Distinguish cephalic presentation from breech presentation. Is it possible to eliminate the pathological position of the fetus. Case Study
Modern methods studies allow at any time to accurately and reliably determine the presentation of the fetus. But for some reason, the future woman in labor does not always resort to them. In this article, we will tell you how to independently, without the help of complex equipment, determine the position of the child in the abdomen, what methods exist for this and whether this can always be done.
At what time does the issue of presentation become relevant?
In the womb, the fetus is not in one position. It is constantly moving and turning.
In the third trimester of pregnancy, the child noticeably grows up and, due to the small space in the uterus, it becomes more difficult for him to roll over. That's when it becomes topical issue his presentation. After all, by about 33-34 weeks, the child usually takes a certain position, which basically does not change before birth.
For the natural physiological resolution of the burden, it is important that the baby is head down. If the presentation turns out to be pelvic or transverse, then there is a high probability that the baby will be born as a result of a caesarean section.
By determining the presentation of the fetus, it is possible to influence its position before delivery. Special gymnastic exercises and complexes, and even, according to psychologists, self-hypnosis and visualization, allow you to change the baby's posture and ensure a less traumatic birth.
Most babies are born with cephalic presentation (94-96%), but the danger wrong placement the baby still exists.
There are also cases when the fetus literally a few hours before birth changes the wrong position of the body to the right one, but it is at least naive to count on such a turn of events.
How to understand how the child lies in the mother's stomach:
Firstly, future mother should listen to your feelings. If the strongest shocks are felt in the area of the ribs, then most likely the child has turned his head down.
If the child hits the mother in the stomach below the navel, or the blows are given to the pelvis (and bladder), then it is possible that the child is in a breech presentation.
The stomach is also very indicative in this regard. In its upper part, you can see the rounded volumetric part of the child. It's either the head or the butt. By pressing on it from top to bottom, you can feel that the child's body is lowering, which means you have pressed on the ass and the baby is in the head presentation. When the volume part shifts separately from the body, then most likely it is the baby’s head (that is, it is possible breech presentation).
To more accurately determine how the fetus lies in the abdomen of a future woman in labor, you can use the following methods:
- By heartbeat.
- According to the "map of the abdomen".
- determination of the position of the child by heartbeat
This is the easiest way. He needs a stethoscope or a stethophonendoscope - a simple device for listening to tones. Every doctor has it. The procedure can be performed by both a gynecologist and someone close to you.
The woman lies on her back, a stethoscope is applied to her stomach. They usually start from the bottom, then listen from the sides. Where the beats will be heard most clearly and rhythmically, and the heart of the child is located. The baby's normal heart rate is 120-160 beats per minute, if you deviate from these numbers, you should consult a gynecologist.
Breech presentation may be indicated by a muffled tone of the heartbeat. And the heart will be located higher than with the head. Usually in these cases it is located at the level of the navel.
- determining the position of the child on the "map of the abdomen"
American midwife Gail Tully (Minnesota) proposed her own system for determining the location of the child in the womb.
Its essence is as follows:
- On paper, a map of the abdomen is depicted in the form of a circle, which is divided into four parts. At the top is the fundus of the uterus, and at the bottom - pubic bone. At the same time, the right side of a woman is left side cards, and left - right.
- There are places where strong and weak kicks are felt, where sometimes a large bulge appears, on which side the stomach is firmer. Where the kicks are the strongest, the baby’s legs are most likely, and where the pushes are light and less impulsive, there are handles.
- If the future woman in labor was determined by the fetal heartbeat, then the heart of the child should also be marked on the map with the corresponding sign.
- When filling out the map, you must remember that the child is located in opposite planes. This is the stomach and back, legs and arms, head and buttocks. Here there is a danger of confusing the feet with the head - if they stick out, then the bulge will be rounded; the arms and legs of the baby are bent, a hard place in the abdomen opposite the legs is the back. You don't need to invent anything. Be clear about what is there.
- Next, you can take any toy that has all the body parts that the child has and place it on the map accordingly. If the child is in the correct head presentation, then the toy will be upside down. Next, it needs to be deployed in the direction where the legs are. If the mother feels the baby's arms in front of the abdomen above the pubis, most likely the child is in the rear position of the occipital presentation - facing forward and his back is next to the mother's back.
- The name of the position is determined. It includes answers to the questions: the baby’s back is turned to the mother’s left or right side, which part of the body enters the pelvis first (nape or sacrum, face or forehead), and to which side of the woman’s body (back, front or thigh) she is turned. The position of the fetus is encrypted in Latin letters and is a kind of key during delivery.
One of the best birthing positions is the left occiput presentation (LOT), meaning the baby is positioned with its back to the mother's left side, head down and facing the woman's thigh.
But not all types of head presentation are safe for the mother and fetus. With facial, frontal and frontal presentation, there is a possibility of neck injuries, and even death of the child. In such cases, an operation may be prescribed. The most dangerous is the facial presentation.
It should be noted that the compilation of a "map of the abdomen" is a pleasant activity and, according to psychologists, strengthens family ties.
Why is it impossible to independently determine the position of the child in the womb?
In the event that the mother has polyhydramnios, and also if the woman is full and she has a large fat layer, it is difficult to determine the position of the fetus on her own. Difficulties also arise if the placenta is attached to the anterior wall or the tone of the uterus is increased and the muscles of the abdominal wall are very tense.
It is also necessary to understand that the closer to childbirth, the greater the opportunity to correctly determine the position of the baby. In the early stages, it is difficult for any woman to do this, and there is no direct need for this.
And if you have tried all the methods and still have doubts about the correct location of the fetus, do not delay a visit to the gynecologist. After all, modern medicine has all the means to help you. Just be sure that it is in your power to facilitate childbirth and ensure a less painful birth of the baby.
Especially for- Elena Kichak
Expectant mothers, having learned from the doctor that their baby is head up in the tummy, begin to worry, because this position of the fetus is considered incorrect. It is called breech presentation. The baby should be head down in the uterus as it is the widest part of the fetus.
It is best if the head appears first during childbirth, and then the rest of the body. However, in 3-5% of women, childbirth occurs with a breech presentation of the fetus, which is fraught with complications.
The location of the child in the uterine cavity is classified as follows:
- foot- both hips are unbent or only one of them, and one leg is located at the exit from the uterus. This type of presentation is observed in 10-30% of pregnant women (most often in multiparous women).
- Gluteal- the legs of the fetus in the hip joints are bent, and the knees are pressed to the tummy and straightened. This presentation occurs in 50-70% of women in position (most often in primiparas).
- mixed(gluteal-leg) - knees and hips are bent. This type of presentation occurs in 5-10% of cases.
Causes of breech presentation of the fetus
Up to 32 weeks, the fetus can take various poses in mom's tummy. Availability free space in the uterus allows it to move. As the child grows, he tends to lie head down.
For the following reasons, the breech presentation of the fetus may persist until delivery:
- oligohydramnios or;
- placental pathology: location in the area of tubal corners,;
- pathology of the uterus: violation of tone, fibroids;
- fetal pathology: anencephaly, hydrocephalus;
- multiple pregnancy;
- consequence of a caesarean section.
