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The position and presentation of the fetus is a determining factor during labor. Malposition. Head presentation of the fetus

Data on the location of the fetus are necessary to determine the woman’s delivery tactics. Normal course childbirth is possible with the correct positions and presentation of the baby.

In the first half of pregnancy, the fetus is small and moves freely in the uterus. Closer to 34-35 weeks, it begins to occupy a stable position, which in most cases remains until childbirth. At this point, the doctor leading the pregnancy can already decide on the method of conducting the birth: naturally or by caesarean section.

Fetal positions

Fetal position- this is the ratio of the axis of the fetus to the length of the uterus. Distinguish three position options:

  1. Longitudinal(the axis of the fetus and uterus coincide or lie parallel). One of the large parts (head or buttocks) is located at the entrance to the pelvis, the other lies in the fundus of the uterus;
  2. Transverse(the axes of the fetus and uterus intersect at right angles). The head and buttocks of the fetus are located in the lateral sections of the uterus;
  3. Oblique(the axes intersect at an acute angle). One of the large parts is located in the upper lateral section of the uterus, the other in the lower section.

Information The longitudinal position is considered correct, in the absence of other contraindications, a woman can give birth naturally.

The main reasons for the appearance of incorrect positions fetus (oblique and transverse) are:

  1. Multiple pregnancy;
  2. Anomalies of the uterus;
  3. Flabbiness of the muscles of the anterior abdominal wall;
  4. Tumors of the uterus (fibroids).

Diagnosis of fetal malpositions:

  1. Visual inspection. In incorrect positions, the abdomen has a spherical shape and is not extended forward;
  2. Measuring abdominal circumference and fundal height of the uterus. Typically the abdominal circumference is higher than normal normal indicators For given period pregnancy and a decrease in the height of the uterine fundus;
  3. External obstetric examination. When palpating the abdomen, the presenting part is not determined; the head or pelvic part is palpated in the lateral parts of the uterus. The fetal heartbeat can be heard in the navel area;
  4. fetus

Incorrect fetal positions can lead to a number of complications during pregnancy and childbirth:

  1. Premature termination of pregnancy;
  2. Loss of small parts: umbilical cord, arm or leg;
  3. Neglected transverse position of the fetus during childbirth (the arm and shoulder are driven into the pelvic bones, preventing the head and torso from passing through the birth canal);
  4. Anomalies of generic forces;
  5. Fetal hypoxia during childbirth;

Management of childbirth with abnormal fetal positions

In transverse position fetal labor cannot complete spontaneously. A woman must be hospitalized in a hospital at 37 weeks and undergo a planned delivery by cesarean section.

In an oblique position make an attempt to invert the fetus. To do this, the woman is placed on her side, where the large part of the fetus (head or buttocks) is located in the iliac region. Often, when moving into the pelvic cavity, the child takes a longitudinal position. If the position on the side does not correct the situation, then delivery is also carried out surgically.

Fetal presentation

Fetal presentation- this is the ratio of the large part (head or buttocks) to the entrance to the pelvis. Presenting part They call that part of the fetus that is located at the entrance to the pelvis and is the first to pass through the birth canal.

Highlight two types of presentation:

Head presentation of the fetus

  • Occipital;
  • Forecephalic;
  • Frontal;
  • Facial.

Breech presentation of the fetus

  • Pure gluteal;
  • Mixed gluteal;
  • Foot.

additionally The correct presentation is considered to be a cephalic occipital presentation (the baby enters the birth canal with the head tightly pressed to the chin). Incorrect (extensor) insertion of the head complicates the course of labor, and often the birth of a child can only occur by cesarean section.

The main causes of extension cephalic presentation:

  1. Narrow pelvis;
  2. Repeated entanglement of the umbilical cord around the fetal neck;
  3. Small or large head sizes;
  4. Violations labor activity ;
  5. Flabbiness of the muscles of the anterior abdominal wall;
  6. Decline.

With anterior cephalic presentation the chin moves slightly away from the chest, the extension of the head is not very pronounced. Labor usually ends spontaneously, but can be prolonged. In the first and second stages of labor, fetal hypoxia must be prevented.

Frontal presentation is the second degree of extension of the head. Spontaneous birth is possible only with a large pelvis, low weight of the child and sufficient strength. However, labor management through natural ways can lead to a number of complications (prolonged labor, fetal hypoxia, etc.), therefore it is preferable to deliver a woman surgically.

Facial presentation manifested by insertion of the head into the pelvis with the front part. This is an extreme degree of extension presentation. Natural delivery is almost impossible and leads to serious complications, including fetal death. IN in this case It is advisable to perform an emergency delivery of a woman by caesarean section.

Breech presentation- This longitudinal arrangement a fetus in which the presenting part is the pelvic end.

Main reasons development of breech presentations:

  1. Anomalies of the uterus;
  2. Premature pregnancy;
  3. Decreased uterine tone.

When clean breech the buttocks are adjacent to the entrance to the pelvis, while the legs are bent in hip joints, bent at the knees and adjacent to the body.

With mixed gluteal in presentation, the legs are bent at the hip and knee joints and are presented together with the buttocks towards the pelvic cavity.

With foot presentation both legs are extended to the pelvis, straightened at the joints (full leg) or one leg, with the second lying higher and bent at the hip joint (incomplete leg).

The course of pregnancy is not much different from cephalic presentation, but cases of premature rupture are not uncommon. amniotic fluid. A woman should be hospitalized in a hospital 2-3 weeks before the expected date of birth. First of all, this is necessary to determine the tactics of labor management.

Managing vaginal delivery often results in to serious complications:

  1. Birth injuries to the fetus;
  2. Weakness of generic forces;
  3. Fetal hypoxia;
  4. Umbilical cord compression, leading to asphyxia and fetal death;
  5. Trauma to the birth canal in a woman.

Important Due to the high risk of complications, it is recommended that the woman be delivered by caesarean section.

Exercises for turning the fetus

There are special gymnastic exercises that help the fetus turn over. The optimal period for such techniques is 30-32 weeks. Exercises can be carried out in more late dates, but then the fetus is already large in size, and the likelihood of it turning over is extremely low.

It is necessary to start exercises only after the permission of the doctor managing the pregnancy, because there are contraindications:

  1. Scars on the uterus after surgery;
  2. Placenta previa;
  3. Tumors of the uterus(myoma);
  4. Severe diseases of other organs and systems in the mother.

