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Turning the fetus manually external. Why is breech presentation of the fetus considered dangerous, what causes it and how does childbirth proceed? Types of breech presentation

Until a certain period, the child in the womb is in constant motion and can change its position several times. Head presentation is considered the most favorable for childbirth, when the fetus is located vertically with its head down. In this case, childbirth takes place without complications.

In about 5% of cases, the fetus is in a breech presentation, in which it is head up. If childbirth takes place naturally, the legs and pelvis are born first, and the head is born last. Pathological is the longitudinal-transverse position, in which childbirth cannot occur on its own.

To avoid the negative consequences of a pregnant woman, it may be recommended to do a caesarean section. But surgery is also regarded by many expectant mothers as highly undesirable. As an alternative option for breech presentation, an external obstetric rotation, once proposed by Arkhangelsky, can be used.

Reasons for the formation of presentation

All the reasons that can provoke an incorrect position can be divided into two groups. The first is caused by the characteristics or pathologies of the mother. These include:

  • abnormalities in the structure of the uterus;
  • violation of the volume of amniotic fluid (oligohydramnios or polyhydramnios);
  • entanglement with the umbilical cord, which prevents the child from turning his head down;
  • pregnancy with twins (triplets);
  • uterine fibroids of large sizes, which creates mechanical obstacles to the normal position;
  • malformations and anomalies in the structure of the mother's pelvic bones;
  • anomalies in the development of the placenta;
  • a slight break between pregnancies, especially if there was a caesarean section in the previous one;
  • decreased uterine tone - more common in multiple births or in those who have undergone multiple abortions, curettage, caesarean section or other operations on the uterus;
  • hereditary factor.

Breech presentation presents certain risks for the baby. Mortality during childbirth in this case is 9 times higher than with the usual head presentation. 80% of pregnancies with this indicator end in a caesarean section. During natural childbirth, the woman in labor increases the risk of rupture of the internal genital organs, and the child may develop asphyxia, hypoxia, and hematomas may appear. Childbirth is often complicated by the weakness of labor activity.

Until the 36th week, the fetus can change its position. If the mother had a breech presentation before this period, this does not mean that it will continue until the very birth. In this case, they take a wait-and-see attitude. After the 36th week, the chances of a natural improvement in the condition are minimal. In this case, medical attention is needed.

Misposition Diagnosis

Presentation is determined no earlier than the 22nd week of gestation. The phenomenon is more common in multiparous women. The course of pregnancy in breech or transverse presentation does not have any specific features.

Diagnosis of pathology is not difficult. During an external examination, attention is paid to the discrepancy between the height of the fundus of the uterus and the circumference of the abdomen, the presence of large parts of the fetus in the lateral sections, listening to the heartbeat in the navel.

The most informative diagnostic method is this. With its help, they not only establish the wrong position, but also determine the location of the placenta, the approximate weight of the unborn child, the amount of amniotic fluid, the presence of tumors or nodes in the body of the uterus, and intrauterine development disorders.

When is an external obstetric turn performed?

If an abnormal position of the fetus was found on the ultrasound, there are a number of measures that can transfer it to the head presentation without medical intervention. Pregnant women are recommended to perform special gymnastics, fitball exercises, swimming or water aerobics. Full-fledged physical activity encourages the child to take a position favorable for childbirth.

Among the recommended exercises, one can single out being in the knee-elbow position for 15 minutes several times a day and quick flips from side to side at intervals of 10 minutes. However, as practice shows, such exercises are not very effective.

Contraindications to corrective gymnastics should be taken into account - the threat of premature birth, low attachment of the placenta, narrow pelvis, high blood pressure.

Corrective gymnastics for pelvic presentation of the fetus

If the presentation by the 34-35th week has remained unchanged, one of the ways out in this situation is the use of an external obstetric turn. This technique has been known for a long time, but over the years it was used quite rarely, because, not wanting to take risks, many doctors preferred to perform a caesarean section. Modern equipment has made it possible to control and monitor the condition of the mother and fetus during the rotation, which has caused doctors to increasingly return to this method and refuse to perform surgery.