Signs of breech presentation of the fetus
Many women are concerned about the question of what the breech presentation of the fetus means, and by what signs it can be determined. Pregnant women do not feel at all that their baby is lying incorrectly in the uterus. There is no discharge or pain. Breech presentation can only be determined by a doctor during an examination.
Experts note that when the baby is positioned head up, there is a higher standing above the pubis of the uterine fundus, which does not correspond to the gestational age. In the region of the navel, the heartbeat of the fetus is more clearly audible.
With a vaginal examination, the doctor may identify signs of a breech presentation of the fetus. With a mixed and foot position of the child, his feet are probed, and with the gluteal position, the sacrum, inguinal fold, soft bulk part, coccyx are felt. Despite all the signs, the exact diagnosis is determined only by ultrasound.
Delivery with pelvic presentation of the fetus
The baby can be born in breech presentation naturally or as a result of a caesarean section.
The choice of a particular method of delivery depends on the following factors:
- the age of the pregnant woman;
- duration of pregnancy;
- history data;
- existing diseases;
- the size of the pelvis;
- type of breech presentation;
- sex and weight of the fetus, the degree of extension of his head.
Childbirth with a breech presentation of the fetus can take place naturally if: the gestational age is more than 37 weeks; the average estimated weight of the fetus is 2500-3500 g; the size of the mother's pelvis is normal; it is known that a girl will be born, not a boy; the presentation is breech or breech.
If the above conditions are not met, then it is required. Besides, operation is necessary in the event that: childbirth is premature; fetal weight is less than 2500 or more than 3500 g; male fetus; breech presentation is foot, ultrasound revealed hyperextension of the fetal head.
The doctor, having begun to take birth in a natural way, may decide to perform a caesarean section. It will be called an emergency. Indications for immediate surgery may include:
- weak generic activity;
- prolapse of the baby's legs, arms or umbilical cord;
- discoordination labor activity(contractions are observed, and the cervix does not open).
Possible complications during childbirth with a breech presentation of the fetus
Breech presentation of the fetus in the longitudinal position absolutely does not affect the course of pregnancy. Complications may occur during childbirth.
First, labor activity can be weak. This is due to the fact that the pelvic end of the fetus is smaller than the head in volume. It weakly presses on the uterus, and as a result, it contracts worse, its neck opens more slowly.
Secondly, during childbirth, the baby's head may tilt back. Her appearance will be difficult. There is a risk that the child will be injured.
Thirdly, often with a breech presentation of the fetus, the umbilical cord is clamped between the wall of the birth canal and the head. Because of this, the flow of oxygen will be difficult. The fetus will go into hypoxia.
Fourthly, during childbirth, throwing back of the handles is possible. It is also fraught with various injuries.
Can breech presentation be corrected?
Many new mothers start to panic too early when they find out that their baby is in the wrong position in the tummy. For example, some women find out on ultrasound about the breech presentation of the fetus at 20, 21 or 22 weeks and are already starting to look for ways to correct his position. However, it is still too early to think about this. In most pregnant women, the baby takes the correct position by 32 weeks or even later.
If at 32 weeks, an ultrasound scan showed that the fetus did not roll over and remained in the head-up position, then you can begin to perform special exercises. They are effective, and in most cases, thanks to them, the breech presentation of the crumbs is replaced by the head.
Exercises can be started with a breech presentation of the fetus from 33 weeks. You should first consult with your doctor. In a pregnancy with complications, you may have to give up exercise altogether so as not to harm the baby. Only a doctor will tell if it is possible to perform physical exercise, and whether they will negatively affect the condition of the expectant mother and fetus.
All classes are recommended to start with a warm-up. Within a few minutes, a pregnant woman can walk with a normal step, and then on her toes and heels. Hand movements (rotation, raising and lowering), raising the knees to the side of the abdomen will not be superfluous. Below are a few examples simple exercises that can be done after 32 weeks with a breech presentation of the fetus.
Exercise 1
Stand up with your back straight and legs apart. The arms should hang freely along the body. Then you should stand on your toes and spread your arms to the sides, bend your back, take a breath. After that, exhale and take the starting position. Do the exercise 4-5 times.
Exercise 2
Pillows are required for this. They are necessary in order to raise the pelvis. The pregnant woman should lie on the floor with a few pillows. The pelvis as a result of this should rise above the level of the shoulders by 30-40 cm. The pelvis, knees and shoulders should form a straight line. This exercise is recommended to be performed a couple of times a day for 5-10 minutes, but not on a full stomach.
Exercise 3
Get on all fours with your head down. While inhaling, round your back. Then return to the starting position. Exhale, bending in the lumbar and raising your head up.
Exercise 4
It is necessary to lie on your back, spreading your legs shoulder-width apart and bending them. The feet should rest on the floor. Hands need to be relaxed and stretched along the body. When inhaling, you should raise your back and pelvis, resting on your shoulders and feet, and when exhaling, take your starting position. Then you need to straighten your legs, take a breath, drawing in your stomach. The muscles of the perineum and buttocks should be tense. When exhaling, return to the starting position. This exercise is recommended to be repeated 6-7 times.
If you want to start exercising early (for example, at 30 weeks with a breech presentation of the fetus), then you should definitely consult a doctor.
Not only exercise can affect the position of the fetus. are of great importance proper nutrition, walks in the open air.
It is advisable for pregnant women to sit on chairs with a firm and straight back and a hard seat. When sitting on upholstered furniture, it is recommended to spread your legs a little so that your stomach lies freely. If possible, you should buy a fitball and perform special exercises on it that can affect the position of the child in the mother's tummy.
Thus, you should not panic if you learn from a doctor about a breech presentation of the fetus before 27 weeks. The baby can change its position several times before giving birth. If desired, from 30-32 weeks in the absence of contraindications, you can begin to perform special physical exercises.
If they do not affect the position of the fetus, then the doctor will select the best delivery option (caesarean section or natural childbirth), which will not harm either the woman herself or her child.
Answers
Every day, the interest of obstetricians in the issue of pelvic presentation of the fetus is growing, which is understandable. Not so long ago, breech births were considered physiological, but today the opinion of doctors has changed dramatically and breech presentations are considered a pathology. Firstly, this is due to the high risk of perinatal complications and death of children in breech presentations, and, secondly, this is due to a high percentage (up to 6) of serious congenital developmental anomalies. In addition, the 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 located longitudinally (that is, along the uterine axis), and the largest part, that is, the head, is presented to the entrance.
They talk about breech presentation when future child lies in the uterus correctly, that is, longitudinally, but the pelvic end (buttocks) or legs is presented to the entrance. Breech presentation is not so rare, in 3 - 5% of births.
Classification
According to the domestic classification, there are the following types breech presentations:
- Gluteal or flexion
- 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;
- Foot or extensor
- incomplete foot - when only one leg adjoins the entrance (and nothing else);
- full foot - respectively, both legs are adjacent;
- knee - the fetus, as it were, stands on its knees, is quite rare, in the process of childbirth it passes into the foot.
