Breech mixed breech presentation. What could be the cause of the breech presentation of the child. What is breech presentation of the fetus

breech presentation fetus

At the beginning of pregnancy, while your unborn baby is still very small, he moves freely inside the uterus, changing his position. Over time, as the fetus grows, it becomes tighter and tighter. However, until about 30 weeks of gestation, his position should not be a cause for concern.

By this time, the child, as a rule, turns head down. This position is called head presentation. This is classic version, the most convenient for childbirth. It is in the head presentation that up to 90% of children are born.

However, it happens that the child takes the opposite position. Thus, the buttocks are the presenting part, and this position is called the gluteal, or breech presentation fetus. At breech presentation of the fetus In this case, natural childbirth is also possible, although more difficult.

Presentation is determined during an ultrasound examination and during a manual examination by a gynecologist by palpation of the abdomen. If after 30 weeks your baby has taken a transverse or pelvic position, you will be advised to do some exercises to help the baby roll over. You should not be afraid of this situation, since many children take a classic pose after 32-34 weeks, or even on the eve of childbirth. The proposed course of exercises will allow you to contribute to this process.

A set of exercises for breech presentation of the fetus

1. "Indian bridge". You need to lie on the floor, raise your legs and put a few pillows under the pelvis so that the pelvis becomes 30-40 centimeters higher than the shoulders. In this case, the shoulders, pelvis and knees should form a straight line. Thanks to this exercise, some children turn into correct position from the very first time. If the child is still stubborn, repeat the lesson 2-3 times a day. However, never do this on a full stomach. There is another version of this exercise. You can sit your husband opposite and put your legs on his shoulders so that your popliteal fossae are on his shoulders.

In addition to this classic method, there are also methods for cauterizing certain points on the outside of the little toe on the leg, as well as acupressure inner surface feet. But this requires highly qualified specialists.

2. With transverse and (or) breech presentation of the fetus three more exercises:

Introductory: Feet shoulder-width apart, hands down. For a count of times, raise your arms to the sides with your palms down, stand on your toes and at the same time arch your back, taking a deep breath. For two - exhale and start position. Repeat 4 times.

Basic: Lie down on the side to which the back of the fetus is facing in breech presentation, or opposite to that to which the head is facing in transverse. Bend your knees and hips and lie still for 5 minutes. Then take a deep breath, turn over your back to the other side and lie still for 5 minutes again. Then straighten the leg that you have on top - with the pelvic, or the one on which you lie, with the transverse position of the fetus. The second leg must remain bent. Take a deep breath and again bend the straightened leg at the knee and hip joints, grab your knee with your hands and take it towards the back in breech presentation or towards the buttocks in transverse presentation. At the same time, the torso will lean forward, and the bent leg will describe a semicircle inward, touching the front wall of the abdomen. Take a deep breath, relax, straighten and lower your leg. Then take a deep breath again and repeat the exercise again. This exercise should be done 5-6 times.

Final: Lying on your back. Bend your legs at the knee and hip joints, rest your feet shoulder-width apart on the floor, stretch your arms along the body. On the count of times - inhale and lift the pelvis, resting on the feet and shoulders. For two - lower the pelvis and exhale. Then straighten your legs, tighten the muscles of the buttocks, draw in the stomach and perineum while inhaling. Relax - exhale. Repeat 7 times.

If during the next ultrasound it is found that you have achieved your goal and the baby has turned from the pelvic to the normal position, you can forget the introductory and basic exercises, and perform the final one until childbirth occurs.

If during classes you feel movement in your stomach or something similar to noise, then most likely you have "persuaded" the child to take the correct position. A long walk will help him fix himself in this position. But to make sure of luck, you need to do an ultrasound.

Childbirth with breech presentation of the fetus The following location of the fetus in the uterus is considered normal: the head is located below, located above the bosom, and during childbirth the first one passes through the mother's birth canal. But this is not always the case. In 3-4% of all women, the fetus is located in the uterus on the contrary, in the so-called breech presentation. In breech presentation, the buttocks of the fetus (gluteal), legs ( foot presentation) or buttocks together with legs (mixed breech presentation).

Childbirth in this case can proceed quite normally, but situations often arise that are unfavorable for the mother and child.

Why does breech presentation occur?

Possible causes of breech presentation of the fetus:

- increased fetal mobility with polyhydramnios, premature pregnancy (the amount of water is greater than with full-term pregnancy), multiple pregnancy,

– narrow pelvis, placenta previa (location on the path of the fetus moving along the birth canal), fetal abnormalities (large disproportionate dimensions of the fetal head)

- oligohydramnios, anomalies in the development of the uterus. This limits the mobility of the fetus in the uterus.

- Decreased uterine tone. The ability of the uterus to correct the position of the fetus in response to irritation of its walls decreases.

What types of breech presentation of the fetus are there?

Allocate the following types breech presentation of the fetus:

gluteal (buttocks are located above the womb, legs are extended along the body)

foot (legs of the fetus are presented)

mixed (buttocks facing the mother's pelvis along with legs bent at the hip and knee joints).

Leg presentations are formed during childbirth. Breech presentations make up 30-33% of all breech presentations. Very rarely, in 0.3%, there is a knee presentation, a kind of foot presentation, in which the bent knees of the fetus face the mother's pelvis.

How to recognize the breech presentation of the fetus?

With external obstetric research during examination of a pregnant woman above the entrance to the pelvis, a large irregular shape and soft consistency of the presenting part. There is also a high standing of the uterine fundus compared with the same gestational age with cephalic presentation. This is due to the position of the pelvic end of the fetus above the entrance to the mother's pelvis until the end of pregnancy and the onset of labor. In the bottom of the uterus, on the contrary, a dense, rounded fetal head is determined. Fetal heartbeat is best heard in pregnant women in breech presentation above the navel.

You can clarify the diagnosis with a vaginal examination. At the same time, softish tissues of the presenting buttocks and legs of the fetus are probed. Since all pregnant women repeatedly undergo an ultrasound examination during pregnancy, diagnosis is not difficult.

How does pregnancy proceed with a breech presentation of the fetus?

Pregnancy with a breech presentation proceeds in the same way as with a head presentation. Starting from the 32nd week of pregnancy, with a diagnosis of breech presentation, a certain set of exercises is recommended to correct it. The pregnant woman, lying on the bed, turns alternately on the right and left side and lies on each for 10 minutes. And so 3-4 times. Classes are held 3 times a day. Often, the fetal rotation on the head occurs during the first 7 days, if there are no aggravating circumstances (oligohydramnios or polyhydramnios, irregular shape of the uterus). The meaning of these exercises is to stimulate the nerve receptors, increase the excitability and motor function of the uterus. If by 37-38 weeks the stubborn baby has not changed its position, childbirth is carried out in a breech presentation. 2 weeks before the expected date of delivery, hospitalization is offered in a hospital, where the issue of the method of delivery is decided.

How to give birth with a breech presentation of the fetus?

AT maternity hospital to decide on the method of delivery (caesarean section or childbirth through the natural birth canal), the following points are evaluated:

age of the woman (the first childbirth after 30 years is referred to as aggravating moments)

how past pregnancies went, whether there were births and how they ended. An important point is the presence in the past of independent childbirth.

how did the real pregnancy go, are there any swelling, high blood pressure, impaired kidney function

estimated fetal weight (estimated baby weight over 3500 g inclines to a decision in favor of caesarean section)

fetal condition (signs of chronic hypoxia, lack of oxygen, which can be aggravated against the background of prolonged labor)

the size of the mother's pelvis (there is a tendency to develop a clinically narrow pelvis during childbirth). It is possible to use X-ray pelviometry (assessment of the size of the bone pelvis using X-rays)

the condition of the cervix, its readiness for childbirth (the mature cervix is ​​soft, shortened to 1.5-2 cm, located in the center of the small pelvis, skips the tip of the finger)

type of pelvic presentation. The most unfavorable is considered - foot presentation ( frequent complications in the form of prolapse of the fetal leg, loop of the umbilical cord

the position of the fetal head (with excessive extension, according to ultrasound, operative delivery is also recommended). This can lead to brain injury, cervical spine.

