How is pregnancy proceeding in the transverse position of the fetus: possible complications and delivery tactics corrective gymnastics
Transverse position of the fetus - the wrong 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 iliac bones of the pelvis. The transverse position of the fetus is determined by external obstetric and vaginal examination, ultrasound. Pregnancy in the transverse position of the fetus can occur uncomplicated, but premature births are possible, which can pose a threat to the life of the mother and the fetus. The optimal tactic in the transverse position of the fetus is operative delivery.
Causes of the transverse position of the fetus
The intrauterine transverse position of the fetus may be due to various factors. These include, first of all, the conditions that provide for excessive mobility of the fetus: high water, flaccidity of the muscles of the abdominal wall, fetal hypotrophy, etc. , increased uterine tone, the threat of spontaneous abortion, anomalies of the structure of the uterus (saddle or two-horned uterus), uterine fibroids, etc.
The transverse position of the fetus in some cases is a consequence of anatomical reasons that prevent the insertion of the head into the pelvis, in particular, placenta previa, tumors of the lower uterus or pelvic bones, narrow pelvis. Anomalies of fetal development such as anencephaly and hydrocephalus may contribute to the transverse position.
Diagnosis of the transverse position of the fetus
The abnormal (oblique or transverse) position of the fetus is established during obstetric examinations of the pregnant woman, abdominal palpation and vaginal examination. With the transverse position of the fetus, the abdomen acquires a transversely stretched (obliquely stretched) irregular shape. Due to the transverse stretching, the uterus has a spherical rather than elongated-oval shape. Note the excess of the norm of the circumference of the abdomen compared with the period of gestation and the insufficient height of the standing of the bottom 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 parts of the uterus. With the transverse position of the fetus heartbeat is better heard in the navel. Difficulties in determining the position and position of the fetus can arise in situations of multiple pregnancy, polyhydramnios, and hypertonus of the uterus. Obstetric ultrasound reliably confirms the lateral position of the fetus.
Gynecological examination performed during pregnancy and the initial period of labor with intact fetal bladder, uninformative. His conduct only confirms the absence at the entrance to the small pelvis of the presenting part of the fetus. After the discharge of water and disclosure of uterine throat by 4-5 cm with the transverse position of the fetus, the shoulder, scapula, ribs, axilla, spinous processes of the vertebrae can be determined, sometimes - the elbow or hand brush. In the event of a fruit handle falling out of the genital slit, there is no doubt about the presence of the transverse position of the fetus.
Risks of the transverse position of the fetus
The presence of the transverse position of the fetus, as a rule, does not violate the general course of pregnancy. However, most often in the transverse position of the fetus occurs premature rupture of amniotic fluid and the development of preterm labor. If the transverse position of the fetus is accompanied by placenta previa, there may be massive bleeding.
The rapid discharge of water often leads to a sharp restriction of the mobility of the fetus, hammering the shoulder into the pelvic inlet, the loss of parts of the fetus (handles, umbilical cord) and the development of the so-called neglected transverse position of the fetus.
With the loss of parts of the fetus upward infection may occur with the development of chorioamnionitis, diffuse peritonitis, sepsis. A long anhydrous period, lasting 12 hours or more, leads to acute hypoxia or fetal asphyxia. Launched lateral position of the fetus against the background of increasing labor activity threatens to rupture the uterus.
In rare cases, with the transverse position of the fetus during childbirth, self-twisting in the head or pelvic presentation or the birth of a baby with a double trunk can occur. Such an outcome of labor is an exception and is possible in the case of strong contractions, deep prematurity of the fetus or with a dead fetus.
Tactics of childbirth in the transverse position of the fetus
For a period of up to 34–35 weeks of gestation, oblique or lateral position of the fetus is considered unstable, since it can independently change to longitudinal. When diagnosing the transverse position of the fetus, a full gynecological examination of the pregnant woman is required to identify the causes of the anomaly, the choice of tactics for further management of pregnancy and the mode of delivery.