Most often, purely breech presentations are noted (up to 68% of all breech presentations), mixed breech presentation in 25%, and foot presentation in 13%. In childbirth, the transition of one type of breech presentation to another is possible. Complete foot is diagnosed in 5-10%, and incomplete foot is observed in 25-35% of births.
Expectant mothers should not immediately be upset because the baby lies incorrectly. A lot of fetuses presenting with the pelvic end by the end of pregnancy turn over and present with the head.
Such a spontaneous turn is more often observed with the presentation of the buttocks, and in multiparous it happens 2 times more often than in the "primogeniture". And, what pleases, if the child rolled over on his own, then his reverse “somersault” is unlikely.
Etiology
With a 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 act from.
maternal factors
This group includes factors that depend on the state of the mother's body:
- Malformations of the uterus- because of improper development uterus, the fetus takes a pathological position or presentation. It can be a saddle or bicornuate uterus, a septum in the uterine cavity, a hypoplastic uterus, and others.
- Tumors 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 are not excluded
- Increased or decreased uterine tone
- Scars on the uterus
- Overdistension of the uterus- V this case may be affected by polyhydramnios either a large number of childbirth in history
- Narrowing of the pelvis - a significantly narrowed pelvis (3 - 4 degrees) or a twisted and irregularly shaped pelvis also interferes with the physiological position of the baby in the uterus
- Tumors of the pelvis
- Burdened gynecological and / or obstetric history - numerous abortions and curettage, childbirth with complications, inflammation of the uterus and cervix, and other pathologies.
fruit factors
From etiological factors associated with the fetus, emit:
- Low birth 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 (in 13%) complicated by the incorrect position and presentation of either one or both babies
- Congenital developmental anomalies- this subgroup includes malformations of the central nervous system (hydrops of the brain, anencephaly, tumors and hernias of the brain), malformations of the urinary system (Potter syndrome), anomalies of the cardiovascular and musculoskeletal system (hip dislocation, myotonic dystrophy). They also play a role chromosomal pathologies and multiple birth defects.
Placental factors
From how organs develop placental system also depends on the location of the fetus in the uterus:
- placenta previa- prevents the larger part of the fetus (head) from being located at the entrance to the small pelvis
- short umbilical cord- limits fetal mobility
- Too much or too little amniotic fluid - promotes either increased activity baby, or reduces his mobility
- Fetoplacental insufficiency- leads to intrauterine retention development of the fetus and its malnutrition, which increases its motor activity
- cord entanglement- prevents the fetus from unfolding properly in the uterus.
Case Study
Late in the evening, a woman with contractions was admitted to the maternity ward. A vaginal examination revealed an opening of the uterine os up to 5 cm, in which the legs of the fetus were well palpated. After diagnosis: Pregnancy 38 weeks. The first period of 5 urgent births. Foot presentation. It was decided to immediately end the birth by caesarean section. I must say that the woman was not young, about 40 years old, had 5 births (4 children were waiting for their mother at home), and she was not registered. I have 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 ended with suturing of the uterus and ligation of the fallopian tubes, that is, sterilization.
I would like to note that such carelessness of the mother could end badly. Vaginal birth is much safer (in many cases) for a woman than operative delivery. In this case postoperative period proceeded without complications, and the "unnecessary" caesarean section made was justified by sterilization. What if it was the first birth? What if something happened after the operation or during it? That's why given example I cite for expectant mothers as a science. You should never disregard your own health (do not see a doctor, do not take tests and do not attend ultrasound).
The course of pregnancy
The final diagnosis of breech presentation is made at week 36, when the fetus has firmly taken its position in the uterus, although spontaneous rotation is not excluded. Pregnancy with breech presentation of the fetus is much more likely to occur with complications than with cephalic presentation. The main complications are:
- the threat of interruption or premature birth;
- preeclampsia;
- placental insufficiency.
All of these complications lead to oxygen starvation of the fetus, and, accordingly, to its developmental delay (hypotrophy and low birth weight), an abnormal amount of amniotic fluid (low or high water), umbilical cord entanglement. In addition, breech presentation is often accompanied by placenta previa, unstable fetal position, and prenatal rupture of water.
Also, such a presentation affects the development of the fetus and the function 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-protective reactions of the fetus during and after childbirth.
- Sexual gonads (testicles and ovaries)
There is a violation of blood circulation and swelling of tissues, mature cells of the genital gonads partially die, which subsequently affects reproductive function(hypogonadism, oligo- and azoospermia) and leads to infertility.
- Congenital malformations
With breech presentation, congenital malformations occur 3 times more often, in contrast to head presentation. First of all, malformations of the central nervous system and heart, as well as anomalies digestive tract and musculoskeletal system.
- Violation of the uteroplacental blood flow
Leads to fetal hypoxia, increased heart rate and decreased motor activity.
Management of pregnancy
Considering high risk complications in pregnant women with breech presentation, preventive measures are prescribed to improve uteroplacental blood flow, prevent the threat of interruption and fetal hypoxia. Pelvic presentation at 21 weeks is considered physiological, and the fetus is established head down by 22 to 24 weeks. Pregnant women are recommended a balanced diet (prevention of fetal hypo- or hypertrophy), as well as a sparing regimen (good sleep, rest).
Special gymnastics
Exercises for breech presentation of the fetus are recommended to start from 28 weeks. But the execution special gymnastics has a number of contraindications:
- scar on the uterus;
- bleeding;
- threat of interruption;
- preeclampsia;
- severe extragenital pathology.
Apply methods according to Dikan, according to Grishchenko and Shuleshova, as well as according to Fomicheva or according to Bryukhina. The simplest gymnastics is Dikan exercises. The pregnant woman lies on one side or the other, turning over every 10 minutes. In one session, you need to make 3 - 4 turns, and the gymnastics itself should be performed three times a day. After the fetus is established in head presentation, the abdomen is fixed with a bandage.
External rotation of the fetus
If there is no effect from gymnastic exercises at 36 weeks, an external rotation of the fetus is recommended. Manipulation is not performed in the following situations:
- existing scar on the uterus;
- planned caesarean section (there are other indications);
- uterine defects;
- deviations on CTG;
- premature discharge of water;
- fetal defects;
- a 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 rollover in breech presentation is necessarily controlled by ultrasound and CTG, the procedure itself is carried out “under cover” of tocolytics (ginipral, partusisten), and after manipulation, a non-stress test is performed and 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, an additional examination of the pregnant woman is carried out:
- clarification of obstetric anamnesis;
- clarification of extragenital pathology;
- ultrasonography(clarification of the presentation, the size of the fetus and the degree of extension of the head);
- radiography of the pelvis;
- amnioscopy;
- evaluate the readiness of the pregnant woman's body for childbirth and the condition of the fetus.
Then they are determined with the method of delivery. A caesarean section with a breech presentation of the fetus is routinely prescribed according to the following indications:
- fetal weight 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;
- fetal death or birth trauma in history;
- overwearing;
- placenta previa;
- breech presentation of the first baby with multiple pregnancy;
- scar on the uterus;
- foot presentation;
- "old" primiparous (more than 30);
- pregnancy after in vitro fertilization;
- extragenital pathology, requiring the exclusion of the second stage of labor.