If there are complications during pregnancy, a narrow pelvis, a fetus weighing more than 3500 g, the age of a primiparous woman is more than 30 years, a decision is made to deliver a pregnant woman with a breech presentation of the fetus by caesarean section. The frequency of caesarean section with breech presentation of the fetus is more than 80% on average.

Assistance in childbirth with breech presentation of the fetus

After the operation, a scar remains on the uterus, so if the condition of the mother and fetus is good, the cervix is ​​mature and the baby is supposed to be small, childbirth is carried out under careful control on one's own.

In the first stage of labor (contractions and dilatation of the cervix), a woman must observe bed rest to avoid complications (premature discharge of water, prolapse of the fetal leg or umbilical cord loops).

If, after all, a decision is made to deliver childbirth through the birth canal, obstetric care is provided in the form of benefits in the second stage of childbirth. The main principle is to maintain the articulation of the fetus (the legs are extended along the body and pressed to the chest by the arms of the fetus). First, the baby is born to the navel, then to the lower edge of the angle of the shoulder blades, then the arms and shoulder girdle, and then the head. As soon as the baby was born before the navel, his head presses the umbilical cord with the development of a lack of oxygen. Before full birth the child should take no more than 5-10 minutes, otherwise the consequences of oxygen starvation can be very unfavorable. A perineal incision is also made to speed up the birth of the head and make it less traumatic. They also use a dropper with reducing agents (), antispasmodics (no-shpa).

Condition of children born in breech presentation with independent childbirth, requires increased attention. Frequent signs hypoxia suffered during childbirth adversely affect the nervous system of the child (consultation of a neurologist). Often such a pathology as a dislocation of the hip joint. A neonatologist must be present at the birth pediatrician) to provide resuscitation, if necessary. With these precautions, children born in this way are no different from other children.

Video. breech presentation at 20 weeks

Breech presentation of the fetus - the placement of the child along the uterine cavity, while the legs and buttocks are directed to the small pelvis. Some women do various exercises with the breech presentation of the fetus, but such activities are not recommended without the advice of the attending physician.

At about 20 weeks, the baby in the womb turns over, that is, takes a head-down position, its back is turned to left side. This placement of the fetus is correct, called cephalic presentation. In this position, all children are born, with the exception of 10%.

Etiology

There are various reasons for the formation of a breech presentation of the fetus. The following factors can prevent the correct position of the fetus in the uterus:

• the presence of fibroids in the lower part of the uterus;
• irregular shape of the pelvis (especially if the pelvis is narrow);
• the presence of neoplasms internal organs pelvis
• diseases: cephalocele, and others;
• low position and .

Too high muscle tone of the lower uterus and low in the upper segment. In this situation, the head turns away from the pelvis and turns to the top of the uterus. Such a contraction of the muscles of the uterus, especially in the third trimester, occurs due to an improperly developed organ. This can happen due to its inflammation, frequent curettage, a large number of births, difficult births.

A negative effect on the tone of the muscles of the uterus has a scar formed after a cesarean. There is another reason that affects this situation - a large activity of the fetus, which can begin with:

• large volume of amniotic fluid;
• delay physical development;
• prematurity.

Low mobility occurs under such conditions:

• change in the shape of the organ during the development of anomalies;
• a small amount of amniotic fluid;
• entanglement of the fetus with the umbilical cord, any part of the body can suffer;
• too short umbilical cord.

Scientists have made some observations, during which the following fact was established: if a woman was born in a breech presentation, then during the period of gestation, the fetus will take the same position. This suggests that one of the reasons is a genetic predisposition. Today, scientists have not yet fully studied this issue.

If a subsequent pregnancy in a woman proceeds against the background of the same negative factors, as the previous one, then the risk reappearance pathology is very high.

In some cases, it can be difficult to establish the cause of this position of the baby, in addition, the factors can be combined.

But still, the main causes of breech presentation are called:

• narrow pelvis of a woman in labor, having an irregular shape;
• pathological changes in the organ, for example, a formed scar, developmental pathology, inflammation;
• the presence of neoplasms;
• diseases in which failures occur in the autonomic nervous system;
• frequent curettage, numerous and complex childbirth;
• absence or excess of amniotic fluid, delayed physical development of the fetus, oxygen starvation.

Despite this, the child still tries to take the most comfortable position for himself, in addition, the instinct of self-preservation "prompts" him to the chosen position.

Classification

Breech presentation in obstetrics is divided into gluteal and foot:

1. Gluteal. Only the gluteal, that is, incomplete - this means that only the baby's buttocks are directed towards the pelvis, the legs will be extended along the body. This position - pelvic longitudinal presentation of the fetus, is observed in seventy percent of cases.
2. Mixed gluteal. It means that not only the buttocks are deployed to the entrance to the pelvis, but also the legs, which are bent at the knees and pelvis. This position of the fetus occurs in twenty-three percent of women in labor.

Foot (observed in ten percent of pregnant women) are divided into the following subspecies:

• complete, when both legs are turned to the pelvis;
• incomplete - only one leg;
• knee - the baby's knees are directed to the pelvis (such a presentation occurs in 0.3 percent of cases).

The classification is carried out on the basis of the features that caused the biomechanism of the onset of labor.

If the fetus has a breech presentation, the pelvis of the woman in labor is not narrow, then the woman can give birth on her own, without complications. When the presentation of the fetus is foot or mixed, it is necessary to resort to a caesarean section, because in this case the prognosis for the health and life of the child is unfavorable.

Foot presentation is the most unfavorable, because serious complications can appear.

Symptoms

Breech presentation in comparison with the head presentation is more dangerous, because it can happen:

• spontaneous abortion;
• will occur, that is, there will be a malfunction in the work of the kidneys, blood vessels and brain of a pregnant woman;

The above conditions can affect the development of the nervous, endocrine and other systems of the baby. Breech presentation, which is diagnosed at 32 weeks of pregnancy, begins to slow down the development of the medulla oblongata. As a result, pericellular and perivascular edema occurs, one of the layers of the adrenal glands is depleted, and the protective reactions of the fetus are reduced.

With breech presentation, the fetus develops defects:

• hearts;
• central nervous system;
• gastrointestinal tract;
• musculoskeletal system.

If there are violations of the placenta in terms of blood flow, then the fetus appears:

• oxygen starvation;
• heart palpitations;
• reduced motor activity.

When labor begins with a breech presentation of the fetus, the intensity of the labor process often decreases in a woman. With mixed breech or foot presentation, more complex changes appear.

Diagnostics

If the pregnancy proceeds normally, without complications, then by the twenty-fourth week the fetus turns head down. However, in a period of three months, the situation may change repeatedly. At this time, multidirectional contractions of the uterus, that is, its individual sections, occur. Such contractions maintain proper blood flow in the uterus and placenta. The change in the posture of the fetus can take place several times a day. The baby takes its final position by the thirty-fifth week. If this is a breech presentation, then you need to prepare for labor activity with this pathology.

Based on the foregoing, we can conclude that the diagnosis of "breech presentation of the fetus" at the thirty-fifth week will be correct. If it is placed at earlier stages of pregnancy, then the conclusion of the doctor is erroneous. To diagnose breech presentation, two types of research are used:

• external obstetric examination;
• vaginal examination.

With breech presentation, the bottom of the uterus is high above the pubis, and this is not typical for certain period pregnancy.

During an external examination, the doctor determines the large, round, hard and moving part - this is the baby's head. With a breech presentation during a vaginal examination, the doctor palpates the soft volumetric part, the inguinal fold, coccyx and sacrum are clearly felt on it. The doctor should not determine the sex of the baby during palpation, because the genitals can be damaged.

If the presentation is foot or mixed-buttock, then you can feel the feet. They can be distinguished from the child's hand by the fact that the calcaneal tubercle and short fingers, which are located on the same line, are easily determined.

Foot presentations are the easiest to recognize. Most often there are problems with the definition of the gluteal, which can be confused with the facial or frontal.