A set of exercises must be performed 3-4 times a day for 7-10 days:

  1. Turns. Lying on the bed, turn from one side to the other 3-4 times (you should lie on each side for 7-10 minutes);
  2. Pelvic tilts. You need to lie down hard surface and raise your pelvis so that it is 25-30 cm above your head. You should remain in this position for 5-10 minutes. The exercise can be repeated for up to 2-3 weeks;
  3. Exercise "Cat". Kneel down and place your hands on the floor. As you inhale, raise your head and tailbone, bend your lower back. As you exhale, lower your head and arch your back. Exercises are repeated up to 10 times;
  4. Knee-elbow position. Stand on your elbows and knees, your pelvis should be higher than your head. You should remain in this position for 15-20 minutes;
  5. Half bridge Lie on the floor, place several pillows under your buttocks so that your pelvis is 35-40 cm higher, and raise your legs. Shoulders, knees and pelvis should be at the same level;
  6. Lying on your back. Lie down on a hard surface, bend your legs at the knees and hip joints, and place your feet on the floor. As you inhale, lift and hold your pelvis. As you exhale, lower your pelvis and straighten your legs. Exercises should be repeated 6-7 times.

Gymnastic exercises are often effective and lead to fetal rotation within the first 7 days.

Position of the fetus in the uterine cavity , Determining the position of the fetus in the uterine cavity is of exceptional importance for the management of pregnancy and childbirth. When examining pregnant women and women in labor, the articulation, position, position, and type of presentation of the fetus are determined.

Articulation of the fetus - the relationship of his limbs to the head and torso. With a typical normal position of articulation, the torso is bent, the head is tilted towards the chest, the legs are bent at the hip and knee joints and pressed to the stomach, the arms are crossed on the chest. With a normal flexion type of articulation, the fetus has the shape of an ovoid, the length of which in full-term pregnancy is on average 25 - 26 cm. The wide part of the ovoid (pelvic end of the fetus) is located in the fundus of the uterus, the narrow part (occiput) faces the entrance to the pelvis.

Fetal movements lead to a short-term change in the position of the limbs, but do not disrupt the characteristic position of the limbs. Violation of typical articulation (extension of the head, etc.) occurs in 1 - 2% of births and complicates their course.

Fetal position - the ratio of the longitudinal axis of the fetus to the longitudinal axis (length) of the uterus.

The following positions of the fetus are distinguished: a) longitudinal - the longitudinal axis of the fetus and the longitudinal axis of the uterus coincide, the axis of the fetus is a line running from the back of the head to the buttocks; b) transverse - the longitudinal axis of the fetus intersects the longitudinal axis of the uterus at a right angle; c) oblique - the longitudinal axis of the fetus forms an acute angle with the longitudinal axis of the uterus. The longitudinal position is normal, it occurs in 99.5% of all births. Transverse and oblique positions are pathological and occur in 0.5% of births. In transverse and oblique positions, insurmountable obstacles to the birth of the fetus arise. In these cases, the help of a doctor is necessary.

Fetal position - the relationship of the fetal back to the right and left sides of the uterus. There are two positions: first and second. In the first position, the fetal back is facing the left side of the uterus, in the second - towards the right. The first position is more common than the second, which is explained by the rotation of the uterus on the left side anteriorly. The back of the fetus is not always turned to the right or left, it is usually turned somewhat anteriorly or posteriorly, so the type of position is distinguished

Position type - the ratio of the back of the fetus to the front or back the wall of the uterus. If the back is facing anteriorly, they speak of an anterior view of the position; if it is turned backwards, they speak of a posterior position.

Fetal presentation - the relationship of the large part of the fetus (head or buttocks) to the entrance to the pelvis. If the fetal head is located above the entrance to the mother’s pelvis, it is cephalic presentation; if the pelvic end is located, it is breech presentation (Fig. 49 and 50). Head presentation occurs in 96% of births, pelvic - in 3.5%. In transverse and oblique positions, the position is determined not by the back, but by the head: the head on the left is the first position, on the right is the second position.

Presenting part This is the part of the fetus that is located at the entrance to the pelvis and is the first to pass through the birth canal. With a cephalic presentation, the back of the head (occipital presentation), the crown (anterior cephalic), the forehead (frontal), and the face of the fetus (facial presentation) can be turned toward the entrance to the pelvis. Typical is the occipital presentation (flexion type). With anterocephalic, frontal and facial presentation, the head is in varying degrees of extension. The extension type of presentation occurs in 1% of all longitudinal positions.

In a breech presentation, the fetal buttocks (pure breech presentation) and legs ( breech presentation), buttocks together with legs (mixed breech-leg presentation).

Inserting the head - the relationship of the sagittal suture to the symphysis and sacral promontory (promontorium). There are axial, or synclitic, and extra-axial, or asynclitic, head insertions.

Synclitic insertion is characterized by the fact that the vertical axis of the head is perpendicular to the plane of the entrance to the pelvis, and the sagittal suture is at the same distance from the symphysis and promontorium. Asyn-clitic insertion is characterized by the fact that the vertical axis of the head is not strictly perpendicular to the plane of the entrance to the pelvis, and the sagittal suture is located closer to the promontorium, they speak of anterior asyn-clitism (the anterior parietal bone is inserted); if the sagittal suture is closer to the symphysis, there is posterior asynclitism (the posterior parietal bone is inserted).

Synclitic insertion of the head is normal. During normal childbirth, temporary, mild anterior asynclitism is sometimes observed, which is spontaneously replaced by synclitic insertion. Often pronounced anterior asynclitism occurs during childbirth with a narrow (flat) pelvis as a process of adaptation to its spatial features. Severe anterior and posterior asynclitism is a pathological phenomenon.

A stable position of the fetus in the uterine cavity is established in the last months of pregnancy. In the first and early second half of pregnancy, the position of the fetus changes due to the fact that the relative size of the uterine cavity and the amount of amniotic fluid at this time is greater than at the end of pregnancy. In the first half of pregnancy, breech presentations are often observed, which later develop into cephalic presentations. Facial presentations are usually created during childbirth. The position and its appearance are also established in the second half of pregnancy. The position of the fetus is relatively constant; he makes movements, after which the position of the members becomes the same.

