Pregnancy 34 weeks transverse position. What causes can lead to the transverse position of the fetus? Factors contributing to the occurrence of malposition of the fetus
If we talk about literature, I will remember many examples when women in childbirth died in childbirth, and often together with an unborn child. One of the causes of high mortality in the 17th - 19th centuries and earlier was difficult childbirth caused by the transverse position of the fetus. At present, this complication of pregnancy, although it remains a danger to both the life of the woman and the baby, the risk of death of both participants in childbirth has significantly decreased. Incorrect positions of the fetus, including the transverse position, occur in 1 case per 200 births, which is 0.5 - 0.7% as a percentage. Tellingly, situations with an incorrect position of the child in the uterus are more often observed in multiparous women (10 times) than in women giving birth for the first time.
Let's define terminology
Depending on how the fetus is located in the uterus, the woman's delivery tactics are also determined. To understand the terms, let's define the following concepts:
- fetal axis - a longitudinal line connecting the buttocks and the baby's head;
- axis of the uterus - a longitudinal line connecting the bottom of the uterus and the cervix, or the uterine length.
The position of the fetus is the ratio of the axis of the baby to the length of the uterus. Distinguish correct position fetus and wrong. The correct position is considered to be longitudinal, when the axes of the uterus and the child coincide, but simply, when the baby and the mother’s body are in the same direction (if the mother is standing, then the child is located vertically with her). In this case, one of the large (head or pelvic end) parts of the baby "looks" at the entrance of the small pelvis, and the other rests against the uterine fundus.
The transverse and oblique positions of the fetus are considered incorrect positions. But it should be remembered that the fetus is very mobile for most of the pregnancy and constantly changes its position. Stabilization of his position occurs by 34 weeks, so talking about the wrong position before the specified period does not make much sense.
Transverse position
In the case of the transverse position (situs transverses) of the child, it is located not along, but across the uterus, that is, the uterine axis and the axis of the fetus are perpendicular to each other and make an angle of 90 degrees. Since the baby is located across, accordingly, there is no presenting part - large parts of the fetus are palpated on the sides of the uterus on the right and left and are above the iliac crests.
What is called oblique position
The oblique position of the fetus (situs obliguus) is said to be when the axis of the fetus is displaced relative to the length of the uterus, which forms sharp corner(less than 45 degrees). In this case, the head or buttocks are located below the iliac crest. You can also highlight the transverse oblique position(does not play a big role) when the axes of the fetus and uterus are at an angle, but do not reach 90 degrees, but more than 45 degrees.
It is also worth mentioning about precarious position fetus. With significant mobility of the fetus, it periodically changes its position from longitudinal to transverse or oblique and vice versa.
Fetal presentation
The presentation of the fetus is the ratio of its large part (it can be the head or the pelvic end) to the entrance to the pelvis. Accordingly, distinguish cephalic presentation(at the entrance to the small pelvis there is a head) and pelvic (can be foot, buttock or mixed).
What contributes to the incorrect positions of the fetus
The reasons for the transverse position of the fetus can be due either to uterine factors (the presence of obstacles in it) or increased or reduced motor activity of the fetus:
- uterine fibroids
Risk wrong position the baby increases significantly in the presence of myomatous / fibrous nodes of the uterus. It is especially large when the nodes are localized in the neck, isthmus or lower uterine segment, or when large sizes nodes located in other places, which prevents the child from taking the correct position. The growth of a uterine tumor during gestation is not excluded, which also deforms the uterine cavity and the fetus is forced to position itself incorrectly.
- Congenital malformations of the uterus
Uterine anomalies also contribute to the transverse position, for example, a septum in the uterus or a saddle or bicornuate uterus.
- Incorrect localization of the placenta
low placentation or low position placenta (5 cm or less from the internal os) or placenta previa (when the placenta partially or completely covers internal os) often causes the wrong position of the baby in the uterus.
- narrowed pelvis
As a rule, narrowing of the pelvis of 1-2 degrees does not create obstacles either for the development of the fetus or for its birth. But more severe degrees of narrowing of the pelvis, especially asymmetric forms of narrowing (oblique, curved by bone exostoses) serve as a prerequisite for the location of the fetus not along the axis of the uterus, but across or obliquely.