To correctly determine the presentation, it is necessary to conduct an ultrasound examination. As additional diagnostics are used:

• echography;
• dopplerography;
• cardiotocogram;
• computer cardiointervalography.

Ultrasound will help to make the correct diagnosis. Sonography will determine the presentation of the fetus and its variety. For this, it is better to use three-dimensional echography.

Treatment

A pregnant woman with a breech presentation of the fetus is determined in a hospital. Basically, this happens as early as the thirty-ninth week. The hospital staff will necessary examinations and choose the mode of delivery. The choice of method takes place only on an individual basis, because it depends on many reasons:

• the number of previous pregnancies and births;
• the age of the woman in labor;
• gestational age;
• readiness of the body for childbirth;
• the size of a woman's pelvis and much more.

It cannot be said unequivocally that a caesarean section is necessary with a breech presentation of the baby. But if it is combined with complicating reasons, then only surgery is prescribed.

A caesarean section will be scheduled if:

• a woman over thirty years old, and this is the first birth;
• the patient suffers from nephropathy;
• extragenital pathology;
• violation of fat metabolism;
• narrow pelvis;
• large fruit, more than four kilograms;
• violation of blood flow;
• Rhesus incompatibility of the blood of the fetus and the pregnant woman;
• breech presentation and foot presentation.

Natural childbirth is possible with a diagnosed breech presentation, if there are no health complications in the mother and unborn child. The baby should be full-term, medium-sized.

It is necessary that with breech presentation the mechanism of childbirth be spontaneous. In the first period of labor, the pregnant woman should not get out of bed and lie only on her side when the fetal spine is determined - this will help reduce the risk of complications. The fetal heartbeat and uterine contraction during this period must be strictly controlled. In the second period, medical personnel provide benefits. The baby is born within five to ten minutes. If necessary, a perineal incision is made.

The birth of a baby in a natural way, if a foot presentation is diagnosed, is possible only in women who have given birth earlier, with a full-term pregnancy, a small fetus. In addition, a written refusal of the woman in labor from a caesarean is required.

After the birth of babies with a breech presentation, they need special attention. Oxygen starvation, which newborns suffered, can give complications to the nervous system. But if the doctors provided qualified assistance, further development such children will not be different from others.

Possible Complications

A child who was born in a breech presentation often suffers from complications:

• intracranial injury;
• spinal pathology;
• hip disorder.

If the baby's neck was wrapped around the umbilical cord or the baby swallowed amniotic fluid, resuscitation is necessary. Immediately after the birth of such children, they should be examined by a neurologist.

As for the woman in labor, after delivery, the woman has such complications:

• rupture or forced incision of the perineum;
• rupture of the cervix;
• vaginal rupture;
• pelvic bone injuries.

How to avoid possible complications, the attending physician will prompt.

Prevention

Preventive measures that contribute to normal delivery are as follows:

• it is necessary to identify the reasons why the pelvic position of the fetus may occur;
• adhere to the physiological course of pregnancy;
• prevention medicines and timely identification of the causes threatening miscarriage;
• warning of a large fetus;
• gymnastics with pelvic presentation of the fetus;
• inform the woman in advance about the caesarean section;
• proper preparation women to upcoming birth;
• professionally performed childbirth;
• rendering special attention baby after childbirth.

All preventive actions are aimed at correcting disorders that occur during pregnancy and childbirth, both in the mother and in the child.

Pregnancy, planned or spontaneous, is a physiological process, which means it is not always predictable. Sometimes, up to 35 weeks, the baby changes its position several times, in which case they talk about the unstable position of the fetus. But after 35 weeks, as a rule. position is determined. In most cases, this is head presentation, less often - pelvic, even more rarely - oblique and transverse position of the fetus. We'll talk about such non-standard situations today.

The position of the fetus in the uterus is determined by many factors, both on the part of the mother and the fetus.

Pregnancy and childbirth with a breech presentation of the fetus is classified as pathological obstetrics due to possible risks and complications.

Causes of breech presentation of the fetus

maternal

Anomalies in the development of the uterus. This includes malformations of the genital organs, such as saddle uterus, bicornuate uterus, doubling of the uterus. Sometimes such anomalies are first detected during pregnancy. Pregnancy in these cases is observed in the group of medium and high risk.

Polyhydramnios. An increase in the amount of amniotic fluid creates the prerequisites for repeated movement of the fetus in the uterus, it turns over several times and may remain in a breech presentation. in addition, with polyhydramnios and breech presentation, there is a high risk of entanglement of the umbilical cord around the neck and trunk of the fetus.

Low water. Reduced, compared with normal, the amount of amniotic fluid, on the contrary, limits the movement of the fetus. Normally, the fetus at full term turns head down; in case of oligohydramnios, it has practically no space for this action.

Umbilical cord wrap. Sometimes entanglement occurs spontaneously. If at this moment the fetus was in a breech presentation (for example, in the period of 23-24 weeks, as is often the case), then the coup is limited by the mechanical tension of the umbilical cord loop.

- Multiple pregnancy. If you are expecting not one baby, but twins or triplets, then you should be prepared for the fact that not all babies will be born with a head. Again, due to the limited space for the coup, one of the fetuses is more likely to be in the breech presentation. If the first fetus goes with the head, and the second in the breech presentation, then the birth proceeds more safely, since the first baby has time to expand the birth canal.

Myoma of the uterus. Large fibroids also create a purely mechanical obstacle to turning the baby head down. Of particular danger are myomatous nodes growing inward, into the uterine cavity.

Decreased tone and contractility of the uterus. Such a condition can be observed in multiparous women, if a history of several abortions or curettage for therapeutic and diagnostic purposes. In women who have undergone a caesarean section or myomectomy, scars remain on the uterus, which also reduce local contractility of the myometrium and can prevent the baby from turning.

Placenta previa. Placenta previa is the complete or partial occlusion of the internal os by the placenta. Normally, the pharynx is free. the placenta is in the bottom or not lower than 7 cm from the internal pharynx. if the pharynx is blocked, then restrictions are created for stretching the lower segment of the uterus, there is less opportunity for the fetus to turn onto the head.

Short umbilical cord. The absolute shortness of the umbilical cord (less than 40 cm) mechanically prevents movement inside the uterus.

Anatomical narrowing of the pelvis or deformities of the pelvic bones. An anatomically narrow pelvis or displacement of the pelvic bones (as a result of trauma or previous diseases, rickets or tuberculosis of the bones, severe scoliosis) limits the movement of the fetus and prevents rotation.

fruit

Malformations of the fetus. Defects that interfere with the movement of the fetus should be very pronounced. For example, a large goiter (enlargement of the thyroid gland) or hydrocephalus with a significant increase in the size of the head. Such defects are diagnosed by ultrasound and in this case the issue of termination of pregnancy for medical reasons is decided. It is rare, detectable by ultrasound is reliable.

Violations of the formation of the vestibular apparatus in the fetus. There is also such a version of the formation of breech presentation, but the diagnosis of the health of the fetus can be carried out only after childbirth. There is no threat to the life of the fetus in this condition.

Prematurity (unstable position of the fetus up to 35 weeks)

Constitutionally small fetus or delay prenatal development. The small size of the fetus predisposes to active movements and movements of the child inside the uterus.

Classification

Breech presentation is divided into several types. It is very important for a doctor and a pregnant woman to decide on the type of breech presentation, since the tactics of childbirth and the prognosis for the life and health of the baby depend on this.

1. Pure breech presentation. This means that the child lies to the exit with the buttocks, the legs are unbent at the knees and pressed to the stomach. this type of breech presentation occurs in 50 - 70% of cases, more often in primiparas.

2. Mixed. In this case, the child, as it were, squats down. Both the buttocks and the feet of the fetus are presented to the exit from the small pelvis.

3. Foot. Most dangerous view pelvic presentation. The legs of the fetus are presented, one (the second is unbent and pressed to the stomach or more often bent at the knee and pressed to the stomach) or both. It is observed in 10 - 30% of cases, mainly in multiparous. Mixed breech presentation is up to 5 - 10%, occurs equally in multiparous and primiparous.