In creating a typical position of the fetus, the main role is played by its motor activity and the reflex reactions of the uterus. The motor activity of the fetus and the excitability of the uterus increase as pregnancy progresses. When the fetus moves, irritation of the uterine receptors and contractions occur, correcting the position of the fetus. When the uterus contracts, its transverse size decreases, which contributes to the formation of a longitudinal position; the head, which has a smaller volume compared to the pelvic end, descends downwards, where the space is smaller than in the fundus of the uterus.

Obstetricians' interest in the issue of breech presentation of the fetus is growing every day, which is understandable. Not so long ago, breech birth was classified as physiological, but today the opinion of doctors has changed dramatically and breech birth is considered a pathology. Firstly, this is due to the high risk of perinatal complications and death of children in breech presentation, and, secondly, this is due to the high percentage (up to 6) serious congenital anomalies development. In addition, breech presentation of the fetus does not exclude consequences for the woman.

Breech presentation: how to understand the term

Not all expectant mothers understand what breech presentation of the fetus means. In general, it's simple. The baby in the uterus should normally be positioned longitudinally (that is, along the uterine axis), and the largest part, that is, the head, should be present at the entrance.

Breech presentation is spoken of when unborn child lies in the uterus correctly, that is, longitudinally, but the pelvic end (buttocks) or legs are located at the entrance. Breech presentation is not so rare, occurring in 3–5% of births.

Classification

According to the domestic classification, there are the following types breech presentations:

  • Gluteal or flexor
    • purely gluteal - when the buttocks are adjacent to the entrance, and the legs are bent at the hip joints, but extended along the body of the fetus and press the arms to the chest, and the head is also pressed to the chest;
    • mixed gluteal – when the buttocks and foot (one or both) are adjacent to the entrance;
  • Leg or extensor
    • incomplete leg - when only one leg is adjacent to the entrance (and nothing else);
    • full leg – respectively, both legs are adjacent;
    • knee - the fetus seems to be on its knees, it is quite rare, and during the birth process it turns into a leg position.

Most often, pure breech presentations are observed (up to 68% of all breech presentations), mixed breech presentation in 25%, and foot presentation in 13%. During childbirth, it is possible to transition from one type of breech presentation to another. Complete leg is diagnosed in 5 - 10%, and incomplete leg is observed in 25 - 35% of births.

Expectant mothers should not immediately become upset because the baby is lying incorrectly. A lot of fetuses that are presented at the pelvic end by the end of pregnancy turn over and are presented at the head.

Such spontaneous rotation is more often observed with the presentation of the buttocks, and in multiparous women this happens 2 times more often than in first-born women. And, what’s good is that if the child turned over on his own, then his reverse “somersault” is unlikely.

Etiology

With breech presentation of the fetus, the causes are not fully understood. But all predisposing factors are divided into three groups, depending on who or what they come from.

Maternal factors

This group includes factors depending on the state of the mother’s body:

  • Uterine malformations- because of abnormal development the uterus accepts the fetus pathological situation or presentation. This may be a saddle or bicornuate uterus, a septum in the uterine cavity, a hypoplastic uterus and others
  • Tumor-like formations in the uterus— various tumors (usually myomatous nodes) often prevent the fetus from turning around correctly and taking the necessary cephalic presentation. Uterine polyps (fibrous) and adenomyosis cannot be excluded
  • Increased or decreased uterine tone
  • Scars on the uterus
  • Overdistension of the uterus- in this case, polyhydramnios or a large number of births in history may affect
  • Narrowing of the pelvis - a significantly narrowed pelvis (3rd - 4th degree) or a curved and irregularly shaped pelvis also impedes the physiological position of the baby in the uterus
  • Pelvic tumors
  • Compounded gynecological and/or obstetric history- numerous abortions and curettages, childbirth with complications, inflammation of the uterus and cervix and other pathologies.

Fruit factors

From etiological factors associated with the fetus are:

  • Low fetal weight or prematurity- in 20% of cases leads to breech presentation due to excessive fetal mobility
  • Multiple pregnancy - pregnancy with more than one fetus is often (13%) complicated by incorrect position and presentation of either one or both babies
  • Congenital malformations- this subgroup includes defects of the central nervous system (dropsy of the brain, anencephaly, tumors and hernias of the brain), defects of the urinary system (Potter's syndrome), anomalies of the cardiovascular and musculoskeletal systems (hip dislocation, myotonic dystrophy). Also play a role chromosomal pathologies and multiple defects intrauterine development.

Placental factors

How organs develop placental system, the location of the fetus in the uterus also depends:

  • Placenta previa- prevents the larger part of the fetus (head) from being located at the entrance to the pelvis
  • Short umbilical cord- limits fetal mobility
  • Excess or lack of amniotic fluid- contributes either increased activity baby, or reduces his mobility
  • Fetoplacental insufficiency— leads to intrauterine growth retardation of the fetus and its malnutrition, which increases its motor activity
  • Umbilical cord entanglement- prevents the fetus from developing correctly in the uterus.

Case Study

Late in the evening, a woman was admitted to the maternity ward with contractions. A vaginal examination revealed an opening of the uterine pharynx up to 5 cm, in which the fetal legs could be clearly felt. After diagnosis: Pregnancy 38 weeks. The first period of 5 term births. Leg presentation. It was decided to immediately end the birth by caesarean section. It must be said that the woman was not young, about 40 years old, she had given birth 5 times (4 children were waiting for her mother at home), and she was not registered. I've never even had an ultrasound. After cutting the uterus and removing the fetus, it turned out that he had no brain (anencephaly). The child died immediately. The operation was completed by suturing the uterus and bandaging fallopian tubes, that is, sterilization.

I would like to note that such carelessness of my mother could have ended badly. Natural childbirth is much safer (in many cases) for a woman than operative delivery. In this case postoperative period proceeded without complications, and what was done was “unnecessary” C-section justified sterilization. What if the birth was the first? What if something happened after or during the operation? That's why this example I present it as science for expectant mothers. You should never disregard your own health (don’t see a doctor, don’t get tested, and don’t attend an ultrasound).