- Fetal malformations
Some of the malformations manifest themselves already in utero. For example, with anencephaly (absence of the brain) or hydrocephalus - dropsy of the brain (the fetal head becomes very large), there may be a transverse / oblique fetal position.
- Pathology amniotic fluid
Excess amniotic fluid leads to excessive expansion of the uterine cavity, which in turn provokes excessive motor activity of the baby. It becomes very mobile, does not feel the borders of the uterus and "fits" in it across or obliquely. With a lack of amniotic fluid, the situation is reversed. The tightness of the uterine space and not a large number of amniotic fluid does not allow the child to actively move and take the necessary longitudinal position.
- Multiple pregnancy
When there are several fetuses in the uterus, they become crowded, which prevents one or all babies from taking the correct position.
- large fruit
The significant size and weight of the fetus (more than 4 kg) reduces its motor activity and provokes the wrong location of the baby in the uterus.
- Increased tone of the uterus
In the event of a threatened abortion, especially a permanent one, the uterus is almost constantly in hypertonicity and limits the movement of the fetus.
- Flabbiness of the muscles of the anterior wall of the abdomen
A similar situation is often typical for multiparous women (4-5 births). The constant stretching of the anterior abdominal wall of the abdomen by the pregnant uterus contributes to excessive motor activity the child (the abdominal muscles do not restrain movement), his coups and somersaults, which ends with the location of the fetus in the uterus transversely.
- Fetal hypotrophy
Insufficient weight and size of the fetus is also the reason for its constant movement and coups in the uterus (the baby himself is small and there is too much space in the uterus for him).
How to determine the transverse position of the fetus
To determine the incorrect position of the fetus is carried out comprehensive examination pregnant:
Examination of the abdomen
During examination of the abdomen of a pregnant woman, its irregular shape is revealed. The abdomen is stretched in a transverse size with a transverse position of the fetus or has an obliquely stretched shape in the case of an oblique position of the baby. The uterus takes the form of a ball instead of the ovoid-elongated one. When measuring the size of the abdomen, it is established that its circumference significantly exceeds the norm, although the height of the uterine fundus does not coincide with the gestational age (less).
Palpation of the abdomen
During palpation of the abdomen, it is impossible to determine the presenting (large part of the fetus) part at the entrance to the pelvic bone ring. In the bottom of the uterus, the head or pelvic end is also not palpated. Large parts of the baby are palpable on the right or left side of the midline of the uterus. The position of the fetus is determined by the head. If the head is on the left, they talk about the first position, if the head is located on the right, about the second. The fetal heartbeat is well heard in the navel, and not on the left or right, as in the longitudinal position. It may be difficult to establish the position and position of the baby in case of uterine hypertonicity (threat premature birth) and with an excess of amniotic fluid.
Obstetric ultrasound
Obstetric ultrasound with a 100% guarantee determines the position of the fetus at any gestational age. But, as already mentioned, the transverse position of the baby in the period of 20 weeks should not be a reason for panic, until due date childbirth, the fetus will have time to take the “correct” position.
Vaginal examination
A vaginal examination, which is performed at the end of pregnancy or when contractions have begun, but the membranes are intact, provides little information. The obstetrician can only determine that the presenting part of the fetus at the entrance to the small pelvis is missing. In case of outflow of water and opening of the uterine pharynx up to 4 cm or more, a vaginal examination is carried out with caution, as it can provoke prolapse of the handle, fetal leg or umbilical cord loop. When water is poured out, the doctor can feel the side of the fetus (ribs with intercostal spaces), the shoulder blade or armpit, in some cases the elbow or hand of the handle.
How is pregnancy and childbirth going?
Pregnancy in the transverse position of the baby, as a rule, proceeds without features. But it is noted that in almost 30% of cases preterm labor begins. Untimely outpouring amniotic fluid is one of the most frequent complications this pathology, which can occur both during pregnancy and cause the onset of premature birth, and in the process of childbirth.