External obstetric rotation should be carried out by a doctor in a hospital.

The procedure can be carried out only if the following conditions are met:

  • one fruit weighing no more than 3700 g;
  • the integrity of the fetal bladder;
  • normal amount of amniotic fluid;
  • lack of increased or decreased tone of the uterus;
  • the size of the woman's pelvis is normal;
  • a satisfactory condition of the woman and the absence of anomalies of intrauterine development of the fetus.

The procedure is carried out only if the operating room is equipped with ultrasound equipment and if it is possible to provide emergency medical care in case of unforeseen circumstances.

Contraindications

External obstetric rotation is not performed if a history of recurrent miscarriage and premature birth was diagnosed. Symptoms of late toxicosis, such as high blood pressure, heart rhythm disturbances, edema as a result of poor kidney function, are also a contraindication.

Other contraindications include:

  • pregnancy with twins, triplets;
  • fetus weighing over 4 kg;
  • cord entanglement;
  • violation of the integrity of the fetal bladder and leakage of water;
  • the presence of large uterine fibroids or multiple myoma nodes;
  • expressed;
  • risk of bleeding and placental abruption;
  • previous births by caesarean section;
  • previous operations on the uterus.

Relative contraindications include excess weight of the pregnant woman.

Approximately 15% of women have Rh negative blood. Before carrying out the manipulation, the presence or absence of anti-Rhesus antibodies in the blood is taken into account. Obstetrical rotation is not possible in the presence of antibodies, which usually occurs with repeated pregnancies. If antibodies are absent, a negative Rh factor is not a contraindication.

How is the procedure carried out?

The rotation procedure takes place in several stages:

  1. Hospitalization of a woman at the 35-36th week of pregnancy and full informing the expectant mother about the upcoming manipulation, her moral preparation.
  2. Conducting ultrasound and CTG to assess the condition of the pregnant woman, determine the location of the placenta, assess the readiness of the female body for the upcoming birth.
  3. General preparation for the procedure, including bowel and bladder emptying.
  4. Carrying out - the introduction of tocolytics, drugs that inhibit the contractile activity of the uterus.
  5. Conducting external obstetric rotation.
  6. Control ultrasound and CTG to assess the condition of the fetus and prevent complications.

The probability of maintaining head presentation until delivery is about 60-70%. If the turn is made at a later date, the effectiveness of the procedure is reduced.

How painful is the manipulation?

During it, the pregnant woman experiences some discomfort, which is still not a reason for the introduction of anesthesia. Multiparous people tolerate obstetric rotation more easily. In some cases, epidural anesthesia is indicated.

The patient should lie on her back on the couch, and the doctor should take a position next to her, facing her. One hand of the doctor is on the pelvic area, and the second - on the head of the fetus. With careful, but rhythmic and persistent movements, the buttocks are displaced towards the back, and the back towards the head. The head is displaced towards the abdominal wall of the fetus.

The obstetrical rotation technique allows its implementation both along and counterclockwise, depending on the position of the fetus. In the transverse position, the fetus is first transferred to the pelvic, and then to the head position.

Control ultrasound allows you to make sure that all procedures were performed correctly. It is mandatory to monitor the fetal heartbeat and. But often the successful outcome of the turn does not guarantee that the child will keep the head presentation until the very birth. Perhaps his return to the pelvic position.

What measures should be taken to reduce the risk of pelvic position recurrence?

To fix the position of the child favorable for childbirth, a special bandage is used. It is a ribbon 10 cm wide, which is fixed at the level of the navel. Such fixation excludes the return of the fetus to the transverse or pelvic position. The bandage must be worn for 2 weeks, that is, almost until the very birth.

Is external obstetric rotation dangerous?

There is an opinion that it is prohibited due to the increased danger to the fetus.

Indeed, turning has certain risks, but caesarean section and even natural childbirth in the pelvic position are no less dangerous.