Course of pregnancy

The final diagnosis of breech presentation is made at 36 weeks, when the fetus is firmly in position in the uterus, although spontaneous rotation is not excluded. Pregnancy with a breech presentation of the fetus is much more likely to have complications than with a cephalic presentation. The main complications are:

  • threat of miscarriage or premature birth;
  • gestosis;
  • placental insufficiency.

All of these complications lead to oxygen starvation of the fetus, and, accordingly, to its developmental delay (hypotrophy and low weight), abnormal amount of amniotic fluid (low or polyhydramnios), and entanglement of the umbilical cord. In addition, breech presentation is often accompanied by placenta previa, unstable fetal position and prenatal rupture of water.

Also, such presentation affects the development of the fetus and the functions of the fetoplacental system:

  • Maturation of the medulla oblongata

By 33–36 weeks, the maturation of the medulla oblongata begins to slow down, which is manifested by pericellular and perivascular edema of the brain, which leads to “swelling” and impaired blood circulation in the brain, and, consequently, to a disorder of its functions.

  • Adrenal glands

The function of the adrenal glands, as well as the hypothalamic-pituitary system, is depleted, which significantly reduces the adaptive and protective reactions of the fetus during childbirth and after.

  • Sex gonads (testes and ovaries)

Impaired blood circulation and tissue swelling are noted, mature cells of the sex gonads partially die, which subsequently affects reproductive function(hypogonadism, oligo- and azoospermia) and leads to infertility.

  • Congenital malformations

When presented with the pelvic end, congenital defects occur 3 times more often, in contrast to cephalic presentation. Primarily defects of the central nervous system and heart, as well as anomalies digestive tract and musculoskeletal system.

  • Disturbance of uteroplacental blood flow

Leads to fetal hypoxia, increased heart rate and decreased motor activity.

Pregnancy management

Considering high risk complications in pregnant women with breech presentation, for preventive purposes, measures are prescribed to improve uteroplacental blood flow, prevent the threat of miscarriage and fetal hypoxia. Presentation with the pelvic end at 21 weeks is considered physiological, and the position of the fetus with its head down occurs by 22–24 weeks. Pregnant women are recommended to have a balanced diet (to prevent fetal hypo- or hypertrophy), as well as a gentle regimen (full sleep, rest).

Special gymnastics

Exercises for breech presentation of the fetus are recommended to begin at 28 weeks. But performing special gymnastics has a number of contraindications:

  • scar on the uterus;
  • bleeding;
  • threat of interruption;
  • gestosis;
  • severe extragenital pathology.

Methods according to Dikan, according to Grishchenko and Shuleshova, as well as according to Fomicheva or Bryukhina are used. The simplest gymnastics are Dikan exercises. The pregnant woman lies first on one side or the other, turning over every 10 minutes. In one session, you need to make 3–4 turns, and perform the gymnastics itself three times a day. After the fetus is in a cephalic position, the abdomen is secured with a bandage.

External rotation of the fetus

If there is no effect from gymnastic exercises at 36 weeks, external rotation of the fetus is recommended. Manipulation is not performed in the following situations:

  • existing scar on the uterus;
  • planned cesarean section (other indications available);
  • uterine defects;
  • deviations on CTG;
  • premature release of water;
  • fetal defects;
  • small amount of water;
  • refusal of a pregnant woman;
  • pregnancy with more than one fetus;
  • placenta previa;
  • oxygen starvation of the fetus;
  • unstable position of the fetus.

Fetal inversion during breech presentation must be monitored by ultrasound and CTG; the procedure itself is carried out “under the cover” of tocolytics (ginipral, partusisten), and after the manipulation a non-stress test is performed and the ultrasound is repeated.

Complications of the procedure include:

  • fetal hypoxia;
  • placental abruption;
  • uterine rupture;
  • fetal brachial plexus injury.

Hospitalization of a pregnant woman

A woman is hospitalized with a breech presentation of the fetus at 38–39 weeks. In the hospital, additional examination of the pregnant woman is carried out:

  • clarification of obstetric history;
  • clarification of extragenital pathology;
  • ultrasound examination (clarification of presentation, fetal size and degree of head extension);
  • X-ray of the pelvis;
  • amnioscopy;
  • assess the readiness of the pregnant woman’s body for labor and the condition of the fetus.

Then they decide on the method of delivery. Caesarean section for a breech fetus is routinely prescribed for the following indications:

  • fetal weight is less than 2 and more than 3.5 kg;
  • narrowed pelvis, regardless of the degree of narrowing;
  • curvature of the pelvis;
  • excessive extension of the head;
  • delayed fetal development;
  • history of fetal death or birth trauma;
  • post-maturity;
  • placenta previa;
  • breech presentation of the first baby with multiple births;
  • scar on the uterus;
  • foot presentation;
  • “old” primigravida (more than 30);
  • pregnancy after in vitro fertilization;
  • extragenital pathology requiring exclusion of the second stage of labor.

Diagnostics

Diagnosing breech presentation is not difficult. For this purpose, external and internal inspection is used, as well as additional methods research.

External inspection

For this purpose, Leopold's techniques are used (determining the position and presentation of the child) and measuring the abdomen:

  • Fundus height

The fundus of the uterus in this type of presentation is high, that is, it exceeds physiological norm. This is due to the fact that the pelvic end is not pressed against the entrance to the pelvis before labor begins.

  • Leopold's techniques

When palpating the abdomen, it is clearly determined that the dense and rounded part (head) is located in the fundus of the uterus, and the buttocks (large, soft, irregular shape and the non-balloting, that is, stationary part) is located at the entrance to the pelvis.

  • Fetal heartbeat

With cephalic presentation, the heartbeat can be clearly heard on the right or left, but below the navel. When the pelvic end is presented, the heartbeat is heard at or above the navel.

Vaginal examination

This method is the most informative when carried out during childbirth:

  • in case of presentation of the buttocks, the soft part and the gap between the buttocks, as well as the sacrum and genitals are palpated;
  • if the presentation is purely gluteal, the inguinal fold is easily determined;
  • in the case of a mixed breech presentation, the foot is felt next to the buttocks;
  • with the foot, the legs of the fetus are determined, and in the case of a prolapsed leg, its main difference from a fallen handle is the sign that it is possible to “say hello” to the handle.

Additional Methods

  • Fetal ultrasound

The presentation of the fetus is specified, as well as its weight, the presence or absence of congenital defects and umbilical cord entanglement, and the degree of extension of the head.