At a period of 30-34 weeks of pregnancy, corrective gymnastics may be prescribed to help the fetus turn to headache. Special exercises are shown in the absence of signs of threatened abortion, uterine scar, fibroids, bleeding, decompensated heart defects in a pregnant woman, etc., and are carried out under the supervision of an obstetrician-gynecologist who supervises the woman. Also, when the fetus is pregnant, it is recommended to lie more time on the side corresponding to the position to be determined.
After 35-36 weeks of gestation, the fetus takes a stable position, therefore, while maintaining its lateral position, the pregnant woman is hospitalized to the maternity hospital to determine delivery tactics.
The method of external rotation on the head - changes in the lateral position of the fetus using external methods are currently not used. This is due to the low efficiency of rotation, since with unresolved causes the fetus often again assumes a lateral position. In some cases, external rotation may result in severe consequences: placental abruption, rupture of the uterus, fetal hypoxia.
The optimal method of delivery of patients with a transverse position of the fetus is a planned caesarean section. Absolute indications for operative delivery are postponed pregnancy, the presence of placenta previa, premature rupture of amniotic fluid, scarring in the uterus, and development of fetal hypoxia. When running the transverse position of the fruit with the loss of his handle or the umbilical cord, the reduction of the dropped out parts is unacceptable.
In the case of complete disclosure of the cervix, determined by the living fetus and its mobility, it is possible to carry out the rotation of the fetus on the leg and its subsequent extraction. However, the prognosis for the fetus in this case is less favorable. Rotation of the leg and natural childbirth are justified in case of prematurity or childbirth twins, when one fetus occupies a transverse position.
In a situation of prolonged anhydrous period, complicated by the development of an infectious process, and viability of the fetus after cesarean section, a hysterectomy (removal of the uterus) and drainage of the abdominal cavity are performed. When a fetus is dead, a fetal destructive embryotomy is performed.
Why does the lateral position of the fetus
Before 30–32 weeks of gestation, the little man is too mobile and constantly changes his position. This means that he can easily turn to the correct position. So do not panic during this period. It is worth worrying then if after 33 weeks the situation does not change.
It is noticed that the wrong lying of the baby in the uterus is found only in 1 out of 200 women giving birth, that is, 0.5 - 0.6% of cases are recorded. Mommies who give birth a second time are 10 times more prone to disruption of the normal course of pregnancy.
Healthy women are less likely to develop complications. Below on the video you can watch and listen to a specialist who will talk in detail about the pathology.
There are several reasons for the abnormal presence of the child in the womb:
- Uterine fibroids. The formation of myomatous nodes in the lower region of the uterine pole and near its neck often provokes an abnormal location of the fetus. Especially in the case of profiling fibroids, a rapidly growing tumor makes it impossible for the baby to turn in the right direction.
- Abnormal development of the uterus. For example, if a pregnant woman has a two-horned uterus, with a septum. Such a phenomenon may make it difficult for the fetus to lie correctly.
- Placental presentation. Finding the placenta near the uterine pharynx prevents the adoption of the correct physiological location of the crumbs.
- Polywater. A large amount of amniotic fluid contributes to the excessive activity of the crumbs in the womb. He does not feel the uterine walls, which violates the correct perception of the surrounding space. This may lead to the selection of an incorrect posture.
- Multiple pregnancy. When a woman has twins, there is a maximum risk of misalignment of children, because they interfere with each other to take longitudinal positions. If during the development of several children premature labor occurred, the chances of them adopting the correct position are extremely small.
- Parity of childbirth. The more times a woman gives birth, the weaker the muscles of the organ become. This leads to maximum intrauterine mobility of the crumbs, which threatens him with the wrong location.
- The narrow ring of the pelvis. If a pregnant woman has a third or greater degree of narrowing of the pelvic ring, the child cannot lie down correctly, which leads to a complication.
- Violation of the development of the vestibular apparatus of the baby. This pathology rarely leads to this situation, but you should not discount this possibility.
- Large or small fruit. With an excess of weight and size, the future man is hard to move, because of what he takes the wrong posture. With a small size of the baby, his activity increases, as a result of which he is constantly spinning, turning over, and by the end of the term may also take the wrong position.