It is almost impossible to injure a child, since it is reliably protected by amniotic fluid. The procedure lasts only a few minutes, and in total a woman spends about three hours in a medical institution (the time for preliminary and control ultrasound and preparation is taken into account).

As a rule, a second visit to the doctor is scheduled after 1-2 days in order to assess the success of the rotation. If everything went well, expect a natural birth. Otherwise, the patient is preparing for a caesarean section.

The failure rate is about 30%. As a rule, they are associated with the contraindications indicated above. If the turn could not be carried out, the patient must be provided with complete rest in order to prevent damage to the fetal bladder and not provoke.

Sometimes manipulation can provoke premature birth. This is not critical, since the rotation is carried out no earlier than the 35th week, when the fetus is already quite viable.

Possible Complications

External obstetric rotation is carried out only in a specialized institution, so the risk of complications is no more than 1%. In some cases, the following negative consequences are possible:

  • premature detachment of the placenta;
  • fetal distress;
  • premature rupture of the fetal bladder;
  • the appearance of severe bleeding;
  • uterine rupture;
  • infectious complications in the postpartum period.

Bleeding and severe cramping pains, aggravated by palpation, testify to premature detachment of the placenta. With a small loss of blood, no signs of hypoxia in the fetus and a satisfactory condition of the pregnant woman, a decision is made to maintain gestation. If the detachment progresses, an urgent caesarean section is necessary to prevent hypoxia (lack of oxygen) of the fetus. Insufficient oxygen supply leads to the development of neurological problems and the child's lag in physical and mental development.

Fetal distress (intrauterine asphyxia) also has a detrimental effect on the child's condition. Due to the lack of oxygen, hemorrhage occurs in the brain, heart, liver, kidneys. The main sign of asphyxia in a newborn is a violation of breathing, which negatively affects the baby's cardiac activity and the functioning of its nervous system.

In the future, children who have had birth asphyxia develop hyperexcitability syndrome, hydrocephalus, a tendency to convulsions and other neurological problems.

Uterine rupture is a very rare occurrence, in most cases occurs in the presence of scars left over from a previous caesarean section or surgery. To eliminate the gaps, the organ is sutured, followed by the appointment of antibiotics and drugs that prevent thrombosis.

To agree to an external obstetric turn or count on, the woman herself decides after weighing all the pros and cons, as well as after consulting a doctor. Even if there are certain risks during the procedure, one should not forget that natural childbirth is always preferable to surgical intervention.

This is an operation with the help of which it is possible to change the position of the fetus, which is unfavorable for the course of childbirth, to a favorable one, and always only longitudinal. There are the following methods of obstetric rotation: external rotation to the head, less often to the pelvic end; internal rotation with full opening of the uterine os - a classic, or timely, rotation.

The external rotation of the fetus is performed by the doctor only by external methods through without any influence from the vagina. Indications: transverse and oblique positions of the fetus, pelvic presentation of the fetus. Conditions for carrying out: good fetal mobility (with receded waters, rotation is not shown); normal pelvic dimensions (true conjugate not less than 8 cm); lack of indications for the rapid completion of labor (, premature detachment, etc.).

Technics. External rotation, especially in multiparous, can be done without anesthesia. With oblique positions of the fetus, it is sometimes enough to lay the woman in labor on the side to 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.

With a clearly expressed transverse position of the fetus, special external techniques are required for rotation. 30 minutes before the operation, a woman in labor is injected subcutaneously with 1 ml of a 1% solution (for some relaxation of the uterine muscles so that further manipulations do not cause unnecessary disturbance). The woman in labor lies on the couch (preferably on a hard one) on her back, with her legs slightly bent and drawn to her stomach. The obstetrician sitting on the side on the edge of the couch puts both hands on the woman in labor so that one of his hands lies on the head, grabbing it from above, and the other on the pelvic end of the fetus, covering its lower buttock (Fig. 1). Grasping in this way, with one hand they press on the head of the fetus towards the entrance to the pelvis, and with the other they push the pelvic end up, to the bottom of the uterus. All these manipulations are done persistently, but extremely carefully, only during a pause, at the moment of complete relaxation of the uterus; when a fight occurs, the obstetrician's hand remains in place, holding the fetus in its position.