Diagnostics
Diagnosing breech presentation is not difficult. For this, external and internal examinations are used, as well as additional methods research.
External examination
For this purpose, Leopold's techniques are used (determining the position and presentation of the child) and measuring the abdomen:
- The height of the uterine fundus
The bottom of the uterus with 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 small pelvis before the onset of labor.
- Leopold's tricks
When probing the abdomen, it is clearly determined that the dense and rounded part (head) is located in the bottom of the uterus, and the buttocks (large, soft, irregular in shape and not balloting, that is, the motionless part) is located at the entrance to the pelvis.
- Fetal heartbeat
With cephalic presentation, a heartbeat is clearly heard on the right or left, but below the navel. When presenting with the pelvic end, the heartbeat is heard at or above the navel.
Vaginal examination
This method is most informative when carried out in childbirth:
- in the case of presentation of the buttocks, the soft part and the gap between the buttocks, as well as the sacrum and genitals are probed;
- 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 a foot, the legs of the fetus are determined, and in the event of a leg falling out, its main difference from a dropped handle is a 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 mass, the presence or absence of birth defects and entanglement with the umbilical cord, the degree of extension of the head.
- CTG and fetal ECG
They allow you to assess the condition of the baby, hypoxia, entanglement or pressing of the umbilical cord loops.
The course of childbirth
Childbirth with a breech presentation of the fetus, as a rule, proceeds with complications. Perinatal mortality in such childbirth increases significantly compared with childbirth in head presentation (four to five times).
Complications during contractions:
Premature discharge of water
Since the pelvic end, compared to the head, does not completely fill the pelvic cavity, which leads to insufficient relaxation of the neck, resulting in the discharge 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 the wall of the vagina, which disrupts the fetoplacental blood flow and leads to fetal hypoxia. If the compression continues for a significant time, then the child's brain may be damaged or his death.
Weakness of tribal forces
Weakness of contractions occurs as a result of untimely outflow 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. The weakness of contractions, in turn, leads to prolonged labor and causes oxygen deficiency in the fetus.
Complications during the period of exile:
Difficult head birth
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 child is significantly smaller than the head, so the birth of the buttocks is quick and without difficulty, and the head "gets stuck". In the case of preterm birth, the pelvic end may also be born with incomplete opening of the cervix, and the subsequent cervical spasm aggravates the situation at birth of the head. Secondly, difficulties in the birth of the head can be caused by its overextension. And, thirdly, the difficult birth of the head may be due to the tilting of the fetal arms. This is seen more frequently with premature birth when the body is born too quickly, and the arms "do not have time."
Injuries to the soft tissues of the birth canal
The birth of a fetus in a breech presentation is fraught not only with complications for him, but also for the mother. All the difficulties associated with the birth of the trunk and the removal of the head often lead to ruptures of the cervix, vaginal walls or perineum.
Birth management
The management of labor in the case of a breech presentation has a significant difference compared to childbirth in a cephalic presentation.
Managing the fight period
- Bed rest
If, during normal childbirth, a woman in labor in the first period is strongly recommended to behave actively (walk), then 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 discharge of water. Lying relies on the side where the back of the baby is facing, which stimulates uterine contractions and prevents weak contractions.
- After the waters break
As soon as the waters have broken, a vaginal examination should be performed to rule out prolapse of the legs or umbilical cord. If the presentation is purely gluteal, you can try to fill the dropped loops. With foot presentation, this method does not apply. If the loop does not tuck in or the legs are present, an emergency caesarean section is performed.
- Monitoring
The first stage of labor is supposed to be carried out under the control of CTG, as a last resort, to auscultate the fetus every half hour (for childbirth in head presentation every hour). You should also monitor the contractile activity of the uterus, conduct a partogram (diagram of the opening of the uterine os).
- Prevention of fetal hypoxia
Timely provision of medical sleep-rest (at the beginning of the first period) and the introduction of a triad according to Nikolaev every 3 hours.
- Anesthesia
- Antispasmodics
The timely introduction of antispasmodics (no-shpa, 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 the weakness of contractions and attempts and maintains the correct position of the baby. With the onset of attempts against the background of the introduction of oxytocin, atropine is administered intravenously to prevent cervical spasm.
- Monitoring
Monitoring of the fetal heartbeat and contractions (CTG) continues.
- Episiotomy
As soon as the buttocks have emerged from the genital slit (eruption of the buttocks), a perineal dissection is performed - an episiotomy.
- manual allowance
Depending on the situation, during the eruption of the buttocks or the birth of the legs, this or that manual allowance(according to Tsovyanov 1 or 2, extraction of the fetus by the pelvic end, Mauriceau-Levre-Lashepel reception).
The third stage of labor is carried out as in normal, physiological childbirth.
Case Study
A young primiparous 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 woman in labor was approximately 32 weeks pregnant. On palpation of the abdomen, it turned out that the pregnancy was twins (2 heads and both in the bottom of the uterus) and 2 heartbeats above the navel. A vaginal examination revealed an opening of the cervix 8 cm, no amniotic sac, presenting legs, one immediately fell out. The woman complains of attempts. Cesarean section to do late. I immediately took it to the birth table. I must say that during the attempts, the woman in labor behaved rather inadequately. She screamed, tried to run off the table and reached for her crotch with her hands while I tried to extract the first baby. The birth of the legs and torso went more or less normally, and the head, of course, was “stuck”. Landing on left hand child as a rider and inserting a finger into the mouth, fingers right hand as I grabbed the child’s neck with a fork (Maurisot-Levre-Lashepel reception), I’m trying to bring the head out. The process took about 3 - 5 minutes, I was no longer waiting for 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 laid”, although there were also difficulties with removing the head. Follow-up period without features. The birth was attended by a neonatologist and an anesthesiologist, who immediately provided resuscitation to the children. After discharge 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, talked with her mother. Children are said to be normal, develop and grow well.
Consequences
Childbirth in breech presentation often ends with complications in the form of birth trauma and have implications for children:
- intracranial injury;
- encephalopathy (as a result of hypoxia and asphyxia);
- dysplasia and / or dislocation of the hip joints;
- disruption of the central nervous system;
- spinal injury.
53. Pregnancy and childbirth with breech presentation of the fetus: classification and diagnosis of pelvic presentation of the fetus; course and management of pregnancy and childbirth.
Pelvicpresentation - this is a presentation in which the pelvic end of the fetus is located above the entrance to the small pelvis, and the head of the fetus is at the bottom of the uterus.
Breech presentation refers to pathological obstetrics, and childbirth in breech presentation refers to pathological.
Classification:
1. Breech presentation (flexion):
A) purely gluteal (incomplete)- the buttocks are facing the entrance to the pelvis: the legs are extended along the body, i.e. bent at the hip and unbent at the knee joints and the feet are located in the chin and face;
b) mixed glutes (full)- the buttocks are facing the entrance to the pelvis along with the legs, bent at the hip and knee joints, somewhat unbent at the ankle joints, the fetus is in the “squatting” position.