Why is childbirth complicated in the case of a transverse position of the fetus
It is extremely rare to complete labor with the transverse position of the fetus on its own and the birth of a live baby. In such cases, an independent rotation of the child into a longitudinal position occurs and the birth of his head or pelvic end. Self-twisting is possible with a small size of the fetus or its prematurity. Basically, the course of childbirth develops unfavorably and is complicated by the following processes:
- Untimely discharge of water
With a transverse arrangement of the fetus, early or premature effusion waters (almost in 99% of cases). This causes the absence of the presenting part, which is pressed against the entrance to the pelvis and divides the amniotic water into anterior and posterior.
- Launched lateral position
This complication occurs after premature or early discharge of water. IN such a case due to the rapid outflow of water, the child’s mobility is sharply limited and either the shoulder is driven into the small pelvis, or small parts (arms or legs) fall out. When the umbilical cord falls out, it is clamped, blood flow is disturbed in it and the fetus dies.
- Rupture of the uterus
Threatening rupture of the uterus accompanies the neglected transverse position of the fetus. After the waters have receded, the shoulder girdle is pushed into the entrance of the small pelvis, and the uterus begins to contract rapidly, which leads to overstretching of the lower segment and the threat of its rupture. If a caesarean section is not performed in a timely manner, the uterus is torn.
- Chorioamnionitis
Premature discharge of water and a long anhydrous interval contribute to the penetration of infection into the intrauterine cavity and the formation of chorioamnionitis, which leads to the development of peritonitis and sepsis.
- Fetal hypoxia
The protracted course of childbirth against the background of a long anhydrous period provokes the development of fetal hypoxia and the birth of a child in asphyxia.
- Twin birth
Due to intense contractions and outflowing waters, the walls of the uterus are in close contact with the fetus, which leads to its flexion in half in the thoracic region. In this case, childbirth ends spontaneously. First is born rib cage with the neck pressed against it, then the stomach and the head pressed into it, and then the buttocks and legs. Live birth in similar situation unlikely.
How is childbirth and pregnancy
Tactics of managing a pregnant woman with a transverse position of the fetus includes careful observation women, restriction physical activity and the appointment of corrective gymnastics (in the absence of contraindications). Up to 32 - 34 weeks, the transverse or oblique position of the child is considered unstable, since there is a high probability that the fetus will adopt a longitudinal position.
Previously, external rotation of the fetus was widely practiced in order to bring it into a longitudinal position. External obstetric rotation was performed at 35–36 weeks in a satisfactory condition of the pregnant woman and no contraindications. To date, this method of correcting the position of the fetus is considered ineffective and is used very rarely due to the many contraindications and complications that arise. During the procedure, detachment of the placenta and the occurrence of fetal hypoxia are possible, and there is also a high probability of uterine rupture.
Corrective gymnastics
Special exercises are prescribed in case of incorrect position of the child in the absence of contraindications:
- abnormal localization of the placenta ( low placentation or presentation);
- pathology of the umbilical vessels;
- pregnancy with more than one fetus;
- scar on the uterus;
- severe somatic pathology of a woman;
- uterine hypertonicity;
- uterine fibroids;
- little or polyhydramnios;
- bleeding from the genital tract.
Gymnastics according to Dikan is successfully applied. A woman is recommended to perform simple exercises three times a day: roll over from one side to the other and lie after turning on each side for 15 minutes. Turns are performed up to 3 times.
A set of exercises that provides rhythmic contraction of the muscles of the abdomen and torso and is combined with deep breathing:
Pelvic tilt
Woman laying down on hard surface and raises the pelvis. The pelvis should be 20-30 cm higher than the head. Be in a position with a raised pelvis for up to 10 minutes.
Exercise "cat"
In a kneeling position, you should rest your hands on the floor. When inhaling, the head and tailbone rise, and the lower back bends. When exhaling, lower your head and arch your back. Repeat exercises 10 times.
Knee-elbow posture
Elbows and knees rest on the floor, while the pelvis should be higher than the head. Stay in this position for 20 minutes (you can read a book).
half bridge
Lie down on a hard surface, and put a couple of pillows under your buttocks. The pelvis rises by 40 cm, raise the legs.
Pelvic lifts
Lying on the floor bend your knees and hip joints and rest your feet on the floor. With each breath, lift the pelvis and hold it in this position. With each exhalation, lower the pelvis and straighten the legs. Exercises are repeated up to 7 times.