4. Knee. The knees of the fetus are presented to the exit, it is extremely rare. In childbirth, it passes into the foot.

Diagnostics

Primary diagnosis is ultrasound screening. In the second trimester, ultrasound determines the position (longitudinal, transverse) and presentation of the fetus (head, pelvic). The location of the fetus, determined at 20-23 weeks is not final, the situation in most cases changes to the head one by the third screening.

In the third trimester, if breech presentation is preserved, it can be determined by gynecological examination. With an external obstetric examination, by palpating the abdomen, the doctor can find out the location of the fetal head. When viewed on a chair, it is possible with a high degree of probability to determine the presenting part: the head, buttocks, feet of the fetus.

Complications of childbirth in breech presentation

1. Premature outpouring of waters. This is because there is no pressure on the head and no distinction between front and rear waters.
2. Prolapse of legs during foot presentation, prolapse of umbilical cord loops.
3. Weakness of tribal forces. Primary and secondary weakness of labor activity develops due to weaker pressure (compared to the head) of the soft pelvic end on the uterine os, as well as long and ineffective contractions (cannot be stimulated).
4. Intranatal hypoxia and fetal asphyxia. During childbirth, the loops of the umbilical cord can be pressed against the walls of the pelvis, if the duration of pressing is more than 5-7 minutes, then severe oxygen deficiency develops.
5. Throwing back the handles and overextension of the head. The pelvic end is soft and narrower than the head, so there is not enough expansion of the birth canal, and the denser and larger part comes out last. This can lead to difficulty in removing the head, tilting. And then, when providing benefits, there is a high risk of overstretching the cervical spine and damage to the nerve plexuses.
6. Aspiration (inhalation) of amniotic fluid. Inhalation of even normal, clear amniotic fluid causes aseptic inflammation varying degrees gravity. In the case of meconium aspiration (inhalation of green waters, which are colored with original feces - meconium), the prognosis worsens significantly.

Management of pregnancy in breech presentation of the fetus

Inspection, laboratory and instrumental examinations are performed according to the standard. Consultation with a geneticist for suspected birth defects fetal development.

If in the period of 32 weeks or more the fetus has not turned head down, while there are no obvious factors causing breech presentation (for example, large fibroids or complete placenta previa), then special complex exercises. It is aimed at the work of the abdominal muscles and increases the likelihood of the baby turning into head presentation.

A set of exercises for breech presentation

Bridge. Lie on the floor, raise your pelvis and place 2-3 pillows under your ass. Then, as you lower yourself onto the pillows, your pelvis and knees form a straight line. Lie in this position for a few minutes, if it does not cause discomfort. Sometimes this exercise helps quickly, but you can repeat it up to 3 times a day. You can not perform this exercise after eating and drinking, if you are already worried about heartburn, if there is a threat of premature birth.

Breath. Stand in the starting position, feet shoulder-width apart, arms down. Inhaling, raise your hands with your palms down to shoulder level, at the same time rise on your toes and slightly bend your lower back forward. Then slowly lower yourself. Repeat 4 times in one go.

Turn. Lie on the floor (the surface should be fairly hard, the sofa will not work), turn on the side towards which the back of the fetus is facing (in a transverse position, on the one where the head is). bend and pull your legs towards you, lie down for 5 minutes.
then take a deep breath and exhale through the back, turn to the other side, lie down for another 5 minutes, breathing is free, even.
Then straighten the upper leg (in the pelvic position) or the lower leg (in the transverse position), take a deep breath and exhale and bend the leg. Take the bent leg outward, without feeling pain and discomfort. If the exercise does not cause discomfort, then you can repeat it up to 5 times in one go.

Bridge-2. Lying on the floor, rest your feet on the floor, arms along the body. As you inhale, lift your pelvis up, hold for a few seconds, and as you exhale, lower yourself. Then, while inhaling, tighten the muscles of the perineum, while exhaling, relax. Repeat several times.
It is better to perform exercises in this order, so the muscles are smoothly included in the work and there is no sharp overload of the body.

If on the ultrasound you saw that the child turned his head, then continue to perform only the last exercise.

Contraindications to exercise: the threat of premature birth, fetal malformations, large fibroids, uterine malformations, complete or partial presentation placenta, bloody issues from the genital tract of an obscure nature, drawing pains in the abdomen and lower back of an obscure nature.

You can perform exercises only in agreement with your doctor, starting from 32 weeks until childbirth.

External rotation of the fetus.

This is an obstetric manual, which was described many years ago by the Russian doctor B.A. Arkhangelsk. Lately he's attracted increased attention especially in Western doctors.

The result is achieved in about 50% of cases. It is performed within 34 - 36 weeks, the earlier the rotation is carried out, the more likely it is to be successful. But the likelihood of a reverse reversion also increases.

Contraindications for admission obstetrical rotation: the threat of premature birth, spotting, uterine defects, placenta previa, twins / triplets, oligohydramnios, signs of fetal hypoxia.

Previously outer turn has not been performed in women with a uterine scar, now it is a relative contraindication (an individual risk assessment is required, examination by a council of doctors is possible).

External rotation is also not started if leakage of amniotic fluid is detected or cervical dilatation has begun.

Ultrasound of the fetus with fetometry. The necessary conditions: small fruit weight (exclude large fruit 4000 g or more), normal amount water, no obvious defects, normal localization of the placenta.
- The introduction of beta-agonists (hexoprenaline) intravenously under the control of blood pressure and pulse. Beta-agonists relax the smooth muscles of the uterus and increase the chances of success. For the mother, the introduction of hexoprenaline (gynepral) may be complicated by a decrease in blood pressure, tachycardia, weakness and headache.
- It is possible (but not always) the use of epidural anesthesia.
- The rotation is started from the presenting part (putting the hand on the pelvic end), as shown in the picture. The movements are smooth, in a circle, without sharp shocks.

After the turn, both in case of success and in case of a failed turn, the condition of the fetus is monitored. First of all, the fetal heartbeat is heard, then cardiotocography (CTG) is performed. Dopplerometry is controlled according to indications.

Complications of external rotation:

Acute hypoxia of the fetus (due to impaired blood flow in the umbilical cord, pressing the loops), is recorded by CTG (decreased heart tones, irregularity, muffled tones),
- placental abruption (partial, rarely complete) up to 1.4% of cases. In this case, emergency operative delivery is indicated.
- trauma of the brachial plexus as a result of throwing back the handles.
- antenatal fetal death (acute hypoxia, uterine rupture along the scar and other rarer causes).

At the right tactics the prognosis for the fetus is favorable. An external obstetric turn, with skillful and competent execution, is also rarely fraught with complications, but it is impossible to insure against them. Whether or not to agree to this procedure is your choice, you can always consider it, discuss all the risks and benefits with your doctor and accept final decision. Independent childbirth with foot and mixed breech presentation does not always have a favorable prognosis, the risk of birth trauma and disability of the child is high.

Birth in breech presentation

In order to determine the tactics of conducting childbirth, a number of factors must be taken into account:

1. Age of the patient. Primiparas over the age of 30 and young primiparous(up to 18 years, and especially up to 16 years) have a greater risk of injury to the mother and fetus during childbirth. This is due to the lesser elasticity and extensibility of the perineal tissues.

2. Obstetric history. It is important to know: what births are in a row (primiparas are more at risk in terms of birth trauma), how the previous births proceeded, whether there were complications, bleeding, trauma to the child, how this pregnancy proceeded.

3. Evaluation of the birth canal
- examination of the cervix, assessment of its maturity (readiness for childbirth),
- evaluation of the woman's pelvis.
If there is an initial anatomical narrowing of the pelvis (even a slight one), then spontaneous childbirth can be dangerous.

4. Assessment of fetal parameters. If a child weighing more than 4000 grams is classically considered a large fetus, then in the case of a breech presentation, a fetus weighing 3600 grams or more is already considered a large fetus.
- Compensated state of the fetus, no signs of hypoxia, palpitations according to CTG and hemodynamic disturbances according to Doppler

5. Features of breech presentation
- type: gluteal, mixed, foot, knee,
- position of the head: flexion (normal), extensor (pathological position).