- Hypertonus of the uterus. The threat of premature termination of pregnancy provokes an increase in the tone of the uterus, which greatly limits the motor ability of the baby.
What is the slant position
To the wrong location of the fetus include not only transverse, but also oblique position. In this case the body of the crumb is at an angle of 45 degrees relative to the axis of the womb. And the head or the buttocks of the future little man are slightly below the iliac crest.
In obstetric practice, there is still a transverse position. In this case, the angle of inclination of the fetus will be more than 45 degrees. But in both cases, the location of the baby is unstable, and with intensive mobility can lead to a turn into a transverse or longitudinal arrangement.
It is possible to distinguish the transverse from the oblique with an external gynecological examination of the abdomen. Large parts (head and buttocks) will be felt from the sides of the abdomen.
What is the danger of such a diagnosis
Such a diagnosis complicates not only childbirth, but also the course of pregnancy, since it increases the risk of such phenomena as:
- preterm labor - when the child is lying across, pressure from the uterus comes earlier than when lying longitudinally, which contributes to premature pushing it out of the womb due to its inability to stretch quickly,
- early rupture of the membranes - occurs due to the lack of uniform distribution of amniotic fluid, creating a load on the lower pole of the bubble,
- neglected lateral position - at rupture of the fetal bladder, a baby may fall out of a limb, which hampers its movement and may cause death.
How to diagnose ailment
In the first and second trimester, lateral diagnosis is ineffective, since the baby is in constant motion, and at any time can change position. No symptoms are manifested in this pathology of pregnancy, it can only be detected during a gynecological examination.
Definition of the problem during the inspection is carried out in several ways:
- visual inspection,
- palpation of the abdomen,
- ultrasound procedure,
- vaginal examination.
Each of these methods has its own characteristics and disadvantages.
Examination of the abdomen
In a normal examination of the abdomen, an abnormal, widened center to the sides is clearly visible. Determine the location of the head with this inspection is impossible. But the transverse or oblique arrangement is easily traced, since the organ becomes transversely stretched or obliquely stretched.
How to understand what is the presence of pathology? Cephalic presentation is noticeable along the uterus extended along its axis. However, when the position is incorrect, the uterus becomes spherical. When measuring the abdomen abnormality occurs - the abdominal circumference slightly exceeds the norm, which should correspond to the duration of pregnancy.
Palpation of the abdomen
On palpation, it is impossible to determine the presenting part of the little man, and the head is palpated to the side of the center line of the pregnant belly. When the head is located on the left, it is considered the first position. When determining the head on the right in the card of a pregnant woman, the second position is recorded.
Listening to the heartbeat of a child near the mother's navel is typical for transverse presentation, while when lying longitudinally, the heart is heard on the left or on the right of the belly.
The disadvantage of this method of examination is the inability to determine the position of the fetus in the case of transverse presentation in case of an excess of amniotic fluid, the development of several fetuses and an elevated uterus tone.
On ultrasound, the position of the fetus is determined very well, even with multiple fetuses and other factors. Guaranteed 100% determination of the location of the baby does not depend on the duration of pregnancy.
It is worth noting that an ultrasound scan made at 20 weeks or earlier should not bother the expectant mother. This period is too short to determine the pathology. But when identifying the clinic at a later date, it is worth adhering to certain rules and recommendations of the doctor.
Information about the placement of the baby can be obtained using vaginal examination. Carry it out shortly before the end of the pregnancy and at the time of the beginning of labor, when the amniotic fluid has not yet departed.
If the probing part of the fetus is not felt during palpation, this indicates its improper placement.
If the uterine ring has opened 4 cm or more, and the fetal bladder has burst, the test is performed very carefully so as not to provoke complications of the labor associated with the loss of the umbilical cord or the limb of the fetus. Poured water allows the midwife to probe the upper part of the body crumbs - ribs, armpits, pen.
Watch the video about the wrong position of the fetus:
How is pregnancy going
The transverse presence of the fetus in the womb rarely disrupts the process of pregnancy as a whole. But for such a disease is typical to cause early termination of pregnancy in late periods, approximately 30% of all cases.