As a rule, the implementation of corrective gymnastics lasts up to 7-10 days, during which the fetus assumes a longitudinal position. Exercise should be done three times a day.
After the fetus takes a longitudinal position in the uterus, the woman is prescribed to wear a bandage with longitudinal rollers. Wearing a bandage fixes the result and is recommended before starting labor activity or pressing the head to the entrance to the pelvis.
Birth management
The optimal method of delivery in the case of the transverse position of the fetus is considered a planned caesarean section. The pregnant woman is hospitalized at 36 weeks, carefully examined, and prepared for surgery. Birth of a child naturally almost impossible, since self-rotation is extremely rare. Childbirth is carried out through the natural birth canal, followed by external-internal rotation of the fetus on the leg only in two cases:
- the fetus is deeply premature;
- twin childbirth, if the second baby is located transversely.
Planned operative delivery before the onset of contractions is performed in the following cases:
- true overgrowth;
- prenatal outpouring of water;
- placenta previa;
- uterine tumors;
- uterus with postoperative scars;
- fetal hypoxia.
In rare cases, with the onset of contractions, it is possible for the fetus to move from a transverse to a longitudinal position and complete labor on its own. With an oblique position of the baby, the woman in labor is laid on that side, at the bottom of which a large part of the fetus is determined. The woman is not allowed to stand up and is in a horizontal position.
In the event of a child's arms or legs falling out, their reduction is not allowed in any way. Firstly, it is absolutely hopeless, and, secondly, it is dangerous. In addition to additional infection of the uterus, the time before the caesarean section is also delayed.
When the child is in a transverse position, an immediate caesarean section is performed, regardless of his condition (alive or dead). A number of obstetricians in the case of a neglected transverse position and fetal death suggest performing a fruit-destroying operation. But a fruit-destroying operation is very dangerous, as it can lead to uterine rupture. If there are signs of infection (temperature jump, purulent discharge from the uterus), then the caesarean section is completed with a hysterectomy and drainage abdominal cavity.
The combined external-internal rotation is carried out under the following conditions:
- live fetus;
- the opening of the uterine os is complete;
- catheter in the bladder;
- consent of the woman;
- the size of the head corresponds to the size of the mother's pelvis;
- preserved fetal mobility;
- expanded operating room;
- there are no tumors of the uterus and vagina, vaginal strictures;
- small size of the fetus (up to 3600 gr.).
Difficulties that may arise when making a combined turn:
- rigidity (not stretched) of the soft tissues of the birth canal - the selection of an adequate dose of narcotic drugs, the introduction of antispasmodics, the performance of an episiotomy;
- uterine rupture - immediate operation;
- falling out of the handle or its removal instead of the leg - putting the loop on the handle and moving the handle towards the fetal head;
- prolapse of the umbilical cord after the completion of the turn - mandatory and quick removal of the fetus by the leg;
- fetal hypoxia and intrapartum death;
- development of infectious complications in the postpartum period.
Question answer
Question:
On the second ultrasound, I was diagnosed with: Pregnancy 23-24 weeks. Transverse position fetus. What to do so that the baby "lie down" correctly?
The gestation period is still small, so no measures should be taken. The baby will be in its final position by 34-35 weeks, and until that time, it can rotate and position itself as you like.
Question:
On last ultrasound the doctor found that the fetus lies across (term 32 weeks). Is it necessary to do gymnastics so that the baby is positioned correctly?
The need for corrective gymnastics should be discussed with the obstetrician who leads the pregnancy. Only with his permission can special exercises to turn the baby into a longitudinal position, since in some cases their implementation is contraindicated and even dangerous.
Question:
I have twins, 36 weeks. The first child is presented with legs, and the second lies across. Is it necessary to do a caesarean section?
Yes, in this situation, caesarean section is the safest and most favorable method of delivery for both mother and baby. If the first child were in a clean breech presentation, then its independent birth is possible, followed by the combined rotation of the second fetus on the leg. But in this case during natural childbirth, difficulties will arise already at the stage of the birth of the first baby, since the legs can be born before the cervix is fully dilated, which will make it difficult to give birth not only to the head (the head is the largest part of the fetus), but also to the pelvic end.