  • CTG and ECG of the fetus

Allows you to assess the condition of the baby, hypoxia, entanglement or compression of the umbilical cord loops.

Course of labor

Childbirth with a breech presentation of the fetus usually occurs with complications. Perinatal mortality during such births increases significantly compared to births in cephalic presentation (four to five times).

Complications during labor:

Premature rupture of water

Since the pelvic end, compared to the head, does not completely fill the pelvic cavity, which leads to insufficient relaxation of the cervix, resulting in the passage of water, and often, prolapse of the umbilical cord. The umbilical cord is compressed by the pelvic end and the wall of the cervix or vaginal wall, which disrupts fetoplacental blood flow and leads to fetal hypoxia. If the compression continues for a significant period of time, the child’s brain may be damaged or die.

Weakness of generic forces

Weakness of contractions occurs as a result of untimely release of water, as well as insufficient pressing of the pelvic end to the entrance to the pelvis, which does not stimulate the opening of the cervix. Weak contractions, in turn, lead to protracted labor and cause oxygen deficiency in the fetus.

Complications during the expulsion period:

Difficult birth of the head

This complication often leads to asphyxia or fetal death. Difficulties in the birth of the head are determined by three factors. Firstly, the pelvic end of the baby is significantly smaller than the head, so the birth of the buttocks occurs quickly and without difficulty, but the head “gets stuck”. In the case of premature birth, the pelvic end may be born with incomplete dilatation of the cervix, and subsequent cervical spasm aggravates the situation during the birth of the head. Secondly, difficulties in the birth of the head can be caused by its hyperextension. And, thirdly, difficult birth of the head may be associated with the throwing back of the fetal arms. This is observed more often during premature birth, when the body is born too quickly, and the arms “do not have time.”

Damage to soft tissues of the birth canal

The birth of a fetus in a breech position is fraught not only with complications for him, but also for the mother. All the difficulties associated with the birth of the body and the removal of the head often lead to ruptures of the cervix, vaginal walls or perineum.

Management of childbirth

The management of labor in the case of breech presentation has a significant difference compared to childbirth in the cephalic presentation.

Managing the period of contractions

  • Bed rest

If at normal birth In the first period, a woman in labor is strongly recommended to behave actively (walk), but in the case of a breech presentation, the woman is supposed to lie down, and it is better to raise the foot end of the bed. This tactic prevents premature or early rupture of water. It is recommended to lie on the side where the baby's back is facing, which stimulates uterine contractions and prevents weak contractions.

  • After the water breaks

As soon as the waters have broken, it is necessary to conduct a vaginal examination to rule out prolapse of the legs or umbilical cord loop. If the presentation is purely breech, you can try to tuck in the dropped loops. This method is not used for leg presentation. If the loop does not tuck or the legs are present, an emergency caesarean section is performed.

  • Monitoring

The first stage of labor should be carried out under the control of CTG, in as a last resort, carry out auscultation of the fetus every half hour (for childbirth in the cephalic presentation, every hour). You should also monitor the contractile activity of the uterus and keep a partogram (graph of the opening of the uterine pharynx).

  • Prevention of fetal hypoxia

Timely provision of medicinal sleep-rest (at the beginning of the first period) and the introduction of the Nikolaev triad every 3 hours.

  • Anesthesia
  • Antispasmodics

Timely administration of antispasmodics (no-spa, papaverine) begins with the opening of the cervix by 4 cm and is repeated every 3 to 4 hours, which prevents its spasm.

Conducting the second period

  • Oxytocin

At the end of the period of contractions and the beginning of the second period, oxytocin is administered intravenously, which prevents weakness of contractions and pushing and maintains the baby’s correct positioning. With the onset of pushing, atropine is administered intravenously against the background of oxytocin administration to prevent cervical spasm.

  • Monitoring

Monitoring of the fetal heartbeat and contractions (CTG) continues.

  • Episiotomy

As soon as the buttocks emerge from the genital slit (eruption of the buttocks), a dissection of the perineum is performed - an episiotomy.

  • Manual manual

Depending on the situation, when the buttocks erupt or the legs are born, one or the other turns out to be manual aid(according to Tsovyanov 1 or 2, extraction of the fetus by the pelvic end, Moriso-Levre-Lashepelle maneuver).

The third stage of labor is carried out as during normal, physiological childbirth.

Case Study

A young primigravida woman was admitted to the maternity hospital with complaints of contractions. Registered in antenatal clinic was not a member (our women do not like to see a doctor). The mother was approximately 32 weeks pregnant. Palpation of the abdomen revealed that she was pregnant with twins (2 heads and both in the fundus of the uterus) and 2 heartbeats above the navel. Vaginal examination revealed a cervical opening of 8 cm, amniotic sac no, the legs were present, one immediately fell out. A woman complains of pushing. It's too late to do a caesarean section. I immediately took it to the birth table. It must be said that during the pushing, the woman in labor behaved rather inappropriately. She screamed, tried to run away from the table and reached for her crotch with her hands while I tried to remove the first baby. The birth of the legs and torso went more or less normally, but the head, of course, was “stuck.” Having planted on left hand child as a rider and inserting a finger into the mouth, fingers right hand I grabbed the baby’s neck with a fork (Morisot-Levre-Lashepelle maneuver), trying to remove the head. The process took about 3 – 5 minutes, I no longer expected the birth of a live baby. But he was born alive, albeit in severe asphyxia. The second child also “walked” with his legs. But with his birth, things went faster, since “the path was paved,” although difficulties also arose with removing the head. The succession period is without features. A neonatologist and an anesthesiologist were present at the birth and immediately provided resuscitation to the children. After being discharged from the maternity hospital, the woman was transferred to the children's department for further nursing of the babies. In conclusion, I would like to say that I saw her and the children about a year after birth, and talked with the mother. The children are said to be normal, developing and growing well.

Consequences

Breech birth often results in complications in the form of birth injuries and has consequences for children:

  • intracranial injuries;
  • encephalopathy (as a consequence of hypoxia and asphyxia);
  • dysplasia and/or dislocation of the hip joints;
  • dysfunction of the central nervous system;
  • spinal injuries.