There are no obvious features of the course of pregnancy. And, starting from the 38th week, the amniotic fluid may recede, as a result of which immediate hospitalization of the pregnant woman will be required. Regional presentation of the placenta in the transverse position can also aggravate the process of gestation. With increased pressure on the lower part of the uterus, the placenta may move towards the uterine throat, causing bleeding.
If lateral presentation was diagnosed at 28 weeks, the expectant mother should follow some rules of behavior:
- in order to avoid rupture of the amniotic bladder, reduce physical activity,
- do not lift weights
- to sleep more,
- Do not neglect medical examinations,
- perform exercises to correct the position of the fetus.
Regarding the question whether it is possible to wear a bandage, if they diagnosed a child lying across, it is better to consult a doctor. But often the wearing of a bandage is specially appointed by the gynecologist, since it helps to distribute the weight of the abdomen evenly, which reduces the load on its lower part. The second positive effect is the reduction of back and abdominal pain.
But it should be borne in mind that with anterior low placenta previa and other pathologies, the bandage cannot be worn.
The choice of bandage should be considered carefully. Those who have already given birth, recommend to try it on when buying or consult with an observant obstetrician-gynecologist, who will tell you the right size.
Separately, it should be said about the opportunity to change the position until the onset of delivery. To this end, experienced midwives at 35-36 weeks conduct an external rotation of the fetus. Previously, such a technique was often practiced, but modern obstetrics treat this method scornfully.
Связано нечастое применение акушерского переворота с многочисленными противопоказаниями:
- несколько детей в утробе,
- плацентарное предлежание,
- низкая плацентация,
- угроза досрочного родоразрешения,
- патология плодных вод,
- проблемы с сосудами пуповины,
Могут возникнуть осложнения в ходе проведения или после процедуры. Например, отслоение плаценты или разрыв матки. Therefore, the implementation of a coup requires maximum skill from the obstetrician. To avoid negative consequences, you need to know the location and position of the baby, and be able to turn so that its back is not behind (turned to the back wall of the uterus).
If, as the birth approaches, the child has not taken the correct longitudinal position, and there is no possibility to turn it, then a cesarean section is prescribed at the time of the diagnosis.
The main reasons associated with improper lying of the child in the womb, can lead to the following complications:
- Untimely discharge of amniotic fluid, especially rapid, can lead to loss of the child's limb through the open pharynx.
- Running lateral lying leads to clamping of the umbilical cord due to its prolapse, which disrupts blood flow and can lead to the death of the baby.
- The rupture of the internal genital organs occurs due to the neglected lateral position, when, due to the fetal shoulder being pushed into the small pelvis of the mother, the uterus begins an active contraction (this leads to its strong stretching in the lower segment). Only a timely caesarean section will save the mother and baby from death.
- As a result of a prolonged anhydrous period of time, an infection can penetrate inside, causing choriamnionitis, leading to peritonitis and blood infection.
- A prolonged course of labor can lead to fetal hypoxia.
- The death of a baby may occur due to the bending of his body in the thoracic region at the time of the beginning of passage through the birth canal. Such an inflection leaves no chance for survival.
Corrective gymnastics in the transverse position of the fetus
There is a way to turn the baby without resorting to obstetric coup and other methods. Since the treatment in this case is not carried out, it is possible to correct the situation with the corrective gymnastics.
However, there are certain contraindications to performing these exercises:
- discharge and bleeding
- excess or lack of amniotic fluid,
- tumors, scars and tumors in the uterus,
- increased uterine tone,
- multiple births
- pathology of the placenta,
- violation of the activity of umbilical cord vessels.
Therefore, the appointment of such a gymnastics necessarily examines the history of the disease and management of pregnancy of the woman.
The complex of gymnastics includes various swimming, physical and breathing exercises, such as:
- pelvic slopes or lifts
- half bridge
- knee-elbow pose and others.
Well-established gymnastics according to the method of I. F. Dikan, which is performed from week 29. It consists of repeating turns three times from one side to the other, when lying on the side between turns takes 15 minutes.