2. Foot presentation (extensor):
A) full- both legs of the fetus are presented to the entrance to the pelvis, slightly unbent at the hip and bent at the knee joints;
b) incomplete- one leg is extended, unbent at the hip and knee joints, and the other, bent at the hip and knee joints, is located higher; are more common than complete;
V) knee- the legs are unbent at the hip joints and bent at the knee, and the knees are presented to the entrance to the pelvis.
Factors contributing to the occurrence of pelvic presentation:
a) Maternal causes: anomalies in the development of the uterus; uterine tumors; narrow pelvis; pelvic tumors; decrease or increase in the tone of the uterus; multiparous women; scar on the uterus.
b) Fetal causes: prematurity; multiple pregnancy; intrauterine growth retardation; congenital anomalies fetus (anencephaly, hydrocephalus); incorrect articulation of the fetus; features of the vestibular apparatus in the fetus.
c) Placental causes: placenta previa; oligohydramnios or polyhydramnios; short umbilical cord.
Diagnosis of pelvic presentation.
1. The diagnosis of breech presentation is made at 32-34 weeks. pregnancy, because after 34 weeks. the position of the fetus is usually fixed.
2. For external obstetric examination, four Leopold techniques should be used:
a) the first reception is determined by: a higher standing of the fundus of the uterus; in the bottom of the uterus, a rounded, dense, balloting head is palpated, often displaced from middle line abdomen to the right or left;
b) at the third reception above the entrance or at the entrance to the pelvis, a large, irregularly shaped presenting part of a softish consistency, incapable of balloting, is palpated;
c) at the fourth dose, the presenting part is usually located above the entrance to the small pelvis until the end of pregnancy.
3. The fetal heartbeat in breech presentation is heard above the navel, sometimes at the level of the navel, on the right or left (depending on the position). The position and types of position are determined by the back (as in head presentation).
4. The diagnosis is specified by vaginal examination:
a) through the anterior fornix of the vagina during pregnancy, a voluminous, softish consistency of the presenting part is palpable (in contrast to the rounded dense head of the fetus)
b) in childbirth, you can palpate the coccyx, ischial tubercles, fetal legs with a mixed breech and foot presentation.
Differential diagnosticfoot and handle differences: the leg has a calcaneus, the fingers are even, short, the thumb does not lag behind and does not have great mobility; knee and elbow differences: the knee has a rounded movable patella.
5. In the diagnosis of pelvic presentation, ultrasound scanning is of great importance, which allows you to determine not only the presentation, but also the sex, type, weight of the fetus, the position of the head (bent, unbent), entanglement of the umbilical cord, localization of the placenta, the size and degree of its maturity, the amount of water , anomalies in the development of the fetus, etc.
Distinguish four options for the position of the fetal head in breech presentation fetus (the angle is measured between the spine and the occipital bone of the fetal head):
the head is bent (angle greater than 110°);
the head is slightly extended (military posture) - I degree of extension (angle from 100° to 110°);
the head is moderately extended - II degree of extension (angle from 90 ° to 100 °);
excessive extension of the head ("looks at the stars") - III degree of extension (angle less than 90).
The position of the fetal head is most clearly determined by ultrasound. Clinical signs of extension of the fetal head are a discrepancy between the size of the fetal head and its expected mass (the size of the head appears large), the location of the head in the fundus of the uterus, and the presence of a pronounced cervico-occipital sulcus.
6. When recording a fetal ECG, the ventricular QRS complex of the fetus is directed downwards, and not upwards, as in cephalic presentation.
7. With amnioscopy, it is possible to establish the nature of the presentation of the fetus, the amount and color of amniotic fluid, the possible presentation of the umbilical cord loops.
8. If necessary, use radiography.
The course of pregnancy and childbirth with breech presentations.
Complications of breech presentation:
a) In the first half of pregnancy: the threat of abortion; early preeclampsia
b) In the second half of pregnancy: the threat of abortion; premature birth; preeclampsia of varying severity; entanglement of the umbilical cord; oligohydramnios; fetal hypotrophy; placenta previa; placental abruption
c) In childbirth: premature and early rupture of amniotic fluid; prolapse of umbilical cord loops and small parts; weakness of labor activity; violation of uteroplacental circulation and the development of hypoxia in the fetus; increased incidence of infection of the membranes, placenta, uterus and fetus; driving the buttocks into the pelvis; turning the fetus backwards backwards, when the chin is fixed under the pubic symphysis - the head unbends: there is a threat of hypoxia, trauma to the fetus and mother; tilting of the handles and extension of the head (three degrees: I - the handle is thrown back anterior to the ear, II - at the level of the ear and III - posterior to the ear of the fetus); compression of the umbilical cord; fetal hypoxia; fetal trauma; injuries in the mother: ruptures of the cervix, vagina and perineum; hypotonic bleeding in the afterbirth period.
With breech presentation, the frequency of congenital anomalies in the development of the fetus also increases, among which there are: anencephaly, hydrocephalus, congenital dislocation of the hip, malformations of the gastrointestinal tract, respiratory tract, cardiovascular system, and urinary system.
The biomechanism of childbirth in breech presentation:
1. Insertion of the buttocks (compression and lowering them, l. intertrochanterica is in one of the oblique sizes).
2. Internal rotation of the buttocks (begins at the transition from the wide to the narrow part of the pelvic cavity, ends in the exit plane, when l. intertrochanterica becomes in direct size exit).
3. Lateral flexion of the lumbar spine of the fetus. A fixation point is formed between the lower edge of the womb and the iliac wing of the anterior buttock. There is a lateral flexion of the spine in the lumbosacral region, the birth of the posterior buttock, and then the anterior one in a direct size. At this time, the shoulders enter with their transverse size into the same oblique size of the entrance to the pelvis through which the buttocks passed.
4. Internal rotation of the shoulders (from an oblique dimension to a straight one) and the external rotation of the body associated with it. The fetus is born to the navel, then to the lower angle of the shoulder blades. The anterior shoulder is set under the womb, a fixation point is formed between the shoulder (on the border of the upper and middle thirds) and the pubic articulation of the mother.
5. Lateral flexion in the cervicothoracic spine - the birth of the shoulder girdle and handles is associated with this moment.
6. Internal rotation of the head with the back of the head anteriorly (the swept suture passes into the direct size of the exit from the small pelvis, the suboccipital fossa is fixed under the bosom).
7. Flexion of the head around the point of fixation. The chin, mouth, nose, crown and back of the head are born in succession.
With foot presentations, the biomechanism of childbirth is the same, only the legs of the fetus are not the buttocks, but the legs of the fetus are shown first from the genital slit.
The birth tumor in breech presentation is located more on one of the buttocks: in the first position - on the left buttock, in the second - on the right. Often, the birth tumor passes from the buttocks to the external genital organs of the fetus, which is manifested by swelling of the scrotum or labia.
With foot presentation, the birth tumor is located on the legs, which become swollen and blue-purple.
Due to the rapid birth of the subsequent head, its configuration does not occur, and it has a rounded shape.