Rice. one. External rotation to the head in the transverse position of the fetus (anterior view).
Rice. 2. General rules for external prophylactic rotation (along the arrows) in breech presentations: displacement of the buttocks towards the back, back towards the head, head towards the entrance to the pelvis.
Rice. 3. The overlying leg is captured (posterior view of the transverse position).

An external rotation to the head in breech presentation, the so-called prophylactic rotation, is done at the 34-36th week in a hospital by a doctor. General rules for a preventive turn - see fig. 2. After turning, it is necessary to systematically monitor the pregnant woman. If the cephalic presentation is again replaced by the breech one, the rotation is immediately repeated.

To prevent breech presentation and correct it in the head, the following method is proposed. A pregnant woman (in terms of 29 to 40 weeks) is prescribed classes: lying on a bed (couch), she should alternately turn to one side or the other, remaining on each of them for 10 minutes. Exercises are repeated 3-4 times (on average, each lesson takes 60-80 minutes.), The exercise is carried out 3 times a day before meals. After several classes (usually in the first 7 days), the fetus turns onto the head. After establishing the head, in order to prevent recurrence of breech presentation, the pregnant woman is recommended to lie on her side, corresponding to the position of the fetus, and on her back, and also to wear a fixative. A pregnant woman should visit a doctor at least once a week. In case of relapse, additional classes are carried out.

Classic inside twist produces . In emergency cases, if it is impossible to call a doctor, a classic internal turn can be performed. When carrying out an internal obstetric turn, one hand is inserted into the uterus, the other through the abdominal wall of the woman in labor helps the first. A classic internal rotation is shown in the transverse position of the fetus, as well as in presentations dangerous for the mother (for example, frontal) and insertions of the head (for example, posterior parietal). With a classic turn, you can turn the fetus from a transverse position (sometimes longitudinal) to the head and to the leg. Turning to the head is currently of no practical importance. Conditions for rotation: full opening of the uterine os, full fetal mobility. A contraindication to internal rotation is the neglected transverse position of the fetus.

Technique of the internal classic turn on the leg in transverse positions. Three stages should be distinguished: 1) the introduction of the hand, 2) the search for and capture of the leg, and 3) the actual rotation of the fetus. In the transverse position of the fetus, it is recommended to insert the arm corresponding to the pelvic end of the fetus, counting the side of the obstetrician.

In the anterior view of the transverse position (back to the front), the underlying fetal leg should be captured (when capturing the overlying leg, a rear view can easily be obtained, which is unfavorable for labor management); in the rear views of the transverse position, the overlying leg should be captured (Fig. 3), since it is easier to transfer the rear view to the front. When searching for the fetal leg, two methods are recommended: “short” - the hand is carried directly to the fetal leg and “long” - the hand is advanced along the back of the fetus to the buttocks, then along, to the corresponding leg. Always capture one leg with the whole hand (Fig. 4) or with two fingers (Fig. 5). When looking for the legs with a hand lying on the abdominal wall ("outer" hand), they help the hand inserted into the uterus ("inner" hand). The “outer” hand lies on the pelvic end of the fetus, bringing it down to the entrance to the pelvis towards the “inner” hand.

As soon as the fetal leg is found and captured, it is necessary to immediately transfer the “outer” hand from the pelvic end to the head and push it to the bottom of the uterus (Fig. 6). If this is not done, leave the hand in the same position and press it on the pelvic end, the head may be pinched - a complication that threatens to completely fail the turn.


Rice. 4. The leg is captured with the whole hand. Rice. 5. The leg is grasped with two fingers. Rice. 6. The leg is captured by the “inner” hand, the “outer” hand is moved from the pelvic end to the head and pushes it to the bottom of the uterus.