There are other methods, but all of them can be performed only with the recommendation of a doctor.
It is important to know how to sleep when lying transversely. The child is most comfortable to be head down, so the mother should choose a position for sleeping according to the location of the baby, that is, sleeping on the side where his head is.
Surgical intervention in the transverse position is fully justified. This approach significantly reduces the mortality rate of one or both participants of labor (mother and child), and also contributes to the absence of the occurrence of complications at the time of labor. This is evidenced by the many positive reviews of women who gave birth safely.
Determine the terminology
Depending on how the fetus is located in the uterus, the delivery tactics of the woman are determined. To understand the terms, we define the following concepts:
- fetus axis - longitudinal line connecting the buttocks and the baby’s head,
- the axis of the uterus is a longitudinal line connecting the bottom of the uterus and cervix, or the longitudinal axis of the uterus.
The position of the fetus is the ratio of the baby’s axis to the long uterus. Distinguish the correct position of the fetus and the 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 vertical with her). At the same time, one of the large (head or pelvic end) parts of the baby “looks” at the entrance of the small pelvis, and the other rests on the uterine bottom.
Incorrect positions are the transverse and oblique position of the fetus. But it should be remembered that the fetus most of the pregnancy is very mobile and constantly changes its position. Stabilization of its position occurs by 34 weeks, therefore, it does not make much sense to talk about the wrong position before the deadline.
What is called oblique position
The oblique position of the fetus (situs obliguus) is indicated when the fetal axis is displaced relative to the long uterus, which forms an acute angle (less than 45 degrees). In this case, the head or buttocks is located below the iliac crest. You can still 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 the unstable position of the fetus. With significant mobility of the fetus, it periodically changes its position from longitudinal to transverse or oblique and vice versa.
What contributes to the wrong position of the fetus
Causes of the transverse position of the fetus may be due to either uterine factors (the presence of obstacles in it) or increased or decreased motor activity of the fetus:
The risk of an abnormal baby position increases significantly with the presence of myomatous / fibrous uterus nodes. It is especially great when localizing nodes in the cervix, isthmus or lower uterine segment, or for large sizes of nodes located in other places, which prevents the child from taking the correct position. Uterus tumor growth 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 partition in the uterus or a saddle-shaped or two-horned uterus.
- Incorrect localization of the placenta
Low placentation or low location of the placenta (5 cm or less from the internal pharynx) or its presentation (when the placenta partially or completely covers the internal pharynx) often causes the wrong position of the baby in the uterus.
As a rule, the narrowing of the pelvis 1 - 2 degrees does not create obstacles neither for the development of the fetus nor for its birth. But more severe degrees of pelvic contraction, especially asymmetric forms of narrowing (skewed, twisted by bone exostosis) are the prerequisite for the location of the fetus not along the axis of the uterus, but across or obliquely.
- Fetal malformations
Some malformations manifest themselves already in utero. For example, with anencephaly (absence of the brain) or hydrocephalus - dropsy of the brain (the head of the fetus becomes very large), the lateral / oblique position of the fetus can be observed.
- Pathology of amniotic fluid
Excess amniotic fluid leads to excessive expansion of the uterine cavity, which in turn provokes an excessive physical activity of the baby. He becomes very mobile, does not feel the border of the uterus and "fit" in it across or slant. With a lack of amniotic fluid, the situation is reversed. The tightness of the uterine space and a small amount of amniotic fluid does not allow the child to actively move and take the necessary longitudinal position.
When there are several fruits in the uterus, they become cramped, which prevents one or all babies from taking the correct position.
Significant size and weight of the fetus (more than 4 kg) reduces its physical activity and provokes the wrong arrangement of the baby in the uterus.
In the case of threatened abortion, especially permanent, the uterus is almost always in hypertonia and restricts fetal movement.
- Flabbiness of the muscles of the anterior abdominal wall
A similar situation is often characteristic of multi-breeding women (4–5 genera). Constant stretching of the anterior abdominal wall of the abdomen of a pregnant uterus contributes to the excessive physical activity of 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.