Independent childbirth

Independent childbirth in the breech presentation is allowed with a purely breech presentation, a compensated state of the fetus weighing from 2500 to 3500 grams, the normal size of the mother's pelvis, and the readiness of the birth canal. Antenatal hospitalization indicated.
Pregnant women with a breech presentation of the fetus are not stimulated for childbirth, do not use the preparation of the cervix with tablets or gels, do not perform amniotomy (opening the membranes).

Women who have a uterine scar from a previous caesarean section or myomectomy are also more likely to have an operative delivery. In this case, they are guided by the desire of the woman (to give birth herself) and the internal protocols of the medical institution.
And take into account all the above factors.

Childbirth is accepted only by a doctor.

During childbirth in head presentation, obstetric assistance is provided by a midwife, only if difficulties arise - by a doctor.

In independent childbirth with breech presentation, an allowance according to Tsovyanov is necessarily provided.

If the allowance for Tsovyanov is provided in the event of a planned birth in the breech presentation (manual according to Tsovyanov No. 1), then the goal is to maintain the safest articulation of the body parts of the fetus (the legs are extended and pressed to the body), to prevent premature birth of the legs, throwing back the arms and overextension of the head.

The doctor is positioned so that his shoulder girdle is at the level of the woman's perineum. The hands are arranged in a ring, thumbs down, the rest on top. As the buttocks of the fetus advance, the doctor shifts the tissues of the perineum with “removing” movements and gradually releases the presenting part, while the thumbs firmly press the legs in the abdomen of the fetus. In 1 - 2 attempts the fetus is born before the umbilical ring. Then you have to bring the handles out, if they do not fall out on their own, then you need to tilt the body of the fetus downward and the front handle falls out from under the pubic arch.

The thinnest part is the removal of the fetal head. If she is not born easily along with an attempt, then the Morisot-Levre technique is used.

When performing this technique, the fetal body is located on the obstetrician's hand, the 2nd and 3rd fingers of this hand are inserted into the vagina, you need to find the fetal mouth and press lower jaw. It turns out that we bend the head. The second hand (index and middle fingers) at this time should hold the fetal neck. Extraction is carried out according to the biomechanism of childbirth, depending on which plane of the pelvis the head is located at this time. At the very end, the body is retracted strongly anteriorly and the head is born.

If the allowance for Tsovyanov (manual according to Tsovyanov No. 2) turns out to be in foot presentation, then the scheme of actions is somewhat different. In general, foot presentation is an absolute indication for caesarean section, but if a woman was admitted already in childbirth, with full opening and surgical intervention is impossible, then you have to act according to the situation. Planned such childbirth should not occur.

The goal in providing benefits for Tsovyanov No. 2 is to prevent premature birth legs, throwing back the handles and hyperextension of the head. This is achieved by the fact that the foot presentation is translated into mixed.

As soon as the legs begin to be determined in the birth canal, the doctor sits down in the same way as when providing the usual benefits according to Tsovyanov, a sterile napkin is placed on the perineum (to weaken the slip) and resistance is exerted with the palm of the hand until the buttocks fall and the fetus "sits on squat."

Then the hands are located in the same way as with the usual Tsovyanov manual, the body of the fetus is wrapped around the hands of the obstetrician and gradually removed using the force of attempts.

When providing any of these benefits, one should not pull the body of the child, only assist the mother's efforts and follow the natural biomechanism of childbirth.

If everything goes well, then the birth of a child goes smoothly, but complications may arise: tilting one or both handles, tilting the head, difficulty in the birth of the head and shoulder girdle.

In these cases, a classic manual aid is provided.

Classic manual manual is performed as follows: the obstetrician's hand is inserted into the vagina on the side of the fetus, with the palmar surface towards the fetus. The angle of the scapula is found and the handle is withdrawn with a "washing" movement. With the left hand, the obstetrician displays left handle, right - right. Further, if the head is in the extensor position, then the Morisot-Levre technique is performed. During all the manipulations, the assistant (midwife) holds the bottom of the uterus.

Indications for caesarean section with pelvic presentation of the fetus:

mixed breech presentation,
foot and knee presentation of the fetus,
breech presentation of the fetus in a pregnant woman with a scar on the uterus,
breech presentation of the first fetus from twins,
extensor position of the head in breech presentation,
large fruit (more than 3600 grams),
breech presentation of the fetus in a woman with anatomical narrowing of the pelvis and / or deformity of the pelvis (oblique, oblique pelvis),
lack of biological readiness for childbirth, a tendency to overbearing (immature cervix),
primiparous age over 35 years ( relative reading),
weighed down obstetric history (habitual miscarriage, long-term infertility, pregnancy as a result of IVF, perinatal loss or perinatal fetal trauma in anamnesis),
low placentation or marginal placenta previa (relative indication).

These are indications for operative delivery, associated only with the position of the fetus. Other indications may arise independently (acute fetal hypoxia, indications from the heart or blood pressure, about diabetes in a pregnant woman, and so on).

The operation of caesarean section is carried out according to the general canons. As a rule, such operations should be carried out in a level 3 facility (in perinatal centers), where there is resuscitation of newborns and the second stage of nursing children.

Transverse and oblique position of the fetus

These provisions are rare, approximately 0.5 - 0.7% of all cases. They are referred to wrong positions fetus.
In the transverse (A) position, all parts of the fetus are above the conditional line connecting the iliac spines.
With oblique (B) - the head or pelvic end crosses this line at an angle.
In both cases, the presenting part is not defined.

The reasons for such positions are the same as for breech presentation. Ultrasound reliably confirms the position of the fetus, and it is also possible to identify a possible cause - polyhydramnios, fetal or uterine defects, placenta previa.

Complications due to oblique or transverse position of the fetus: premature outflow of water, premature birth, increased risk of postpartum hemorrhage.

Delivery is only operative.

In a planned manner during full-term pregnancy, or in urgent order when water breaks or any other emergency obstetric situation develops.

Prolapse of small parts of the body is a specific complication that is characteristic only for the transverse, less often oblique position of the fetus. With the outflow of water and a large opening of the uterine pharynx, the uterus begins to develop labor and push the fetus out. The fetus, located incorrectly, cannot be born on its own. There is an acute fetal hypoxia and prolapse of the handle or leg. This is an extremely unfavorable prognostic sign. Most often, in this case, the fetus is no longer viable.

In this case, the mother has a high risk of infection, up to the development of obstetric sepsis.

The unphysiological position of the fetus leads to overstretching of the uterus and an increased risk of rupture, especially the risk is high in multiparous women (dystrophic changes in the uterine wall) and in women with a scar. Pregnancy is carried out under careful supervision, an attempt at an obstetric turn is possible. Antenatal hospitalization indicated.

If you are carrying a baby who is not located as you and the doctor would like, then this is an occasion to take your condition more closely, to take additional actions and follow the recommendations. But there is no reason for panic and frustration. Look after yourself and be healthy!

The correct position is when the fetus is in the uterus with its head closer to pelvic floor and legs up. If the fetus is located with the buttocks or legs down, the birth of the baby may pass with complications. This position in the uterus is called "breech presentation of the fetus." Doctors can voice such a diagnosis to a pregnant patient after the 30th week, when the baby takes the most comfortable position for himself before childbirth. And so that such words of the gynecologist do not become a reason for frustration, we decided to tell you why the child can take this position, and how the birth takes place with the breech presentation of the fetus.

Breech presentation of the fetus is quite common among women in interesting position(in 8-9% of all cases). At the same time, the natural birth of a child in this position is not excluded, although such births are much more difficult.

From conception to birth

From the moment the embryo begins to actively move, it can move freely in the uterine cavity and change its position quite often. However, when he grows up and rapidly gains weight, he has less room for free movement. Therefore, from about 29-32 weeks, the child takes the most comfortable position for himself, remaining in it until he is born.