The rules for turning the fetus (turning itself): traction (attraction) is performed outside the fight; traction is done downward, towards (with traction on oneself, and especially upward, the symphysis will interfere); do traction until the knee comes out of the genital gap. When the leg is brought out to the knee and the fetus has taken a longitudinal position, the turn is completed.

Further, if there are no contraindications, childbirth can be left to the forces of the body and carried out in the same way as with incomplete foot presentation. Currently, most obstetricians adhere to a different tactic: in the interests of the fetus, after the turn made, they immediately perform an operation to extract the fetus by the pelvic end (see).

The internal classical rotation of the fetus on the leg with head presentation is done according to the same rules as in the transverse position of the fetus.

Indications: the need to urgently complete childbirth. Into the uterus as deeply as possible (up to the elbow), a hand is inserted corresponding to the small parts of the fetus, counting the side of the obstetrician. When holding the hand into the uterus, you must first push the head to the side and, most importantly, do not forget to timely transfer the "outer" hand from the pelvic end to the head, after the leg is captured. head in these cases is particularly disadvantageous.

With obstetric head-to-pedicle rotation, it is easy to mix the stem with the handle. To avoid this, it is necessary to insert the hand deeper, and then, when grasping the leg, pay attention to the calcaneal tubercle, which serves as a difference between the leg and the handle.

Complications in obstetric rotation and assistance with them. 1. Handle falling out, . The dropped part is not set back, since the filled part usually falls out again. A loop should be placed on the handle that has fallen out so that in the future it cannot tip over the head. 2. Obstetric rotation fails because traction is done incorrectly (toward or up, not down). 3. The obstetric turn is done incorrectly - during the fight, while it must be done outside the fight. 4. Infringement of the head (the “outer” hand was not transferred after grabbing the leg from the pelvic end to the head). First of all, you must carefully try to push the head away. In case of failure, you should reduce the second leg (create more space for yourself in the uterine cavity) and again make an attempt to push the head away. If this fails, it is necessary to perforate the head. 5. Crossing of the legs: the leg resting against the symphysis, crossing with the lowered leg, prevents the fetus from turning. It is necessary to reduce the second leg.

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

Why obstetricians do not like breech presentation of the fetus?

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

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

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

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

The most common fear expressed by a pregnant woman is that the fetus can be injured or damaged. It is impossible to injure the fetus during the rotation, it is in a state of hydroweightlessness and is protected by amniotic fluid, and the rotation is carried out with light movements. In the world, such a complication has not been reported, although the manipulation is performed in large numbers.

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

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

Breech presentation of the fetus occurs in 3% -5% of cases at full-term pregnancy. Vaginal delivery with a breech presentation of the fetus is associated with high risks for both the mother and the fetus. Thus, breech presentation is now considered pathological, even if the conditions necessary for vaginal delivery are ideally met, and the fetus is relatively small in relation to the size of the mother's pelvis. During vaginal delivery, the arms and head of the fetus may tilt back, which can lead to injury.

Currently, the most common method of delivery in breech presentation is caesarean section (90%). Among the indications for the use of caesarean section, breech presentation is in third place among others worldwide. However, this operation does not make it possible to completely eliminate the risk of trauma to the fetus, since when it is removed, the arms and head of the fetus can also be thrown back, and complex manipulations are necessary to release them.

To correct breech presentation today, the world is using EXTERNAL OBSTETRIC TURN OF THE FETUS ON THE HEAD , proposed at the end of the century before last by the Russian obstetrician Arkhangelsky B.A.

External cephalic fetal rotation (EFRT) is a procedure in which a doctor turns the fetus from breech to cephalic from outside through the wall of the uterus. A successful attempt at NAPP allows women to give birth on their own, avoiding a caesarean section.

What is needed for external obstetric rotation of the fetus on the head?

External obstetric rotation of the fetus on the head is performed before the onset of labor, usually starting from 36 weeks of pregnancy.