Insufficient weight and size of the fetus are also the cause of its constant movement and upheavals in the uterus (the baby is small and there is too much space in the uterus for him).
How are pregnancy and childbirth
Pregnancy with the transverse position of the baby, as a rule, proceeds without features. But it is noted that premature labor begins in almost 30% of cases. Untimely rupture of amniotic fluid is one of the most frequent complications of this pathology, which can occur both during pregnancy and cause the onset of preterm labor and during labor.
Why labor is complicated in the case of the transverse position of the fetus
It is rarely possible completion of childbirth with the transverse position of the fetus independently and the birth of a live baby. In such cases, an independent rotation of the child in the longitudinal position and the birth of his head or pelvic end occurs. Samozvorot possible with small sizes of the fetus or its prematurity. Basically, the course of labor develops adversely and is complicated by the following processes:
- Untimely discharge of water
With the transverse arrangement of the fetus occurs early or premature rupture of water (almost 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 the front and rear.
- Running lateral position
This complication occurs after premature or early discharge of water. In such a case, due to the rapid outpouring of water, the mobility of the child is sharply limited, and either the shoulder is hammered into the small pelvis, or small parts (handles or legs) fall out. When the umbilical cord loops, it is clamped, the blood flow is disturbed and the fetus dies.
A threatening rupture of the uterus accompanies the neglected lateral position of the fetus. After the water has departed, the shoulder girdle is entered into the entrance of the small pelvis, and the uterus begins to shrink rapidly, which leads to overstretching of the lower segment and the threat of its rupture. If a cesarean section is not performed in time, the uterus is torn.
Premature discharge of water and a long anhydrous period contribute to the penetration of infection into the intrauterine cavity and the formation of chorioamnionitis, which leads to the development of peritonitis and sepsis.
The protracted course of labor against the background of a prolonged anhydrous period provokes the development of fetal hypoxia and the birth of a child in asphyxia.
Due to intense contractions and poured water, the walls of the uterus are in close contact with the fetus, which leads to its bending in half in the thoracic region. In this case, childbirth ends spontaneously. First, the chest is born with the neck pressed to it, then the stomach and the head pressed into it, and then the buttocks and legs. The birth of a living fetus in such a situation is unlikely.
How to give birth and pregnancy
The tactics of management of a pregnant woman with the transverse position of the fetus include careful observation of the woman, restriction of physical activity and the appointment of corrective gymnastics (in the absence of contraindications). Up to 32 - 34 weeks, the lateral or oblique position of the child is considered unstable, since it is highly likely that the fetus will assume a longitudinal position.
Previously, external rotation of the fetus was widely practiced in order to bring it into a longitudinal position. External obstetric turn was performed in terms of 35 - 36 weeks with a satisfactory condition of the pregnant and no contraindications. To date, this method of correcting the position of the fetus is considered ineffective and is used very rarely because of the many contraindications and complications that arise. During the procedure, the placenta can detach and cause fetal hypoxia, and there is also a high probability of uterine rupture.
Lying on the floor, bend the legs at the knees and hip joints and rest your feet against the floor. With each breath, raise the pelvis and hold it in that position. With each exhalation, lower and straighten the pelvis. Exercises are repeated up to 7 times.
As a rule, the performance of corrective gymnastics lasts up to 7–10 days, during which the fetus assumes a longitudinal position. Exercises should be done three times a day.
After the fetus takes a longitudinal position in the uterus, the woman is prescribed wearing a bandage with longitudinal rollers. Wearing a bandage fixes the result and is recommended before the onset of labor or the head is pressed against the entrance to the pelvis.
The optimal method of delivery in the case of the transverse position of the fetus is the planned caesarean section. A pregnant woman is hospitalized for a period of 36 weeks, carefully examined, and prepared for surgery. The birth of a child in a natural way is almost impossible, since self-turning happens extremely rarely. Births are conducted through the birth canal, followed by external-internal rotation of the fetus on the leg only in two cases:
- the fruit is deeply premature,
- childbirth twins, if the second baby is located transversely.