In most cases, the fetus is positioned longitudinally head down (classic cephalic presentation). This option is considered a classic, in which natural childbirth is allowed. In other situations, if the buttocks, legs are supposed to enter the birth canal, or when the baby is located transversely to the pelvis, doctors advise the woman to give birth through.

However, it is always worth remembering that until the moment of birth, the baby can change its position by turning its head towards the entrance to the small pelvis. This will allow a woman to give birth naturally without injuring the child and without surgical intervention.

To help the baby take the position necessary for delivery, it is necessary to perform special exercises. In addition, turning the fetus in the uterus allows outdoor method exposure (principle of action in the photo), in which the manipulation is carried out by doctors in stationary conditions, it is necessary when using relaxing uterus medications and under ultrasound guidance.

However, let's go back to the beginning and tell you what a breech presentation of the fetus is and what other types of baby positions in the uterus are during pregnancy.

Basic terms and concepts

The ideal option is for the child to assume the correct position before childbirth, when, during delivery, his head appears first, and then the rest of the body. But under the influence of a number of reasons, the baby can turn upside down, which can lead to many adverse effects at his spontaneous birth.

This position is called breech presentation (or breech). And there is the following classification of pelvic presentation of the fetus:

1. Breech presentation- this is when the baby in the uterus is located in such a way that his buttocks will be present at the bottom of the pelvis, and his legs will be straightened and pressed with his knees to the tummy. A similar phenomenon is observed in 50-55% of pregnant patients, mostly primiparas. In turn, the gluteal type of presentation can be purely gluteal or mixed. In the first case, the baby will be located with his buttocks closer to the exit to the birth canal, while his legs, straightened at the knees, will be extended along the body. In the second case, the child in the uterus occupies a position - with the buttocks and feet of the legs bent at the knees (or one foot) closer to the entrance to the birth canal (see photo).

2. foot, which also comes in several types depending on the position of the legs of the fetus:

• full foot presentation - both lower limbs of the child are presenting;
• incomplete - only one leg is adjacent to the entrance to the birth canal;
• knee presentation is a rather rare position when the baby in the stomach takes a pose, as if kneeling.

3. Breech presentation of the fetus- a very common occurrence when a baby in this position is waiting for its birth. The most common is purely gluteal and mixed presentation gluteal type. However, this position may not be maintained until the moment of delivery, because there is a high probability that an arbitrary rotation of the fetus will occur during breech presentation. In addition, the expectant mother can help the baby roll over by performing special exercises for breech presentation. Therefore, women in an interesting position should not be prematurely upset and panic if the doctor announced a similar diagnosis during the examination.

Etiology and provoking factors

Clarifying what breech presentation means, future women in labor are also interested in what the etiology and causes of occurrence can be similar phenomenon. First of all, until now, doctors cannot say definitively what are the causes of breech presentation of the fetus. However, they have already identified a list of provoking factors that can indirectly affect the fact that the baby in the uterus will take a non-classical position.

It is worth noting that all predisposing factors are divided into three groups, depending on what their etiology is.

1. A group of factors that are associated with the body of the expectant mother:

• various congenital or acquired malformations of the uterus, as well as neoplasms and some diseases;
• or decreased uterine tone;
• overstretching of the uterus, provoked by or a large number of births in history;
• pathology of the development of the pelvis;
• numerous abortions, mechanical interventions;
• pregnancy and childbirth with deviations.

2. Factors that are directly related to the fetus:

• prematurity of the fetus, due to which the baby moves less and can remain in the breech presentation until the birth itself;
• bearing 2 or more children, which occurs with the wrong presentation of one or two babies;
• congenital pathologies of fetal development, which include malformations of the central nervous system, urinary, cardiovascular and musculoskeletal systems. In addition, pathologies at the chromosomal level can also affect whether a doctor diagnoses a breech presentation of the fetus during pregnancy.

3. A group of factors whose etiology is associated with the formation and development of the placental system:

• short or umbilical cord wrapping around the baby's neck;
• the placenta presenting to the entrance to the birth canal;
• many;
• , which provokes increased fetal activity, and can also cause malnutrition or abnormalities in the development of the child.

How does pregnancy proceed with such a diagnosis?

As previously indicated, the doctor makes the final diagnosis regarding the position and presentation of the baby in the uterus at 30-36 weeks. But, despite the fact that the child at the time of diagnosis will be in a breech presentation, there is always a chance for a spontaneous coup in the weeks remaining before the birth.

It is worth noting that the classic version of the position of the fetus (upside down) during pregnancy excludes the occurrence of any complications. The likelihood of abnormalities in pregnant women with a breech presentation of the fetus is higher. Therefore, from the moment of diagnosis, doctors put such patients under special control in order to be able to more closely monitor the development of the fetus and the course of pregnancy.

The main deviations that may occur in a patient in a position diagnosed with a breech presentation of the fetus are:

• risk of premature delivery;
• risk of miscarriage;
• placental insufficiency;
• symptoms of gestosis.

Each of these deviations is fraught with oxygen starvation baby in the womb. In turn, this can provoke a delay in development and the appearance of anomalies.

Very often, pregnancy with a breech presentation of the fetus is accompanied by abnormal formation of the placenta (), premature rupture of amniotic fluid, and an unstable position of the child in the uterus.

Considering what breech presentation means and what consequences it entails, doctors not only put patients with such a diagnosis on special account, they prescribe whole line preventive measures. They are considered necessary, as they can prevent the threat of miscarriage, as well as hypoxia. In particular, patients in position are advised to rest more, observe special diet, refrain from intimacy and perform gymnastic exercises that will help “turn” the baby in the womb before the scheduled delivery.

When examining a pregnant woman, gynecologists throughout the entire period of bearing a child monitor its position in the uterine cavity. Therefore, breech presentation up to 21 weeks is considered physiological and does not pose a threat to the baby and his mother. After 30-36 weeks, if the baby does not change its position, experts consider its position presented by the pelvic end to be pathological. This diagnosis is the reason for the appointment of a caesarean section. It will be relevant until an arbitrary fetal flip or external rotation occurs, performed under the condition of stationary observation and constant monitoring of the patient's condition.

What is prevention?

To stimulate the rotation of the fetus in breech presentation, doctors advise expectant mothers not only to reduce physical activity and follow a special diet, but also to perform certain exercises. Especially in order to provoke a coup of the baby in the womb, future women in labor are prescribed special exercises with a breech presentation of the fetus. Techniques according to Dikan and Shuleshova, Bryukhina are actively practiced.

It is worth noting that the most popular exercises for flipping a baby from a pelvic position to a classic one are according to Dikan. To perform them, a woman should take a pose lying on her back. From this position, she needs to turn on her side and lie down for 10 minutes, and then roll over to the other side for another 10 minutes. In just one session, it is enough to roll over 3-4 times. It is advisable to do 2-3 sets per day so that the child turns over. As soon as he assumes a classic pose, it is necessary to fix his position.

One more effective exercise- bridge with support. It can be performed by a pregnant woman with a diagnosis of breech presentation of the fetus after 20 weeks. Having taken a supine position, a woman needs to put her feet on a chair or sofa, placing a roller or a large pillow under her lower back so that the pelvis is above the level of the head, as shown in the photo. It is allowed to lie in this position for about 10-15 minutes (no more). In total, you can resort to this exercise twice during the day, until the baby takes the classic presentation position.

However, despite the high probability of an arbitrary overturn, the implementation of gymnastic exercises has some contraindications. So, for example, if a patient is diagnosed with a severe form of EGP, preeclampsia, or the threat of the onset of labor ahead of schedule, she should not do gymnastics with a breech presentation of the fetus. In addition to this, doctors do not recommend performing physical exercise pregnant women who have a scar on the uterus or appear during / after class.

How can childbirth take place in patients with such a diagnosis?

Although the diagnosis of breech presentation is not definitive until the child is born, it remains a significant factor in determining the delivery option. As a rule, in similar situations when the baby did not want to roll over in the uterus to take the correct position, the doctors insist on a surgical option - a caesarean section. But natural childbirth is not excluded.