Pregnancy, whether 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 speak of the unstable position of the fetus. But after 35 weeks, as a rule. position is determined. In most cases, this is a cephalic presentation, less often - a pelvic presentation, and even less often - an oblique and transverse position of the fetus. It is such non-standard situations that we will talk about today.

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

Pregnancy and childbirth with a breech fetus are classified as pathological obstetrics due to possible risks and complications.

Causes of breech presentation of the fetus

Maternal

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

Polyhydramnios. An increase in the amount of amniotic fluid creates the preconditions 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 the umbilical cord entwining around the neck and torso of the fetus.

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

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

- Multiple pregnancy. If you are expecting not just 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 turning, one of the fetuses more often ends up in a breech presentation. If the first fetus comes with its head, and the second is in a breech presentation, then the birth proceeds more safely, since the first baby manages to expand the birth canal.

Uterine fibroids. Myoma large sizes also creates a purely mechanical obstacle to turning the baby head down. Myomatous nodes growing inward into the uterine cavity are especially dangerous.

Decreased tone and contractility of the uterus. This condition can be observed in multiparous women if there have been several abortions or curettages for therapeutic and diagnostic purposes in the anamnesis. In women who have undergone a cesarean section or myomectomy, scars remain on the uterus, which also reduce the local contractility of the myometrium and may prevent the baby from turning.

Placenta previa. Placenta previa is the complete or partial obstruction of the internal os by the placenta. Normally, the pharynx is free. the placenta is located at the bottom or at least 7 cm from the internal os. if the pharynx is blocked, then restrictions are created for stretching the lower segment of the uterus, and there is less opportunity for the fetus to turn onto its 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 deformation of the pelvic bones. An anatomically narrow pelvis or displacement of the pelvic bones (as a result of injury or previous diseases, rickets or bone tuberculosis, severe scoliosis) limits the movement of the fetus and prevents rotation.

Fruit

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

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

Prematurity (unstable fetal position before 35 weeks)

Constitutionally small fetus or intrauterine growth retardation. Small fetal size predisposes to active movements and movements of the baby inside the uterus.

Classification

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

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

2. Mixed. In this case, the child seems to squat down. Both the buttocks and feet of the fetus are present at the exit from the pelvis.

3. Foot. Most dangerous look breech presentation. The fetal legs are presented, one (the second is extended 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 women. Mixed breech presentation accounts for up to 5 - 10%, and occurs equally in multiparous and primiparous women.

4. Knee. The fetal knees are present at the exit; it is extremely rare. During childbirth it turns into foot pain.

Diagnostics

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

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

Complications of breech birth

1. Premature rupture of water. This happens because there is no pressing of the head and no differentiation of water into front and back.
2. Prolapse of the legs during breech presentation, loss of umbilical cord loops.
3. Weakness of generic forces. Primary and secondary weakness of labor 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. Intrapartum hypoxia and fetal asphyxia. During childbirth, the umbilical cord loops may be pressed against the walls of the pelvis; if the pressure lasts for more than 5–7 minutes, then severe oxygen deficiency develops.
5. Throwing back the arms and hyperextending the head. The pelvic end is soft and narrower than the head, so the birth canal does not expand sufficiently, and the denser and larger part comes out last. This can lead to difficulty in removing the head and tilting. And then, when providing benefits, there is a high risk of hyperextension of the cervical spine and damage to the nerve plexuses.
6. Aspiration (inhalation) of amniotic fluid. Inhalation of even normal, light amniotic fluid causes aseptic inflammation of varying severity. In the case of meconium aspiration (inhalation of green water that is colored by original feces - meconium), the prognosis is significantly worse.

Management of pregnancy with breech presentation of the fetus

Inspection, laboratory and instrumental examinations are performed according to the standard. Consultation with a geneticist for suspected congenital malformations of the fetus.

If at 32 weeks or more the fetus has not turned head down, and there are no obvious factors causing breech presentation (for example, large fibroids or full presentation placenta), then it is performed special complex exercises. It is aimed at working the abdominal muscles and increases the likelihood of the baby turning into a cephalic presentation.

A set of exercises for breech presentation

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

Breath. Get into the starting position, feet shoulder-width apart, arms down. Inhaling, raise your arms with your palms down to shoulder level, at the same time rise onto your toes and slightly bend your lower back forward. Then slowly lower yourself down. Repeat 4 times at a time.

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

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

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

Contraindications to exercises: threat of premature birth, fetal defects, large fibroids, uterine malformations, complete or partial placenta previa, bloody issues from the genital tract of unknown nature, nagging pain in the abdomen and lower back of unknown origin.

Exercises can only be performed in consultation with your doctor, starting from 32 weeks until birth.

External rotation of the fetus.

This is an obstetric manual that was described many years ago by the Russian doctor B.A. Arkhangelsk. IN Lately he attracts increased attention, especially among Western doctors.

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

Contraindications to taking an obstetric turn: threat of premature birth, bleeding, uterine defects, placenta previa, twins/triplets, oligohydramnios, signs of fetal hypoxia.

Previously, external rotation was not performed in women with a uterine scar; now this is a relative contraindication (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 the cervix has begun to dilate.

Ultrasound of the fetus with fetometry. The necessary conditions: small fetal weight (exclude large fetuses 4000 grams or more), normal amount of water, absence of obvious defects, normal location of the placenta.
- Administration of beta-adrenergic agonists (hexoprenaline) intravenously under supervision blood pressure and pulse. Beta-agonists relax the smooth muscles of the uterus and increase the chances of success. For the mother, the administration of hexoprenaline (gynepral) can be complicated by low blood pressure, tachycardia, weakness and headache.
- It is possible (but not always) to use epidural anesthesia.
- The rotation begins from the presenting part (placing the hand on the pelvic end), as shown in the picture. The movements are smooth, in a circle, without sudden jolts.

After the rotation, both in case of success and in case of unsuccessful rotation, the condition of the fetus is monitored. First of all, the fetal heartbeat is listened to, then cardiotocography (CTG) is performed. Doppler measurements are monitored according to indications.

Complications of external rotation:

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

At correct tactics the prognosis for the fetus is favorable. External obstetric rotation, when performed skillfully and competently, is also rarely fraught with complications, but it is impossible to insure against them. Whether or not you agree to this procedure is your choice, you can always think it over, discuss all the risks and benefits with your doctor and make the 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 with breech presentation

In order to determine the tactics of labor management, you need to take into account a number of factors:

1. Age of the patient. Primiparas over the age of 30 and young primigravidas (under 18 years of age, and especially under 16 years of age) have a greater risk of injury to the mother and fetus during childbirth. This occurs due to less elasticity and extensibility of the perineal tissue.