- incorrect location of the fetus in the uterus, in which its longitudinal axis intersects with the axis of the uterus at an angle of 90 °; while large parts of the fetus (buttocks, head) are located above the line of the crests of the iliac bones of the pelvis. The transverse position of the fetus is determined using an external obstetric and vaginal examination, ultrasound. Pregnancy with a transverse position of the fetus can proceed uncomplicated, however, premature birth is possible, which can pose a threat to the life of the mother and fetus. The optimal tactic in the transverse position of the fetus is operative delivery.
The transverse position of the fetus in some cases is a consequence of anatomical reasons that prevent the insertion of the head into the small pelvis, in particular, placenta previa, tumors of the lower segment of the uterus or pelvic bones, narrow pelvis. Fetal abnormalities such as anencephaly and hydrocephalus may contribute to the transverse position.
Diagnosis of the transverse position of the fetus
An incorrect (oblique or transverse) position of the fetus is established during an obstetric examination of a pregnant woman, palpation of the abdomen and vaginal examination. With the transverse position of the fetus, the abdomen acquires a transversely stretched (obliquely stretched) irregular shape. Due to transverse stretching, the uterus has a spherical, and not elongated-oval shape. Attention is drawn to the excess of the norm of the circumference of the abdomen in comparison with the gestational age and the insufficient height of the fundus of the uterus.
In the process of palpation, the presenting part of the fetus is not determined; the head can be felt to the right or left of the median axis of the body of the pregnant woman, and large parts (head or pelvic end) - in the lateral sections of the uterus. With the transverse position of the fetus, the heartbeat is better heard in the navel. Difficulties in determining the position and position of the fetus may arise in situations of multiple pregnancy, polyhydramnios, uterine hypertonicity. Obstetric ultrasound reliably confirms the transverse position of the fetus.
In rare cases, with the transverse position of the fetus during childbirth, self-torsion in the head or pelvic presentation or the birth of a baby with a double body can occur. Such an outcome of childbirth is an exception and is possible in case of strong contractions, deep prematurity of the fetus, or with a dead fetus.
Tactics of conducting labor in the transverse position of the fetus
For up to 34-35 weeks of gestation, the oblique or transverse position of the fetus is considered unstable, since it can independently change to a longitudinal one. When diagnosing the transverse position of the fetus, a complete gynecological examination a pregnant woman to identify the causes of the anomaly, the choice of tactics for further management of pregnancy and the method of delivery.
At a period of 30-34 weeks of pregnancy, corrective gymnastics may be prescribed, which contributes to the reversal of the fetus in the head presentation. Special sets of exercises are indicated in the absence of signs of a threatened abortion, a scar on the uterus, fibroids, spotting, decompensated heart defects in a pregnant woman, etc. and are carried out under the supervision of an obstetrician-gynecologist observing a woman. Also, in the transverse position of the fetus, a pregnant woman is recommended to lie on her side for more time, corresponding to the position being determined.
After 35-36 weeks of gestation, the fetus takes a stable position, therefore, while maintaining the transverse position, the pregnant woman is hospitalized in the maternity hospital to determine the tactics of delivery.
The optimal method of delivery for patients with a transverse position of the fetus is a planned caesarean section. Absolute indications for operative delivery is a post-term pregnancy, the fact of the presence of placenta previa, premature discharge of amniotic fluid, scars on the uterus, the development of fetal hypoxia. When the transverse position of the fetus is started with the prolapse of its handle or umbilical cord, the reduction of the fallen parts is unacceptable.
In the case of full disclosure of the cervix, determined by the live fetus and its mobility, it is possible to turn the fetus on the leg and its subsequent extraction. However, the prognosis for the fetus in this case is less favorable. Turning on a leg and natural childbirth is justified in case of prematurity or twins, when one fetus occupies a transverse position.
In a situation of a long anhydrous period, complicated by the development of an infectious process, and the viability of the fetus after a cesarean section, a hysterectomy (removal of the uterus) and drainage of the abdominal cavity are performed. With a dead fetus, a fruit-destroying embryotomy operation is performed.