When deciding how to give birth in pregnant women with a breech presentation, doctors are also guided by additional information. In particular, they evaluate:

• the age of the patient in position (the risk group is women after 30, for whom pregnancy is the first);
• the course of previous pregnancies (especially the presence of independent childbirth);
• the course of the actual pregnancy (presence or absence of deviations, pathologies);
• the state of the child in the mother's womb;
• the approximate weight of the baby (children weighing more than 3.5 kg are helped to be born surgically);
• features of the physiological structure of the body and the state of the uterine cavity of the woman in labor;
• type of presentation of the pelvic type, as well as the position of the fetus in the uterus.
  In the cases discussed above, obstetricians tend to favor a caesarean section with a breech presentation of the fetus.

Childbirth in patients with a similar position of the fetus in the uterus proceeds under special control. With the onset of labor activity, the woman in labor is advised to observe bed rest. This is necessary to avoid the threat of early rupture of amniotic fluid and prolapse of the lower extremities from the birth canal. If childbirth proceeds naturally, doctors try to maintain the child's articulation, and for the speedy exit from the birth canal without complications () make a perineal incision. Obstetricians carefully monitor the state of health of a newborn born on their own during the first day after the actual delivery.

Delivery in women with a breech baby by caesarean section is performed if there is no evidence in favor of natural childbirth.

Summing up what breech presentation means, and what options for the birth of a baby in this position can be, you should always remember that the process of giving birth to a child is a very responsible and incredibly hard work not only for a newborn, but also for him. mother. Therefore, each case of pregnancy is considered purely individually in order to assess the possible risks and help the child be born completely healthy.

In the early stages of pregnancy, the baby is still so small that it moves freely in the uterine cavity and can take any position there. However, over time, the baby grows and its movements in the uterus become more limited. Thus, by about 28–30 weeks of gestation, it occupies a certain position - as a rule, longitudinal head down. This position of the baby is called head presentation. Normally, a baby is born head first. But sometimes a situation arises when the buttocks or legs of the child are installed above the entrance to the small pelvis by the end of pregnancy. In this case, they speak of a breech presentation of the fetus. The incidence of this complication varies within 2.7–5.4%.

There are several types of pelvic presentation of the fetus:

• purely gluteal (the buttocks of the fetus are installed above the entrance to the small pelvis, while the legs are bent at the hip joints, unbent at the knees and extended along the body);
• mixed gluteal (buttocks are presented with one or two legs bent at the hip and knee joints);
• foot (complete - both legs are presented and incomplete - one leg is presented).

Pure breech presentation is the most common (approximately 65% ​​of cases).

Often during childbirth, a transition from one type of breech presentation to another can occur. Pure breech presentation is more often observed in primiparas, mixed breech and foot - in multiparous women, which is associated with a decrease muscle tone uterus and anterior abdominal wall A: The fetus has the ability to move more. It is noted that breech presentation in multiparous occurs approximately 2 times more often than in primiparas.

Risk factors

There are a number of factors that can contribute to breech presentation:

• narrow pelvis;
• abnormal shape of the pelvis (for example, after rickets suffered in childhood);
• malformations of the uterus (saddle-shaped, bicornuate uterus, the presence of a septum in the uterus);
• uterine fibroids (its benign tumor) and tumors of the uterine appendages;
• placenta previa (the placenta partially or completely blocks the exit from the uterine cavity). In this case, and other states listed above, the normal arrangement fetus, the head cannot take the correct position due to the presence of an obstacle and it is more convenient for the child to sit down with the buttocks;
• excessive mobility of the child with polyhydramnios or limited - with oligohydramnios, multiple pregnancy;
• pathological hypertonicity of the lower segment of the uterus and a decrease in the tone of its upper sections. In this case, the fetal head, as the largest and densest part of the body, repels from the entrance to the pelvis and occupies a position in the upper part of the uterine cavity. Similar violations of the contractile activity of the uterus in the third trimester of pregnancy may be due to dystrophic changes in the myometrium due to previous inflammatory processes, repeated curettage, multiple pregnancies and complicated childbirth;
• malformations of the fetus (for example, hydrocephalus - an excessive increase in cerebrospinal fluid in the cranial cavity, when the enlarged head is too crowded in the lower segment of the uterus and the fetus turns down with the pelvic end).
  In addition, it is noted that those patients who themselves were born in a breech presentation often have a similar situation during their own pregnancy. These facts may testify in favor of a hereditary predisposition to breech presentation. However, this issue requires further study.

Diagnostics

You can determine the location of the fetus in the uterus during a routine external examination by a doctor. antenatal clinic. With breech presentation, the following signs are determined:

When feeling the abdomen, the fetal head is located in the bottom of the uterus (its upper part) in the form of a dense formation, and the buttocks are located below the entrance to the pelvis (large, irregular shape, softer presenting part).

The fetal heartbeat is heard more clearly at the level of the navel and above, in contrast to head presentation, when the heartbeat is heard below the navel.

The most accurate nature of the fetal presentation is revealed by ultrasound, in which it is important to establish the type of pelvic presentation, to trace the location of the legs in breech presentation, to determine whether the head is bent or unbent, what are the features of the location of the umbilical cord. All these data are important in determining further tactics when choosing a method of delivery.

Correction methods

The nature of the presentation is finally formed by the 34–36th week of pregnancy, before this period the baby can still roll over. Breech presentation of the fetus up to 28 weeks of gestation is the norm and does not require any remedial measures - just dynamic observation is enough. The cephalic rotation occurs spontaneously before delivery in 70% of multipregnant women and in 30% of breech-pregnant primigravidas.

If, at a gestational age of more than 28–30 weeks, the doctor detects breech presentation during examination and it is confirmed at the third screening ultrasound of the fetus (at 32–34 weeks of gestation), it is recommended that the pregnant woman perform a set of gymnastic exercises that contribute to the rotation of the fetus on the head. The essence of all these exercises is to create discomfort in a child in a certain position, after which he seeks to take a comfortable and comfortable position, turning over.

There are several methods for such exercises:

Methodology Grishchenko I. I. and Shuleshova A. E.

Exercises are performed before meals 4-5 times a day. It is necessary to lie on the side opposite to the position of the fetus (that is, opposite to the location of the back of the child). Bend your legs at the knee and hip joints. In this position, you should spend about 5 minutes, and then straighten the upper leg and press it to the stomach while inhaling, while exhaling, straighten the leg, bending slightly forward. Repeat these movements slowly for 10 minutes. Then you should lie down for 10 minutes without moving on your back, then take knee-elbow position for 5–10 minutes. Thus, the child has an additional effect that creates inconvenience, and he tends to turn around in order to get into more comfortable conditions.

Method of Dikan I. F.

Exercises are performed 3-4 times a day. It is necessary to alternately lie on the right and on the left side for 10 minutes. You need to change position during the exercise 4-5 times. This technique is well suited for pregnant women with increased tone uterus, since in the position on the side the uteroplacental blood flow improves, the muscles of the uterus relax, and the child has room for movement and the ability to roll over.

"Bridge". It is necessary to lie on a flat sofa or bed, you can on the floor, put a pillow under the lower back so that the pelvis is 20-30  cm above the head.In this position, you should stay for 10-15 minutes. Performed 2 times a day before meals. With this exercise, the baby's head strongly rests against the bottom of the uterus, creating a baby significant discomfort, and it tends to make a turn.

It should be remembered that for all these exercises there are certain contraindications, which include:

• a scar on the uterus (after a caesarean section in a previous birth or other operations on the uterus);
• placenta previa;
• the threat of premature birth;
• oligohydramnios;
• polyhydramnios;
• multiple pregnancy;
• preeclampsia (toxicosis of the second half of pregnancy, manifested by edema, increased pressure, the presence of protein in the urine);
• uterine tumors;
• heavy accompanying illnesses mother (for example, heart defects, arterial hypertension, diabetes).

The effectiveness of these exercises is, according to different authors, about 75%.

