetus

caesarean section rate

1. Notzon F.C., Cnattingius S., Bergsjo P., et al. Cesarean section delivery in the 1980s: international comparison by indication. Am J Obstet Gynecol. Feb 1994;170(2):495-504.

2. Hofmeyr GJ1, Kulier R. External cephalic version for breech presentation at term.

3. Carl V Smith, C.JM Van De Ven et al External Cephalic Version. Updated: Dec 28, 2015 http://emedicine.medscape.com/article/1848353-overview

4. Fernandez C.O., Bloom S.L., Smulian J.C., Ananth C.V., Wendel G.D. Jr. A randomized placebo-controlled evaluation of terbutaline for external cephalic version. Obstet Gynecol. 1997. No. 5: P.775-9.

5. Hannah M.E., Hannah W.J., et. al. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomized multicentre trial Lancet. 2000. No. 356(9239): P. 1375-83.

6. Kukarskaya I.I. Prevention and reserves to reduce maternal mortality in the Tyumen region Abstract of the thesis. dis. doc. honey. Sciences. - Moscow, 2012 - 41 p.

Currently, there is an increase in the frequency of caesarean sections in all regions of the world with affordable medical care. This contributes to an increase in complications associated with operative delivery and increases the risk of complications in subsequent pregnancy and childbirth. The problem of increasing the frequency of cesarean section is also relevant for the Russian Federation, although our country is not the leader of this trend, but it must be taken into account that in many countries one of the leading reasons for the increase in the frequency of cesarean section is the choice of a pregnant woman in the absence of medical indications, this is not for our country legal basis for the operation. In the Russian Federation, the increase in the frequency of cesarean section is due to purely medical reasons.

Classically, approximately 85% of caesarean sections performed for medical reasons are performed for 4 main reasons: a postoperative scar on the uterus; pelvic presentation of the fetus; childbirth dystocia; fetal distress.

In the south of the Tyumen region, the proportion of caesarean sections performed in connection with the breech presentation of the fetus is 11.2% of all caesarean sections. However, in reality, the effect of breech presentation on caesarean section rates is even greater. The main indication for surgery is a postoperative scar on the uterus. And in these women, the need for a caesarean section is more often dictated by a decision made in a previous pregnancy, when the first operation was performed and some of these women were initially operated in connection with the breech presentation of the fetus.

Despite the fact that childbirth with a scar on the uterus has become a well-established practice, it must be recognized that the majority of pregnant women with a scar on the uterus will have a second caesarean section. Therefore, the role of prevention of primary caesarean section is so high. External obstetric rotation is undoubtedly one of the methods of such prevention.

The tactics of providing medical care for breech presentation has changed over the past two decades. Until relatively recently, breech presentation was not considered as a reason for performing a caesarean section. But as medicine developed, perinatal risks decreased, childbirth became safer, and at the same time, the caesarean section itself became safer. The publication of a multicentre randomized trial in 2000 forced obstetricians to rethink their practices. According to this study, in medical settings with low rates of perinatal mortality, breech cesarean delivery is a safer mode of delivery than spontaneous delivery. The results of the study have caused a lot of controversy and criticism, and to date, the mode of delivery in breech presentation is being discussed. But nevertheless, this is a fairly high-quality study, the results of which oblige obstetrician-gynecologists to convey this information to their patients, as a result of which, with a breech presentation of the fetus, patients usually choose a caesarean section.

Given that 3-4% of full-term pregnant women have a breech presentation of the fetus, the transition to the tactics of surgical delivery has significantly increased the trend towards an increase in the frequency of caesarean section. However, there was an alternative to caesarean section - this is an external obstetric rotation of the fetus. As a result of the discussion, the position turned out to be popular - to avoid independent childbirth, but at the same time, to offer external obstetric rotation of the fetus.

A Cochrane review indicates the results of 1245 attempts at obstetric rotation of the fetus, the result of these attempts was a reduction in the frequency of caesarean section in this group by 2 times. At the same time, the group in which the obstetric rotation was performed and the group in which the obstetric rotation was not performed did not differ in the state of the newborns after birth.

There are contraindications for obstetric fetal rotation.