And what is previa, we will talk about this in this article.
Terminology
The interest of expectant mothers in how the baby is located in their tummy is quite understandable. From the first movements of the baby, mother, with bated breath, listens to her feelings with the hope of recognizing what these at first barely perceptible waves inside her mean - movement or somersault, anxiety or playing with mom. Location has Very great importance both for the health of the child and the mother. It will affect the process of pregnancy, intrauterine and childbirth. It can be:
- Longitudinal. If you conditionally draw a line through the baby's pelvis and head, and it will coincide with the axis of the uterus.
- Transverse. If the conditional line of the fetus is perpendicular to the uterus.
- Oblique. If the child takes a middle position at an angle to the uterus.
For that to determine the position of the fetus, the doctor must conduct an external examination using a stethoscope or an obstetric tube, find the baby's heartbeat, and he can also conduct a vaginal examination. As a rule, many expectant mothers can do it on their own, especially if the child does not determine the position of the crumbs. To do this, they only need to listen even more carefully to their feelings and pay attention to:
- the place where the baby's heartbeat is most noticeable, - top part backs;
- where most often you can feel the blows of the crumbs are his legs;
- light tickling feelings - handles;
- the place that sticks out the most is the baby's ass;
- the back of the baby is felt more evenly and firmly.
Developing in the womb, the baby can repeatedly roll over and somersault, but over time, its size increases, it has less and less room to change its location freely, and it takes a certain position. Correctly, when the child is in the mother's abdomen vertically, all other positions of the fetus are called incorrect.
The presentation of the fetus indicates which part of the baby's body will come out first at the time of birth. It can be:
1. head, subdivided in turn into:
- occipital: the chin is at and the back of the head goes forward. It can be anterior, the most optimal position at birth, and posterior, depending on where the back of the head is turned;
- anterocephalic- ahead goes big fontanel;
- frontal extension- steps forward frontal part
- facial extension- the baby is turned face.
2. Pelvic.
- foot- legs go in front;
- gluteal- it is most favorable when the baby is in a squatting position.
3.
4. Transverse.
Incorrect presentation of the fetus- oblique, transverse, as well as foot, head with frontal and facial extension, as well as relatively anterior head presentation. Having taken this position, it is quite difficult for the baby to be born on his own. It is important to note that these types of presentation are not very common. The decision on how the birth will take place is made by the doctor, given the large number of important factors, and, as a rule, childbirth takes place through
Causes that lead to the transverse and oblique position of the fetus
The baby in utero can take various poses. Some of them allow a woman to give birth on her own, others can lead to complications in the development process and the baby in utero, and then during delivery. The fetus can take a non-standard position under the influence of such factors:
- fetus;
- flabbiness of the muscles of the abdominal wall.
These conditions allow the baby to be excessively active. Conversely, the following restrictions on the ability to freely move can also provoke an incorrect position of the fetus:
- multiple pregnancy;
- big baby;
- increased tone of the uterus;
- the threat of spontaneous
- fibroma of the uterus and anomalies of its structure.
- anatomical reasons due to which the head cannot take the necessary place in a narrow pelvis;
- low
- formation of tumors of the lower segment of the uterus and pelvic bones;
- and anencephaly, developmental abnormalities of the baby.
Did you know?The age of children in East Asian countries, for example, in Vietnam, is considered taking into account their life in the mother's stomach. Thus, they become 9 months older than their peers from other countries of the world.
How to determine diagnostic methods
A gynecologist can diagnose how the fetus is located under the heart of the mother based on routine visual inspection. Thus, in a longitudinal position, the abdomen has a vertically oval shape; in an incorrect position, it will have a transverse-oval or oblique-oval shape. The circumference of the abdomen, as a rule, exceeds the norms corresponding to the duration of pregnancy, since the uterus becomes like a ball, and does not acquire an oval shape, and there is also a low standing of the uterine fundus.
It is visually impossible to determine the presentation, this will require:
- to palpate the lateral sections of the uterus;
- to listen to the fetal heartbeat, either by applying to the stomach, or with a stethoscope or obstetric tube.