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

3. Assessment of the birth canal
- examination of the cervix, assessment of its maturity (readiness for childbirth),
- assessment 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 classically large fruit a child weighing more than 4000 grams is considered, then in the case of breech presentation, a fetus weighing 3600 grams or more is already considered a large fetus.
- Compensated condition of the fetus, absence of signs of hypoxia, heartbeat disturbances according to CTG and hemodynamic disturbances according to Doppler measurements

5. Features of breech presentation
- view: gluteal, mixed, leg, knee,
- position of the head: flexion (normal), extension (pathological position).

Independent childbirth

Independent birth in a breech presentation is allowed with a purely breech presentation, a compensated condition of the fetus weighing from 2500 to 3500 grams, normal dimensions of the mother’s pelvis, and readiness of the birth canal. Prenatal hospitalization is indicated.
Pregnant women with a breech presentation of the fetus are not induced to give birth, do not use tablets or gels to prepare the cervix, and do not undergo amniotomy (opening of the amniotic sac).

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

Only a doctor attends the birth.

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

In independent childbirth with breech presentation, Tsovyanov’s manual is required.

If the Tsovyanov benefit is provided in the event of a planned delivery in the breech position (manual according to Tsovyanov No. 1), then the goal is to maintain the safest position of the fetal body parts (the legs are extended and pressed to the body), to prevent premature birth of the legs, throwing back of the arms and hyperextension 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 below, the rest above. As the fetal buttocks advance, the doctor moves the perineal tissues with “removing” movements and gradually releases the presenting part, while the thumbs tightly press the legs in the fetal abdomen. In 1 - 2 attempts, the fetus is born up to the umbilical ring. Then you have to remove the handles; if they do not fall out on their own, then you need to tilt the fetal body downwards 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 with pushing, then the Morisot-Levre technique is used.

When performing this technique, the fetal body is placed 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 on the lower jaw. It turns out that we bend the head. The second hand (index and middle finger) should hold the fetal neck at this time. Extraction is carried out according to the biomechanism of childbirth, depending on which plane of the pelvis the head is located at that time. At the very end, the body is pulled far anteriorly and the head is born.

If the manual according to Tsovyanov (manual according to Tsovyanov No. 2) turns out to be a foot presentation, the pattern of actions is somewhat different. In general, leg presentation is an absolute indication for cesarean section, but if the woman was admitted already in labor, with full dilation and surgery impossible, then you have to act according to the situation. Such births should not happen as planned.

The goal when providing benefits according to Tsovyanov No. 2 is to prevent premature birth legs, throwing back the arms and hyperextending the head. This is achieved by converting leg presentation into mixed presentation.

As soon as the legs begin to be identified in the birth canal, the doctor sits down in the same way as when providing the usual Tsovyanov manual, a sterile napkin is placed on the perineum (to weaken the sliding) and resistance is exerted by pushing with the palm until the buttocks drop and the fetus “sits on squat."

Then the hands are positioned in the same way as with the usual Tsovyanov manual, the fetal body is clasped by the obstetrician’s hands and gradually removed using the force of pushing.

When providing any of these benefits, you should not pull the child’s body, only assist the mother’s pushing and follow the natural biomechanism of childbirth.

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

In these cases, classic manual assistance is provided.

Classic manual guide It is performed as follows: the obstetrician’s hand is inserted into the vagina from the side of the fetus, with the palmar surface facing the fetus. Find the angle of the shoulder blade and remove the handle with a “washing” motion. The obstetrician moves the left arm with his left hand, and the right one with his right hand. Next, if the head is in an extension position, then the Morisot-Levre technique is performed. During all manipulations, the assistant (midwife) holds the fundus of the uterus.

Indications for caesarean section for breech 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 of twins,
extensor position of the head during breech presentation,
large fruit (more than 3600 grams),
breech presentation of the fetus in a woman with anatomical narrowing of the pelvis and/or deformation of the pelvis (oblique, oblique pelvis),
lack of biological readiness for childbirth, tendency to post-term pregnancy ( immature cervix uterus),
age of primigravida over 35 years (relative indication),
complicated obstetric history ( recurrent miscarriage, long-term infertility, pregnancy as a result of IVF, perinatal losses or a history of perinatal trauma to the fetus),
low placentation or marginal presentation placenta (relative indication).

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

The cesarean section operation is carried out according to the general canons. As a rule, such operations should be carried out in a 3rd level health facility (in perinatal centers), where there is intensive care for 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 classified as abnormal fetal positions.
In the transverse (A) position, all parts of the fetus are above the conventional line connecting the iliac spine.
With oblique (B) - the head or pelvic end intersects this line at an angle.
In both cases, the presenting part is not determined.


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

Complications caused by oblique or transverse position fetus: premature rupture of water, premature birth, increased risk of postpartum hemorrhage.

Delivery is only surgical.

As planned during a full-term pregnancy, or as an emergency when water breaks or any other emergency obstetric situation develops.

Prolapse of small parts of the body is a specific complication, characteristic only for the transverse, less often oblique, position of the fetus. With the release of water and a large opening of the uterine pharynx, the uterus begins to develop labor and push out the fetus. A fetus that is not positioned correctly cannot be born on its own. Acute fetal hypoxia and loss of an arm or leg occurs. 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, including the development of obstetric sepsis.

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

If you are carrying a baby who is not positioned the way you and the doctor would like, then this is a reason to take a closer look at your condition, take additional actions and follow the recommendations. But there is no reason for panic and frustration. Take care of yourself and be healthy!

– longitudinal position of the fetus with the head facing the entrance to the pelvis. Depending on the presenting part of the fetal head, occipital, anterior cephalic, frontal and facial locations are distinguished. Determining fetal presentation in obstetrics is important for predicting labor. Fetal presentation is determined during examination using special obstetric techniques and ultrasound. Head presentation is the most common and desirable position for independent childbirth. However, in some cases (with frontal presentation, posterior view facial presentation etc.) surgical delivery or the application of obstetric forceps may be indicated.