It is necessary to consult a doctor and conduct an ultrasound examination to confirm the fact of breech presentation of the fetus and determine the conditions for NAPP, starting from 34-35 weeks of pregnancy.

When is NAPP possible?

  • From 36 to 37 weeks, since with earlier use there is a high probability of its return to breech presentation.
  • In the presence of a singleton pregnancy.
  • Subject to the mobility of the buttocks of the fetus (if they are tightly pressed against the entrance to the mother's pelvis, it will be extremely difficult to change the position of the fetus).
  • Sufficient amount of amniotic fluid. With oligohydramnios, this manipulation can be traumatic for the fetus, while with polyhydramnios, there is a high probability of the fetus turning back into a breech presentation.
  • When the fetal head is bent

When NAPP is not possible:

  • With the outflow of amniotic fluid.
  • If the patient has contraindications to the use of drugs used to relax the uterus (tocolysis).
  • In the presence of obstetric indications or indications from the health of the mother for delivery by caesarean section.
  • With the extensor position of the fetal head.
  • If the fetus has congenital developmental features.
  • With multiple pregnancy.
  • In the presence of structural features of the uterus in a pregnant woman

However, in addition to this, there are a number of factors that may favor or, conversely, serve as a contraindication to external obstetric rotation of the fetus on the head, and which can only be determined by a doctor during a direct examination of a pregnant woman.

How NAPP is carried out

For manipulation, hospitalization in the maternity hospital is necessary. Preliminary, an additional examination of the pregnant woman is carried out in the required volume, including an ultrasound examination.

When conducting an NAPP:

Immediately before the start of the manipulation, a CTG is recorded to assess the condition of the fetus.

Drugs are administered to prevent uterine contractions (tocolytics).

Holding both hands on the surface of the pregnant woman's abdomen, one on the head of the fetus, and the other on the buttocks of the fetus, the doctor pushes and rotates the fetus to the “upside down” position. A pregnant woman may feel some discomfort during the procedure. The degree of discomfort depends on the individual sensitivity of each patient.

After the procedure is successfully completed, the CTG is re-recorded to make sure that the fetus feels well and successfully endured the procedure. Usually, the condition of the mother and fetus is monitored during the day, after which the patient is discharged and continues the pregnancy until spontaneous labor occurs.

If the doctor notices a deterioration in the condition of the fetus according to the monitoring data, then the procedure is immediately stopped.

If the first attempt was not successful, your doctor may suggest another attempt if the fetus is in good health.

APP is performed ONLY in a maternity ward where there is an opportunity for an emergency delivery, if necessary.

Risks Associated with NAPP

Subject to constant monitoring of the condition of the fetus, constant tocolysis (administration of drugs that relax the uterus), the risks of this manipulation are minimal. Complications from its use occur in less than 1-2% of cases.

Complications of NAPP include:
- compression or "twisting" of the umbilical cord. In this case, constant monitoring of the condition of the fetus allows you to immediately fix its deterioration and stop the procedure.
- discharge of amniotic fluid or the development of labor. This complication can be considered relative, since the rotation in most cases is carried out at full-term pregnancy.

Any deviation from the normal course of the procedure serves as a reason to stop the manipulation and decide on the choice of further management tactics.

Conducting NAPP with Rh-negative maternal blood.

The presence of Rh isoimmunization (that is, the presence of anti-Rh antibodies in the mother's blood) is a contraindication to this procedure, as it increases the risk of anemia in the fetus.

In the absence of isoimmunization (absence of anti-Rh antibodies), it is possible to carry out NAPP with prophylaxis by introducing anti-Rh immunoglobulin.

If you have a breech presentation of the fetus and you want to know about further options for pregnancy management, delivery, external obstetric rotation of the fetus on the head, indications and contraindications for its implementation, please consult our specialists.

1

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 on 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.

An attentive attitude should be observed when an entanglement of the umbilical cord of the fetus is detected, 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 a 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 a 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"