What are the dangers
The process of pregnancy can proceed without supervision, however, the risk of their occurrence exceeds the norm. The dangers that a pregnant woman may face are:
- premature effusion and rapid onset
- in the transverse position with there is a high probability of a strong
- with a rapid discharge of water, the child’s activity is significantly limited, there is a possibility of his parts falling out, for example, it can be a pen or which leads to a neglected transverse position. This, in turn, can cause complications such as ascending infection, diffuse peritonitis, sepsis. Being in a waterless space long time, the baby may feel the need for air, and he may develop an acute or even neglected transverse position for a woman, which may threaten to rupture the uterus.
Features of the course of pregnancy
If at the gestational age of 28-32 weeks there are signs of a non-standard placement of the baby in the womb, the gynecologist may recommend her in the transverse position of the fetus, which can help the baby roll over and take a head presentation. A reversal is possible until the 35th-36th week, since later its size will no longer allow it to be done.
Turning on a leg is also acceptable at birth when one of the babies has taken a transverse position. 
Features of operative delivery
The caesarean section is planned, because the danger natural childbirth in the wrong position is very large for both the child and the health of the mother. Surgery takes place according to the following plan:
- The abdominal wall is dissected.
- An incision is made in the uterus.
- Extraction of the fetus, which is performed jointly with an assistant. The doctor, grabbing the child's leg, translates it into pelvic position and removes by the pelvic end. The assistant's job is to help guide the baby's body in the right direction from the outside. If it is difficult to extract, then the incision on the uterus is increased. In this procedure, there may be a risk of damage to the vascular bundles.
- The placenta is removed and the uterine cavity is scraped.
- The final stage is the suturing of the uterus, examination of the abdominal cavity and restoration of the abdominal wall.
Transverse presentation of the fetus is not a pathology, however, pregnancy should take place under the constant supervision of a gynecologist so that there is no threat to the life of the child and the expectant mother.
The bearing of the fetus in primiparas and in women who have given birth earlier in 0.5-0.7% of cases may be accompanied by its incorrect location - transverse. At the same time, in primiparas, such a problem is fixed 10 times less often. The importance of diagnosing and correcting the transverse position is due to the fact that in case of inaction, the likelihood of a progressive anomaly increases. birth process, including premature outpouring of water, injury and perforation of the uterus, death of the fetus and / or mother.
Another variant of the distorted location of the fetus is the oblique position. In this case, the axes of the fetus and uterus intersect, creating two acute and two obtuse angles. The head or pelvic part of the fetus is located below the conditional line connecting the iliac crests. The peculiarity of this arrangement is that it can change to another (correct or incorrect). In the transverse position, it is important to establish the type of position of the fetus and its position relative to pelvic floor. Depending on the location of the head, one can judge the 1st (head on the left) and 2nd (head on the right) positions of such types: posterior and anterior (due to which wall of the uterus - posterior or anterior - the fetus is located with its back).
Causes of the transverse position of the fetus
Circumstances that can provoke a transverse or oblique position of the fetus can be grouped as follows.
Group 1. Conditions under which there is a difference from normal level fetal activity. What is meant by both hyperactivity and hypermobility, and inertness, inactive development of the fetus. Among the factors for increasing the level of mobility, polyhydramnios, excessive sagging of the walls of the uterus, etc. are distinguished. Among the reasons for limiting activity are oligohydramnios, a significant size of the fetus, increased uterine tone, etc.
Group 2 Anatomical causes. Factors such as placenta previa or neoplasms in the lower uterine segment, along with fetal malformations, prevent its optimal intrauterine location.
Diagnosis of the transverse position of the fetus
Deviations from the norm in the position of the fetus are diagnosed by an obstetrician based on the results of a vaginal and / or manual examination. The shape of the abdomen can indicate the type of abnormal position of the fetus: if the abdomen is stretched diagonally, the position is oblique; if there is stretching horizontally, the position is transverse. The norm is considered to be an elongated oval shape of the abdomen. The level of abdominal circumference is also important, taking into account the gestation period, the level of the fundus of the uterus and the pelvic floor as a whole.