Management of pregnancy and childbirth in breech presentations.
Breech presentation, diagnosed before 28 weeks of gestation, requires only expectant observation. In 70% of multiparous and 30% of primiparous pregnant women, cephalic rotation occurs spontaneously before delivery and in a small percentage during delivery.
Measures aimed at changing the pelvic presentation to the head:
1) TOcomplex of gymnastic exercises in terms of 29-34 weeks of pregnancy. The simplest set of exercises: a pregnant woman, lying on a couch, alternately turns on her right and left side and lies on each of them for 10 minutes. The procedure is repeated 3-4 times. Classes are held 3 times a day. Fetal head rotation can occur during the first week. A positive effect is observed in 76.3% of cases.
Contraindications: diseases of the cardiovascular system in the stage of decompensation, diseases of the liver and kidneys, late toxicosis of pregnant women, threats of abortion, bleeding from the vagina, a scar on the uterus, anomalies of the pelvis and soft birth canals that prevent delivery.
2) Hexternal prophylactic rotation of the fetus on the head according to Arkhangelsk. The operation of external rotation requires compliance with a number of conditions: it is performed in a hospital at 32-34 weeks of gestation (however, in Lately it is proposed to rotate after 36-37 weeks) with a sufficient amount of amniotic fluid under ultrasound control; monitoring of the fetal heart activity is necessary before the rotation and within an hour after its implementation; mandatory is the appointment of β-mimetic agents to reduce uterine tone.
Contraindications: threatened miscarriage, narrow pelvis, primiparous age over 30 years, history of infertility or miscarriage, lack of good fetal mobility, late gestosis, cardiovascular diseases in the decompensation stage, oligohydramnios and polyhydramnios, multiple pregnancy, fetal malformations, uterine scar, malformations of the uterus and appendages, anomalies of the pelvis and soft birth canal, preventing delivery through the natural birth canal.
In the absence of the effect of corrective gymnastics and external rotation, hospitalization of the pregnant woman in a hospital at 38 weeks of gestation is necessary.
The choice of method of delivery in breech presentation of the fetus depends on the age of the woman, the duration of pregnancy, the condition and estimated weight of the fetus, the degree of extension of the fetal head, the size of the small pelvis, the "maturity" of the cervix, concomitant extragenital pathology, complications of this pregnancy.
Delivery tactics (determined before childbirth):
spontaneous onset of labor and delivery through the natural birth canal;
labor induction at or before the term of delivery;
planned caesarean section.
To select the method of delivery, all clinical data and results obtained using objective research methods should be evaluated on a point scale for the prognosis of childbirth with a breech presentation of a full-term fetus.
Evaluation is carried out on 12 parameters from 0 to 2 points. If the total score is 16 or more, then childbirth can be carried out through the natural birth canal.
Scale for the prognosis of childbirth in the breech presentation of a full-term fetus.
|
Parameter |
score |
||
|
0 |
1 |
2 |
|
|
Gestational age |
37-38 weeks and more 41 weeks | ||
|
Estimated fetal weight, g |
4000 and more | ||
|
Kind of breech presentation |
mixed |
Pure gluteal |
|
|
Position of the fetal head |
Excessively extended |
Moderately extended |
bent |
|
"Maturity" of the cervix |
"Immature" |
"Not Mature Enough" |
"Mature" |
|
Fetal condition |
chronic suffering |
Initial Signs of Suffering |
Satisfactory |
|
Small pelvis dimensions, cm: Direct Entry Transverse entry Straight cavity Interosseous Bituberous direct exit |
Less than 11.5 |
Over 12.0 |
|
Conducting childbirth through the natural birth canal suggests in the first stage of labor prevention of untimely rupture of the fetal bladder and prolapse of small parts and the umbilical cord of the fetus (strict bed rest; laying on the side where the back is facing, i.e. corresponding to the position of the fetus).
With the development of regular labor and the opening of the cervix by 3-4 cm, the introduction of painkillers and antispasmodics is indicated.
During childbirth, monitoring of the fetal heart rate and uterine contractions is mandatory. To assess the dynamics of the birth process, it is necessary to conduct a partogram.
It is necessary to carry out the prevention of fetal hypoxia according to Nikolaev, use 1% solution of sigetin (2 ml), chimes 0.5% solution (2 ml), galascorbin (0.5 g), cocarboxylase (0.05 g).
After amniotic fluid lithium, the fetal heartbeat should be heard and a vaginal examination should be performed to exclude or confirm prolapse, small parts and the umbilical cord. You can try to fill the fallen loop of the umbilical cord with a purely breech presentation of the fetus, if the attempt fails, it is necessary to perform a caesarean section.
Important tasks are the timely diagnosis of labor anomalies and their treatment (oxytocin, prostaglandins).
In the second stage of labor for prophylactic purposes, the introduction of oxytocin or prostaglandin intravenously is indicated. By the end of the second period of labor, to prevent cervical spasm, it is recommended to introduce 2 ml of a 2% solution of papaverine hydrochloride, 2 ml of a 1.5% solution of ganglerone, 1.0 ml of a 1% solution of atropine sulfate or other antispasmodics.
When eruption of the buttocks, it is necessary to perform an episiotomy.
To avoid pressing the head of the fetus on the umbilical cord after the birth of the trunk until bottom corner scapula further birth of the fetus should not last more than 5 minutes. At the same time, due to untimely intervention, complications such as throwing back the handles, spasm internal os, posterior formation, fetal hypoxia.
Indications for caesarean section in breech presentation: post-term pregnancy, lack of biological readiness for childbirth at full-term pregnancy, anatomically narrow pelvis, anomalies in the development of the genital organs, fetal weight more than 3500 g and less than 2000 g, severe chronic fetal hypoxia, excessive extension of the fetal head, aggravated obstetric anamnesis, prolonged infertility, age of primiparous older than 30 years, umbilical cord previa, placenta previa and abruption, scar and abnormal development of the uterus, severe forms of preeclampsia, extragenital pathology, twins with breech presentation of the first fetus, etc.
Obstetric benefits for pelvic presentation of the fetus.
1. RA manual for purely breech presentation using the Tsovyanov method. It is started at the moment of eruption of the buttocks, the buttocks being born are supported without any attempts to extract the fetus. primary goal- contribute to the normal articulation of the fetus, prevent the legs from being born prematurely, for which they are held with their thumbs pressed against the body of the fetus. The remaining 4 fingers are placed on the sacrum of the fetus. As the fetus is born, the hands move along the body to the posterior commissure of the woman in labor. In oblique size, the body is born to the lower angle of the anterior scapula, the shoulder girdle is set in direct size. At this point, it is advisable to direct the buttocks towards yourself in order to facilitate spontaneous birth from under the pubic arch of the anterior shoulder. For the birth of the rear handle, the fetus is again lifted anteriorly. Having entered the small pelvis in an oblique section, the fetal head delays its internal rotation, descends to pelvic floor with good labor activity and is born independently.
2. Manual aid for leg presentations according to the Tsovyanov method. With this method, the legs of the fetus were held in the vagina until the uterine os was fully opened.