Absolute contraindications:

The decision to perform a caesarean section for other indications (including emergency obstetric conditions),

Rupture of fetal membranes

Fruit with tilted head

Multiple pregnancy (except turning the second after the birth of the first)

Relative contraindications:

maternal obesity,

Small for gestational age fetus (less than 10% OB or weight),

Oligohydramnios (IAI less than 5 cm, reduces the likelihood of a successful turn),

Postoperative scar on the uterus from caesarean section or myomectomy.

Attention should be given to the detection of entanglement of the umbilical cord of the fetus, which prevents the rotation. Cord entanglement around the neck is mentioned as a contraindication in some early guidelines for turning, but these pregnancies are very common and turnable, but should be done as carefully as possible under good heart control and ultrasound surveillance. You should refrain from such manipulations if you are just mastering this manipulation.

It is also interesting to analyze the safety of external obstetric rotation with a postoperative scar on the uterus, previously its presence was often considered as an absolute contraindication, when performing a rotation, we are concerned not only with the condition of the fetus, but also with the integrity of the uterus. However, there are increasing numbers of small studies demonstrating the safety of external obstetric rotation for uterine scarring. And apparently, in some situations, this manipulation can be considered with caution, although the scar is a relative contraindication.

There are ways to increase the likelihood of successful fetal rotation, these include the implementation of the rotation against the background of the introduction of beta-mimetics. The use of other tocolytics is associated with less efficacy or risk of side effects.

Some studies have described the successful use of spinal or epidural anesthesia for turning, which was associated with more frequent successful turns and no increased risk to the fetus. However, this method is often objected to by practitioners due to the fear that anesthesia increases the risk of excessive force when making a turn. This method looks tempting as a last attempt before starting a caesarean section due to the breech presentation of the fetus.

We have been using external obstetric rotation since 2001. More than 400 attempts have been made. In different years, it was possible to deploy from 30% to 78% of the fetuses from the number of pregnant women who attempted external obstetric rotation. The varying rates of successful NAPP were associated with varying degrees of selection at the referral stage, the skill of the obstetrician, and the use of tocolysis prior to the procedure. The use of external obstetric rotation has reduced the need for caesarean section in breech presentation of the fetus. The last series of 50 NAPPs made it possible to deploy 70% of fetuses into cephalic presentation without complications. However, for the entire period of NAPP we have registered 2 cases of detachment of a normally located placenta, which was manifested by bleeding from the genital tract that occurred immediately after the manipulation. All cases of PPROM occurred during an attempt to turn at 37 weeks. In one of the cases, the fetus could not be deployed; in the second case, the fetus was deployed with extraordinary ease into cephalic presentation, after which bleeding began. All two cases of PROM were completed by emergency caesarean section, the newborns were removed in a satisfactory condition. Both cases were not accompanied by large blood loss and the puerperas were discharged on the 4th day with the child home. According to traditional recommendations, we did not use methods of fixing the position of the fetus after a successful rotation. In 4% of cases, a reverse turn of the fetus into a breech presentation was noted. If such a reversal was diagnosed in a timely manner during outpatient follow-up (before the onset of labor), then we practiced a second attempt at NAPP followed by amniotomy. Of the other complications, it is worth paying attention to cases of incoming fetal bradycardia, which occurs in some cases immediately after the rotation, and in some cases during its implementation, which makes it necessary to abandon further attempts to perform it. The possibility of complications during NAPP implementation dictates the need for this manipulation only in a maternity hospital with the availability of rapid deployment of the operating room. Ultrasound control is required before and during the manipulation, monitoring of the fetal heart rate. After the rotation, we practice the control of cardiotocography for an hour. However, many years of experience with NAPP in breech presentation has shown that this procedure is safe and can successfully prevent a caesarean section in many women with a breech presentation.

Bibliographic link

Rudzevich A.Yu., Filgus T.A. EXTERNAL OBSTETRIC TURN IN BELT PRESENTATION OF THE FETUS // International Journal of Applied and Fundamental Research. - 2016. - No. 6-2. – P. 277-279;
URL: https://applied-research.ru/ru/article/view?id=9596 (date of access: 03.11.2019). We bring to your attention the journals published by the publishing house "Academy of Natural History"