Hospital before delivery

Upon reaching the period of 38–39 weeks, all pregnant women with breech presentation are shown antenatal hospitalization in a hospital. There is an in-depth examination of a pregnant woman:

• Ultrasound to determine the type of presentation (pure gluteal, mixed gluteal or foot), the degree of extension of the head (normally, the head of the fetus is bent and the chin is pressed to the chest, extension of the head can complicate its birth), the size of the fetus;
• according to indications (for example, if a large fetus is expected) - X-ray pelviometry ( precise definition pelvic dimensions using computed tomography or magnetic resonance imaging);
• assessment of the fetal condition using cardiotocography - studies of the fetal heartbeat and uterine tone, conducting non-stress test(studying the reaction from of cardio-vascular system fetus in response to its movements: during physical activity, an increase in heart rate occurs);
• assessment of the readiness of a woman's body for childbirth.

Based on the results of the examination, the prognosis of childbirth and the choice of obstetric tactics for their management are determined. During the examination, pregnant women are divided into 3 groups according to the degree of risk of the upcoming birth for the fetus.

To I group include pregnant women high degree risk:

• the estimated weight of the fetus is more than 3600 g - a large fetus;
• narrowing of the pelvis;
• chronic hypoxia(lack of oxygen) fetus;
• extragenital (not related to pregnancy) diseases that affect the condition of the fetus and labor, such as arterial hypertension, diabetes mellitus, kidney failure;
• primiparous older than 30 years.

These pregnant women, as a rule, perform a caesarean section in a planned manner.

In II group includes pregnant women who may develop complications in childbirth (for example, with a low location of the placenta, entanglement of the umbilical cord, rapid labor in past). Childbirth in this group should take place under mandatory intensive monitoring of the state of labor and the fetal heartbeat. If complications occur during childbirth, a caesarean section is performed.

To III group are considered low-risk pregnant women. Childbirth is carried out with the usual observation. This includes women under 30 years of age without serious chronic diseases, with an estimated fetal weight of up to 3600 g, normal sizes pelvis and a satisfactory condition of the fetus according to CTG and Doppler (a method for studying utero-fetal-placental blood flow).

Indications for surgery

Absolute indications for a planned caesarean section are:

• extragenital diseases that require the exclusion of attempts (for example, heart defects, including those operated on, threatening retinal detachment, etc.);
• pronounced violation of fat metabolism (obesity of the 2nd degree and above);
• pregnancy after IVF;
• prolongation of pregnancy (pregnancy 42 or more weeks);
• malformations of the internal genital organs;
• narrowing of the pelvis;
• scar on the uterus;
• estimated fetal weight less than 2000 g or more than 3600 g;
• placenta previa (situations when the placenta partially or completely covers the internal pharynx of the cervix);
• cicatricial changes in the cervix;
• multiple pregnancy (breech presentation of the first, located closer to the entrance to the small pelvis, fetus). In other cases, a caesarean section is performed according to a combination of indications (for example, age future mother over 30 years, complications during pregnancy, chronic fetal hypoxia).
  The caesarean section rate in breech presentation is 80% or more.

How will the birth go?

The main difference between childbirth in the breech presentation through the natural birth canal from childbirth in the head presentation is as follows. The largest part of the fetus - the head - during childbirth in the head presentation, is the first to overcome all the narrow parts of the bone pelvis, while being configured due to soft sutures and fontanelles. If there is a discrepancy between the size of the head and the bone pelvis, then the child simply cannot be born on his own and an emergency caesarean section is performed. If the head has successfully passed all the narrow parts of the pelvis and was born, then the rest of the baby is born without special efforts. In breech presentation, the narrow sections of the pelvis are the first to overcome the buttocks of the child, which happens quite easily, but when it comes to the head, a discrepancy may occur, which will be critical, and surgical intervention will be required.

In childbirth with breech presentation, the following complications may develop:

• Premature discharge of amniotic fluid (rupture of the membranes before the opening of the cervix by 5–6 cm is considered premature, since until this moment the fetal bladder is involved in the process of disclosure). This happens due to the strong pressure of small parts of the fetus on the lower pole of the fetal bladder.
• Prolapse of small parts of the fetus and umbilical cord occurs with premature rupture of the membranes and outflow of amniotic fluid due to the lack of tight contact between the pelvic end of the fetus and the lower segment of the uterus.
• Primary weakness labor activity occurs at the beginning of labor due to premature rupture of amniotic fluid and insufficient pressure, which is softer than the head of the pelvic end of the fetus on the cervix.
• Secondary weakness of labor activity develops during childbirth due to the fact that the woman in labor is exhausted by protracted labor. It is manifested by weak contractions, in which the opening of the cervix is ​​slowed down or stops.
• When the fetal head passes through the birth canal, the umbilical cord may be pressed tightly against the walls of the pelvis. If it lasts more than 5-7 minutes, then fetal death may occur (since oxygen-carrying blood stops flowing to the fetus, and severe hypoxia occurs).
• Throwing back the arms and extension of the head in the second stage of labor occurs reflexively at the birth of the body.
• Aspiration of amniotic fluid - entry of water into Airways baby when trying to take a breath, when his head is still in the birth canal and has not been born.
• Injuries to the birth canal and trauma to the fetus (traumatic brain injury with cerebral hemorrhage) occur when the birth of the head and shoulders of the fetus is difficult.

Birth management

In the first stage of labor, constant monitoring of the condition of the fetus is necessary ( CTG record), contractile activity of the uterus. Timely anesthesia of childbirth and the introduction of antispasmodic drugs are carried out in order to accelerate the opening of the cervix. Important timely diagnosis possible complications, their correction and determination of further tactics of childbirth.

During contractions, a pregnant woman is recommended bed rest, the vertical position is unacceptable, since premature outflow of water is possible, prolapse of the umbilical cord loops. This is due to the size of the presenting part, which is smaller than the head and does not fit tightly against the entrance to the small pelvis.

Childbirth with a breech presentation of the fetus is accepted by a doctor, in contrast to physiological childbirth taken by a midwife under the supervision of a doctor. In the second stage of labor (during attempts), it is desirable to control cardiotocography, while during normal childbirth, sometimes it is enough to simply listen to the fetal heartbeat between attempts with an obstetric stethoscope. OXYTOCIN (a drug that increases the contractile activity of the uterus) is administered intravenously to prevent weakness of attempts. It is mandatory to cut the perineum (episiotomy) to speed up the passage of the head after the pelvic end and reduce the duration of compression of the umbilical cord by the head. Depending on the type of breech presentation, after the eruption of the presenting part, special obstetric benefits are provided (actions that the obstetrician-gynecologist performs). The most common is the allowance for Tsovyanov - it is used for pure breech presentation. It is based on the preservation of the normal articulation of the fetus (the legs are held in a bent position, pressed to the body until they are fully born), which prevents the development of such serious complications as throwing back the arms and extending the head. Next, perform the classic manual manual for breech presentation (release of the shoulder girdle and fetal head).

With a mixed breech presentation, benefits are provided from the moment the lower corners of the shoulder blades appear from the genital gap; it is aimed at releasing the shoulder girdle of the fetus and facilitating the birth of the head.

A generic tumor (swelling of the soft tissues of the presenting part) with breech presentations is located on the buttocks, with legs - on the legs of the child, which become edematous and blue-purple. Often, the birth tumor passes from the buttocks to the external genitalia of the fetus, which looks like swelling of the scrotum or labia.

The need for a caesarean section during natural childbirth may arise in the following cases:

• when loops of the umbilical cord or small parts of the fetus fall out;
• with a deterioration in the condition of the fetus due to an increase in hypoxia;
• with uncorrected weakness of labor activity for 2–3 hours or with ineffective labor stimulation during this time during prenatal outflow of water;
• at premature detachment normally located placenta.

In conclusion, it should be said that no matter how your baby is located and no matter how he is born, the most important thing is that he is born healthy. And do not be upset if the doctors recommended you a caesarean section. When you are next to your child, you will forget all your doubts and just enjoy happy motherhood! But if the doctor talks about the possibility of natural childbirth and does not see indications for a caesarean section, do not be afraid of natural childbirth. The main thing is a positive attitude, confidence that everything will go well, and careful implementation of all the doctor's recommendations during childbirth.