In case of difficulties that arose during the birth of the shoulder girdle, and even more so when throwing back the handles, you should proceed to the release of the handles and the head of the fetus with the help of classic manual aid. The latter is also used for mixed breech and foot presentations of the fetus. The provision of this benefit should begin after the birth of the fetus to the lower angle of the anterior scapula. The back handle of the fetus is released first, and the obstetrician's hand of the same name is inserted from the side of the back of the fetus, two fingers of it slide along the shoulder, reaching the shoulder fold. The torso of the fetus, set aside to the side opposite to the position when the elbow bend is reached, is brought to the middle position by pressing on the elbow bend, the handle is removed from the genital slit with a washing movement. The palms of both hands, together with the released handle, cover the sides of the body of the fetus with a “boat” and rotate it so that the front handle moves from under the womb to the rear position. In this case, the back should pass under the bosom in order to maintain the front view. Similarly release the second handle.
3. Removal of the head according to Mauriceau-Levre-Lachapelle: the fetus is seated in the "rider" position on the obstetrician's left hand, the fetal head at this time goes into a straight size. The middle finger of the left hand is inserted into the fetal mouth and with a slight pressure on the lower jaw, the head is flexed. The index and middle fingers of the second hand grasp the fork-shaped shoulder girdle of the fetus from above (carefully, collarbones!). With the same hand, traction is made towards oneself and down (until the scalp appears and a fixation point is formed between the suboccipital fossa and the womb), and then up.
4. Extraction of the fetus by the leg used for incomplete foot presentation. To do this, the leg (usually the front one) is grabbed by the hands, and the thumbs should be located along the length of the lower leg, and the remaining fingers should cover it in front. Thus, the entire lower leg lies as if in a splint, which prevents the leg from breaking. Then produce traction down. As the birth progresses, the leg is grasped as close to the genital slit as possible. From under the symphysis, the region of the anterior inguinal fold and the wing of the ilium appear. This area is fixed under the symphysis so that the posterior buttock can be cut through. To do this, the front thigh, captured with both hands, is strongly raised upwards. The posterior buttock is born and the posterior leg falls out with it. After the birth of the buttocks, they clasp the fetus with their hands so that the thumbs are on the sacrum, and the rest clasp the inguinal folds and thighs. In order to avoid damage to the abdominal organs, it is impossible to mix hands on the stomach during traction. By traction on themselves, the body is pulled to the lower angle of the anterior scapula and proceed first to the release of the handles, and then the head, as this is done with the classic manual aid in breech presentation.
5.Extraction of the fetus by both legs. If the fetus is in full foot presentation, extraction is started from both legs. To do this, each leg is grasped with the same hand so that the thumbs lie along the calf muscle of the fetus, and the rest cover the lower leg in front. As the extraction proceeds, both hands of the obstetrician should gradually slide upward along the legs, being all the time near the vulva. Further eruption of the buttocks, extraction of the trunk, arms and head occurs in the same way as when extracting the fetus by one leg.
6.Extraction of the fetus by the inguinal fold. The necessary conditions for this operation are: full disclosure of the uterine os, correspondence of the size of the fetus to the size of the small pelvis, finding the buttocks on the pelvic floor. With a high standing of the buttocks and their sufficient mobility, a purely gluteal presentation is transferred to an incomplete foot position by lowering the legs, and then the fetus is removed. Extraction by the inguinal fold to the umbilical ring is carried out with the index finger inserted into the inguinal fold. Tractions are produced during attempts downwards. To strengthen the thrax, the hand performing the operation is grasped with the other hand in the wrist area. In this case, the assistant presses on the bottom of the uterus. The anterior buttock is removed bottom edge pubic symphysis. The fetal ilium becomes the point of fixation. Then the finger of the second hand is inserted into the posterior inguinal fold and the posterior buttock is removed. After that, the obstetrician places both thumbs along the sacrum of the fetus, clasping his hips with the rest of the fingers, and removes the fetus to the umbilical ring. After the birth of the buttocks, the operation proceeds in the same way as when extracting the fetus by the legs.
The course and management of the third stage of labor does not differ from that in cephalic presentation.
The postpartum period in most puerperas proceeds normally.
The prognosis for the fetus is less favorable than with head presentations in terms of immediate and long-term consequences.
Breech presentation of the fetus
At the beginning of pregnancy, while your unborn baby is still very small, he moves freely inside the uterus, changing his position. Over time, as the fetus grows, it becomes tighter and tighter. However, until about 30 weeks of gestation, his position should not be a cause for concern.
By this time, the child, as a rule, turns head down. This position is called head presentation. This classic version, the most convenient for childbirth. It is in the head presentation that up to 90% of children are born.
However, it happens that the child takes the opposite position. Thus, the buttocks are the presenting part, and this position is called the gluteal, or breech presentation fetus. At breech presentation of the fetus In this case, natural childbirth is also possible, although more difficult.
Presentation is determined during an ultrasound examination and during a manual examination by a gynecologist by palpation of the abdomen. If after 30 weeks your baby has taken a transverse or pelvic position, you will be advised to do some exercises to help the baby roll over. You should not be afraid of this situation, since many children take a classic pose after 32-34 weeks, or even on the eve of childbirth. The proposed course of exercises will allow you to contribute to this process.
A set of exercises for breech presentation of the fetus
1. "Indian bridge". You need to lie on the floor, raise your legs and put a few pillows under the pelvis so that the pelvis becomes 30-40 centimeters higher than the shoulders. In this case, the shoulders, pelvis and knees should form a straight line. Thanks to this exercise, some children turn into the correct position the first time. If the child is still stubborn, repeat the lesson 2-3 times a day. However, never do this on a full stomach. There is another version of this exercise. You can sit your husband opposite and put your legs on his shoulders so that your popliteal fossae are on his shoulders.
In addition to this classical method, there are also methods for cauterizing certain points with outside little finger on the leg, as well as acupressure of the inner surface of the foot. But this requires highly qualified specialists.
2. With transverse and (or) breech presentation of the fetus three more exercises:
Introductory: Feet shoulder-width apart, hands down. For the count of times, raise your arms to the sides with your palms down, stand on your toes and at the same time arch your back, doing deep breath. For two - exhale and start position. Repeat 4 times.
Basic: Lie down on the side to which the back of the fetus is facing in breech presentation, or opposite to that to which the head is facing in transverse. Bend your knees and hips and lie still for 5 minutes. Then take a deep breath, turn over your back to the other side and lie still for 5 minutes again. Then straighten the leg that you have on top - with the pelvic, or the one on which you lie, with transverse position fetus. The second leg must remain bent. Take a deep breath and again bend the straightened leg at the knee and hip joints, grab your knee with your hands and take it towards the back in breech presentation or towards the buttocks in transverse presentation. At the same time, the torso will lean forward, and the bent leg will describe a semicircle inward, touching the front wall of the abdomen. Take a deep breath, relax, straighten and lower your leg. Then take a deep breath again and repeat the exercise again. This exercise should be done 5-6 times.