The planned operative delivery before the start of contractions is performed in the following cases:
- true perenashivanie,
- prenatal discharge of water,
- prelying placenta,
- uterine tumors,
- uterus with postoperative scars,
- fetal hypoxia.
In rare cases, with the onset of contractions, the fetus can move from a transverse position to a longitudinal position and end the labor independently. With an oblique position of the baby, the mother is placed on that side, at the bottom of which a large part of the fetus is determined. A woman is not allowed to stand up and is in a horizontal position.
In the event of a child’s hand or foot falling out, they should never be retracted in any way. Firstly, it is absolutely unpromising, and, secondly, it is dangerous. In addition to additional infection of the uterus, the time to caesarean section is also delayed.
When the child is running in the transverse position, an immediate cesarean section is performed regardless of its condition (live or dead). A number of obstetricians, in the case of neglected lateral position and death of the fetus, suggest performing a fruit-destroying operation. But the fruit-destroying operation is very dangerous, as it can lead to rupture of the uterus. If there are signs of infection (temperature jump, purulent discharge from the uterus), then a cesarean section is completed with a hysterectomy and drainage of the abdominal cavity.
The combined external-internal rotation is carried out under the following conditions:
- living fetus
- opening of uterine pharynx is full,
- bladder catheter,
- woman's consent
- head sizes correspond to the size of the pelvis of the mother,
- preserved fetal mobility,
- deployed operating room
- there are no tumors of the uterus and vagina, strictures of the vagina,
- small size of the fruit (up to 3600 gr.).
Difficulties that may occur 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 surgery
- loss of the handle or its removal instead of the leg - putting the loop on the handle and moving the handle towards the head of the fetus,
- the loss of the umbilical cord loop after the completion of the rotation - mandatory and quick removal of the fetus by the leg,
- fetal hypoxia and its intranatal death,
- birth injury,
- development of infectious complications in the postpartum period.
The gestation period is still small, so no action should be taken. The child will take the final position to 34 - 35 weeks, and until that time he can turn and be placed as you like.
The need for corrective gymnastics should be discussed with the obstetrician who is leading the pregnancy. Only with his permission, you can perform special exercises for turning the baby into a longitudinal position, since in some cases their implementation is contraindicated and even dangerous.
Yes, in this situation, cesarean section is the safest and most favorable method of delivery for both mom and babies. If the first child were in purely breech presentation, then his independent birth is possible, followed by the combined rotation of the second fetus on the leg. But in this case, during childbirth, difficulties naturally arise at the stage of the birth of the first baby, since the legs can be born before the cervix is fully opened, which makes 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.
What it is?
During pregnancy, the baby repeatedly changes its position in the womb. In the first and second trimester, the child has a lot of free space in the uterus to roll over, tumble and take a variety of positions. Presentation of the fetus on these dates is voiced only as a fact and no more than that, this information has no diagnostic value. But in the third trimester, everything changes.
У малыша становится мало места для маневров, к 35 неделе беременности устанавливается постоянное расположение в матке и переворот становится весьма маловероятным. В заключительной трети срока гестации очень важно, какое положение занят малыш – правильное или неправильное. On this depends on the choice of tactics of delivery and the likely risk of complications for both the mother and her baby.
Speaking of presentation, it is important to understand what exactly it is about. Let's try to go broke in terminology. The presentation of the fetus is the ratio of a large part of the fetus to the exit from the uterus to the pelvic area. The baby can be turned to the exit either by the head, or by the buttocks, or be in an oblique position, across the uterus.
The position of the fetus is the ratio of the location of the longitudinal axis of the baby’s body to that of the uterine cavity. The crumb can be located longitudinally, transversely or obliquely. The norm is considered a longitudinal position. The position of the fetus is the ratio of its back to one of the walls of the uterus - left or right. The type of position is the ratio of the back to the back or front wall of the uterus. Chidrenozhennostyu called the ratio of arms, legs, baby head in relation to his own body.
All these parameters determine the position of the baby, and it is necessarily taken into account when deciding how to give birth to a woman - naturally, naturally with stimulation or by caesarean section. This decision can be influenced by a deviation from the norms in any of the listed parameters, but the previa is usually decisive.