General information

Head presentation of the fetus is characterized by the baby's head facing towards the internal os cervix. With a cephalic presentation of the fetus, the largest part of the baby’s body, the head, moves first along the birth canal, allowing the shoulders, torso and legs to be born quickly and without much difficulty. Until 28-30 weeks of pregnancy, the presenting part of the fetus may change, but closer to the due date (32-35 weeks), in most women the fetus takes on a cephalic presentation. In obstetrics there are cephalic, pelvic and transverse presentation fetus Among them, cephalic presentation occurs most often (in 90% of cases), and the vast majority of natural births occur precisely with this position of the fetus.

Variants of cephalic presentation of the fetus

With a cephalic presentation of the fetus, several options for the location of the head are possible: occipital, anterior cephalic, frontal and facial. Among them, obstetrics and gynecology considers the flexion occipital presentation to be the most optimal. The leading point of advancement along the birth canal is the small fontanel.

With the occipital variant of the cephalic presentation of the fetus, during passage through the birth canal, the baby’s neck is bent in such a way that the occiput of the head appears first at birth. This is how 90-95% of all births proceed. However, with a cephalic presentation of the fetus, there are options for extensor insertion of the head, which differ from each other.

  • I degree of head extension– anterocephalic (anteroparietal) presentation. In the case of anterior cephalic presentation of the fetus, the large fontanelle becomes the wire point during the expulsion period. Anterior cephalic presentation of the fetus does not exclude the possibility of spontaneous birth, however, the likelihood of birth trauma to the child and mother is higher than with the occipital version. Labor is characterized by a protracted course, therefore, with such a presentation, it is necessary to prevent fetal hypoxia.
  • II degree of head extension - frontal presentation. Frontal cephalic presentation is also characterized by the entry of the fetal head into the small pelvis by its maximum size. The conducting point through the birth canal is the forehead, lowered below the other parts of the head. With this option natural childbirth impossible, and therefore surgical delivery is indicated.
  • III degree of head extension- facial presentation. The extreme degree of extension of the head is the facial version of the cephalic presentation of the fetus. With this option, the leading point is the chin; the head emerges from the birth canal backwards with the back of the head. In this case, the possibility of spontaneous childbirth is not excluded, provided that the woman’s pelvis or small fetus is of sufficient size. However, breech presentation is generally considered an indication for caesarean section.

Extensor variants of cephalic presentation of the fetus account for about 1% of all cases of longitudinal positions. The reasons for various non-standard positions and presentations of the fetus may be the presence of a narrow pelvis in the pregnant woman; abnormalities in the structure of the uterus, uterine fibroids, which limit the space available to the child; placenta previa, polyhydramnios; flabby abdominal wall; heredity and other factors.

Diagnosis of cephalic presentation

Fetal presentation is determined by an obstetrician-gynecologist starting from the 28th week of pregnancy using external obstetric research. To do this, the doctor places the open palm of the right hand above the symphysis and covers the presenting part of the fetus. With a cephalic presentation of the fetus, the head is identified above the entrance to the pelvis, which is palpated as a dense round part. Head presentation of the fetus is characterized by voting (mobility) of the head in the amniotic fluid.

External examination data are clarified during a vaginal gynecological examination. With a cephalic presentation of the fetus, the heartbeat can be heard under the woman’s navel. With the help of obstetric ultrasound, the position, position, presentation, position of the fetus and its appearance are clarified.

Birth tactics for cephalic presentation

In obstetrics, births that occur with an anterior occipital cephalic presentation (the back of the head is facing anteriorly) are considered correct and prognostically favorable, which helps to create an optimal relationship between the size and shape of the head, as well as the pelvis of the woman in labor.

In this case, at the entrance to the pelvis, the fetal head is bent, the chin is close to the chest. When moving through the birth canal, the small fontanelle is the leading conducting point. Bending the head somewhat reduces the presenting part of the fetus, so the head passes through the small pelvis in its smaller size. Simultaneously with the movement forward, the head makes an internal rotation, as a result of which the back of the head turns out to be facing the pubic symphysis (anteriorly), and the face is facing the sacrum (posteriorly). When the head erupts, it is extended, then the shoulders rotate internally and the head externally rotates so that the baby’s face is turned toward the mother’s thigh. Following the birth of the shoulder girdle, the baby's torso and legs appear without difficulty.

In the case of labor progressing in the posterior view of the head occipital presentation The back of the fetus's head turns toward the sacral cavity, i.e., posteriorly. The forward advancement of the head with a posterior-occipital cephalic presentation of the fetus is delayed, and therefore there is a possibility of developing secondary weakness of labor or fetal asphyxia. Such births are conducted expectantly; in case of weak labor, stimulation is performed; if asphyxia develops, obstetric forceps are applied.

The mechanism of birth with anterior cephalic presentation of the fetus in its main points coincides with the previous version. The conductive point with such a presentation of the head is the large fontanel. The tactics of childbirth are expectant; surgical delivery is undertaken in the event of a threat to the health of the mother or fetus.

With frontal cephalic presentation of the fetus, spontaneous labor is extremely rare and takes a long time with a protracted period of expulsion. With independent childbirth, the prognosis is often unfavorable: complications in the form of deep perineal lacerations, uterine ruptures, the formation of vesical-vaginal fistulas, asphyxia and fetal death are common. If a frontal cephalic presentation is suspected or determined, the fetus can be rotated even before the head is inserted. If rotation is not possible, a caesarean section is indicated. In case of complicated spontaneous labor, a craniotomy is performed.

The conditions for a successful independent delivery with a facial cephalic presentation of the fetus are the normal size of the mother's pelvis, active labor, a small fetus, and an anterior view of the cephalic presentation (chin facing anteriorly). The birth is conducted expectantly, with careful monitoring of the dynamics of labor and the condition of the woman in labor, the fetal heartbeat using cardiotocography, fetal phonocardiography. In the posterior type of facial presentation, when the chin is turned posteriorly, a cesarean section is required; If the fetus is dead, a fetal destruction operation is performed.

Prevention of complications during childbirth

Pregnancy management in women at risk is associated with an abnormal course of labor. Such women should be hospitalized in a maternity hospital in advance to determine the optimal tactics for childbirth. At timely diagnosis incorrect position or presentation of the fetus, the most favorable procedure for mother and child is cesarean section.