Final: Lying on your back. Bend your legs at the knee and hip joints, rest your feet shoulder-width apart on the floor, stretch your arms along the body. On the count of times - inhale and lift the pelvis, resting on the feet and shoulders. For two - lower the pelvis and exhale. Then straighten your legs, tighten the muscles of the buttocks, draw in the stomach and perineum, while inhaling. Relax - exhale. Repeat 7 times.
If during the next ultrasound it is found that you have achieved your goal and the baby has turned from the pelvic to the normal position, you can forget the introductory and basic exercises, and perform the final one until childbirth occurs.
If during classes you feel movement in your stomach or something similar to noise, then most likely you have "persuaded" the child to take the correct position. A long walk will help him fix himself in this position. But to make sure of luck, you need to do an ultrasound.
Childbirth with breech presentation of the fetus The following location of the fetus in the uterus is considered normal: the head is located below, located above the bosom, and during childbirth the first passes through the mother's birth canal. But this is not always the case. In 3-4% of all women, the fetus is located in the uterus on the contrary, in the so-called breech presentation. In breech presentation, the buttocks of the fetus (buttock), legs (foot presentation) or buttocks with legs (mixed breech presentation) face the entrance to the mother's pelvis (above the womb).
Childbirth in this case can proceed quite normally, but situations often arise that are unfavorable for the mother and child.
Why does breech presentation occur?
Possible causes of breech presentation of the fetus:
- increased fetal mobility with polyhydramnios, premature pregnancy(the amount of water is greater than with a full-term pregnancy), multiple pregnancy,
- narrow pelvis, placenta previa (location on the way of the fetus moving along the birth canal), fetal abnormalities (large disproportionate dimensions of the fetal head)
- oligohydramnios, anomalies in the development of the uterus. This limits the mobility of the fetus in the uterus.
– low tone uterus. The ability of the uterus to correct the position of the fetus in response to irritation of its walls decreases.
What types of breech presentation of the fetus are there?
There are the following types of pelvic presentation of the fetus:
- gluteal (buttocks are located above the womb, legs are extended along the body)
foot (legs of the fetus are presented)
mixed (buttocks facing the mother's pelvis along with legs bent at the hip and knee joints).
Leg presentations are formed during childbirth. Breech presentations make up 30-33% of all breech presentations. Very rarely, in 0.3%, there is a knee presentation, a kind of foot presentation, in which the bent knees of the fetus face the mother's pelvis.
How to recognize the breech presentation of the fetus?
During an external obstetric examination, during an examination of a pregnant woman, a large, irregularly shaped and softish presenting part is probed above the entrance to the pelvis. There is also a high standing of the uterine fundus compared with the same gestational age with cephalic presentation. This is due to the position of the pelvic end of the fetus above the entrance to the mother's pelvis until the end of pregnancy and the onset of labor. In the bottom of the uterus, on the contrary, a dense, rounded fetal head is determined. Fetal heartbeat is best heard in pregnant women in breech presentation above the navel.
You can clarify the diagnosis with a vaginal examination. At the same time, softish tissues of the presenting buttocks and legs of the fetus are probed. Since all pregnant women repeatedly undergo an ultrasound examination during pregnancy, diagnosis is not difficult.
How does pregnancy proceed with a breech presentation of the fetus?
Pregnancy with a breech presentation proceeds in the same way as with a head presentation. Starting from the 32nd week of pregnancy, with a diagnosis of breech presentation, a certain set of exercises is recommended to correct it. The pregnant woman, lying on the bed, turns alternately on the right and left side and lies on each for 10 minutes. And so 3-4 times. Classes are held 3 times a day. Often, fetal rotation on the head occurs within the first 7 days, unless there are aggravating circumstances (oligohydramnios or polyhydramnios, irregular shape uterus). The meaning of these exercises is to stimulate the nerve receptors, increase the excitability and motor function of the uterus. If by 37-38 weeks the stubborn baby has not changed its position, childbirth is carried out in a breech presentation. 2 weeks before the expected date of delivery, hospitalization is offered in a hospital, where the issue of the method of delivery is decided.
How to give birth with a breech presentation of the fetus?
In the maternity hospital, to decide on the method of delivery (caesarean section or birth through the natural birth canal), the following points are evaluated:
- age of the woman (the first childbirth after 30 years is referred to as aggravating moments)
how past pregnancies went, whether there were births and how they ended. An important point is the presence in the past of independent childbirth.
how was it real pregnancy, is there swelling, increased arterial pressure, impaired renal function
estimated fetal weight (estimated baby weight over 3500 g inclines to a decision in favor of caesarean section)
fetal condition (signs chronic hypoxia, lack of oxygen, which can be aggravated against the background of prolonged labor)
the size of the mother's pelvis (there is a tendency to develop a clinically narrow pelvis during childbirth). It is possible to use X-ray pelviometry (assessment of the size of the bone pelvis using X-rays)
the condition of the cervix, its readiness for childbirth (the mature cervix is soft, shortened to 1.5-2 cm, located in the center of the small pelvis, skips the tip of the finger)
type of pelvic presentation. The most unfavorable is considered - foot presentation ( frequent complications in the form of prolapse of the fetal leg, loop of the umbilical cord
the position of the fetal head (with excessive extension, according to ultrasound, operative delivery is also recommended). This can lead to injuries to the brain, cervical spine.
If there are complications during pregnancy, narrow pelvis, the weight of the fetus is more than 3500 g, the age of the primiparous woman is more than 30 years, a decision is made on the delivery of a pregnant woman with a breech presentation of the fetus by caesarean section. The frequency of caesarean section with breech presentation of the fetus is more than 80% on average.
Assistance in childbirth with breech presentation of the fetus
After the operation, a scar remains on the uterus, so if the condition of the mother and fetus is good, the cervix is mature and the baby is supposed to be small, childbirth is carried out under close supervision independently.
In the first stage of labor (contractions and dilatation of the cervix), a woman must observe bed rest to avoid complications ( premature effusion water, prolapse of the fetal stem or umbilical cord loops).
If, after all, a decision is made to deliver childbirth through the birth canal, obstetric care is provided in the form of benefits in the second stage of childbirth. Main principle- maintain the articulation of the fetus (the legs are extended along the body and pressed to the chest by the arms of the fetus). First, the baby is born to the navel, then to the lower edge of the angle of the shoulder blades, then the arms and shoulder girdle, and then the head. As soon as the baby was born before the navel, his head presses the umbilical cord with the development of a lack of oxygen. Until the full birth of the child, no more than 5-10 minutes should pass, otherwise the consequences of oxygen starvation can be very unfavorable. A perineal incision is also made to speed up the birth of the head and make it less traumatic. They also use a dropper with reducing agents (), antispasmodics (no-shpa).
Condition of children born in breech presentation at independent childbirth, requires heightened attention. Frequent signs of hypoxia suffered during childbirth adversely affect nervous system child (consultation of a neurologist). Often such a pathology as a dislocation hip joint. A neonatologist (children's doctor) must be present at childbirth to provide resuscitation measures if necessary. With these precautions, children born in this way are no different from other children.
Video. breech presentation at 20 weeks