During manual examination, the part of the fetus that is located at the pelvic floor is not determined. In accordance with the position of the fetus (first or second), you can feel the head: to the left or right of the navel of the pregnant woman. In the umbilical region, the fetal heartbeat can be heard if the position is transverse. In some cases (against the background of a lot or oligohydramnios, increased tone uterus) it is difficult to determine the true position of the fetus. When there are obstacles exact definition position can be resorted to ultrasound diagnostics.
It should be emphasized the uninformativeness of studies that are carried out at the beginning of the birth process and with an intact fetal bladder. This is due to the fact that with an integral structure of the bladder, it is not possible to accurately determine the location of the parts of the fetus that are potentially prone to presentation. On the contrary, the discharge of water and some opening of the pharynx (from 4 cm) makes it possible to identify the anatomical parts of the fetus, and if the fetal handle is shown from the pharynx, it can be argued about its transverse position.
Risks of the transverse position of the fetus
Usually the general course of pregnancy is not complicated by the presence of a transverse position of the fetus. But sometimes such a deviation can contribute to the development of preterm labor, and in combination with placenta previa transverse arrangement may cause bleeding. As a result of the rapid discharge of water, there is a risk of a number of complications, among which is the neglected transverse position of the fetus. It is also possible for the umbilical cord or other parts of the fetus to fall out, which is fraught with the development of an infectious process (with subsequent peritonitis, sepsis).
If the fetus is in an anhydrous environment for more than 0.5 days, then oxygen starvation develops and subsequent fetal asphyxia. Prolonged transverse position of the fetus in an anhydrous environment with progressive labor can lead to uterine rupture. In rare cases, if this was preceded by complications of pregnancy, the fetus is premature and its transverse position is observed, arbitrary torsion (self-torsion) of the fetus is possible, followed by breech or head presentation. Also, this situation is possible with intrauterine fetal death.
Tactics of conducting labor in the transverse position of the fetus
Until the end last trimester there is no need to talk about the stability of any kind of malposition of the fetus. So, if an obstetrician-gynecologist diagnosed a transverse location for up to 36 weeks, it is believed that the fetus can still change it on its own. But in any case, in order to exclude various kinds of developmental anomalies and identify true reasons incorrect position of the fetus, as well as to develop a plan for obstetrics, a pregnant woman is shown a gynecological examination. If the fetus is in the wrong position from the 30th week of gestation, in the absence of contraindications, the pregnant woman can be prescribed special complex exercises, the implementation of which under the supervision of a physician contributes to the normalization of the position of the fetus. In addition to gymnastics, a pregnant woman is shown to take a horizontal lateral position, which also has a constructive effect. By the end of 36 weeks, we can talk about some stability in the position of the fetus, therefore, a pregnant woman should be hospitalized if she has been diagnosed with a transverse intrauterine position in order to predict delivery and choose the optimal tactics of obstetric care.
If earlier the technique of obstetric rotation (external rotation) was used to change the position of the fetus, today it is used extremely rarely. This is because it is important to eliminate the causes of the change in position, which the technique does not allow, and the fetus may soon return to the same incorrect position. Rarely, obstetric rotation can cause mechanical damage fetus or oxygen starvation, placental abruption and/or uterine rupture. It is believed that the incorrect (including transverse) position of the fetus is an indication for planned caesarean section. Surgical intervention should also be carried out if there are complications such as placenta previa, changes in the structure of the walls of the uterus, the presence of scars on them, a post-term fetus or its hypoxia. If the transverse position is started for some reason, and the umbilical cord or fetal handle prolapses, then attempts to set the fallen parts can have adverse consequences, and therefore are unacceptable in obstetrics and gynecology.
After the full disclosure of the cervix is established, it becomes possible to mechanically correct the position of the fetus by means of obstetric pediculation with subsequent extraction of the fetus. But such a technique can have a negative outcome, therefore it is justified only in the case of multiple pregnancy, when one fetus has a transverse position, as well as in the case of early delivery. If the transverse position is significantly neglected, the fetus is in an anhydrous environment for a long time, an obvious infectious process is observed and there is a risk of fetal death, then a hysterectomy is performed, conditions are created for the outflow of the contents of the abdominal cavity. If intrauterine death of the fetus occurs, its destruction is performed followed by extraction.