Depending on which part of the body is closest (adjacent) to the exit from the uterus into the small pelvis (and this is the beginning of the baby’s path at birth), there are several types of presentation:
In about 4-6% of pregnant women, the baby is positioned towards the booty or legs. A complete pelvic presentation is a position in the uterus in which the baby is aimed toward the exit of the buttocks. It is also called the buttock. An ankle is considered to be a presentation in which the child's legs “look” towards the exit — one or both. Mixed (combined or incomplete) pelvic presentation is considered to be such a position in which the buttocks and legs are adjacent to the exit.
There is also a knee breech, in which the baby's legs bent at the knee joints are attached to the exit.
Pelvic previa is considered a pathology. It can be very dangerous for both mother and child. The most common is gluteal presentation, with his predictions are more favorable than with the foot, especially with the knee.
The reasons for which the baby takes breech presentation may be different, and not all of them are obvious and understandable to physicians and scientists. It is believed that the head and booty down are most often children whose mothers suffer from pathologies and abnormalities of the structure of the uterus, appendages, ovaries. Women who have experienced many abortions and surgical curettage of the uterus, women with scarring on the uterus, who often give birth to a lot, are also at risk.
The cause of pelvic presentation may be a chromosomal disorder in the child himself, as well as abnormalities in the structure of his central nervous system - lack of brain, microcephaly or hydrocephalus, violation of the structure and functions of the vestibular apparatus, congenital malformations of the musculoskeletal system. Of the twins, one baby can also take a sitting position, and it is dangerous if this baby is lying first to the exit.
Low water and high water, short umbilical cord, entanglement, preventing crumble, low placenta previa are all additional risk factors.
Headache presentation is considered to be correct, provided as nature itself is ideal for the child. When it to the exit in the small pelvis of a woman adjoins the head of the baby. Depending on the position and type of position of the child, there are several types of head presentation. If the crumb is turned to the exit by the nape, then this is an occipital headache presentation. The first to appear is the back of the head. If the baby is located at the exit to the profile, this is a front-heel or temporal presentation.
In this position, childbirth usually proceeds a little more difficult, because this size is wider and it is a little more difficult for the head to move in such a position in a woman’s genital tract.
Frontal previa - the most dangerous. With him, the baby "punches" his way forehead. If the baby is turned to exit with faces, this means that the presentation is called facial, it is the facial structures of the crumbs that will be born first. The occipital variant of head presentation is considered safe for mother and fetus during labor. The remaining species are extensor variants of cephalic presentation, and it is rather difficult to consider them normal. When passing through the birth canal, for example, when the facial presentation, there is a possibility of injury to the cervical vertebrae.
Also headache presentation may be low. They talk about him at the "finish line", when the stomach is "lowered", the baby presses his head against the exit to the small pelvis or partially goes into it too early. Normally, this process takes place in the last month before birth. If the omission of the head occurs earlier, pregnancy and presentation are also considered pathological.
In headache previa, up to 95–33 weeks of gestation, up to 95% of all babies are located.
Abnormal fetal position is considered pelvic when the buttocks or the lower limbs of the fetus are facing the pelvis. The frequency of such presentation - 4%. Until the 28th week of gestation, it is characteristic of 25% of the fruit. As the fetus grows, it passes into the head presentation, which most closely matches the shape of the uterus. By the 34th week of gestation, most fetuses are in the longitudinal position and occipital presentation.
The main factor predisposing to pelvic presentation is prematurity. About 20-30% of children born as a result of singleton pregnancy in pelvic presentation have a low birth weight (less than 2500 g). However, fetal structural abnormalities (eg, hydrocephalus) may limit its ability to occipital presentation. In pelvic previa, the prevalence of structural abnormalities is more than 6%, which is 2 times higher than in head prevalence. Other etiological factors include abnormalities of the uterus (for example, the two-horned uterus), multiple pregnancy, placenta previa, polyhydramnios, narrow pelvis, and pelvic neoplasms overlapping the birth canal.
There are three main types of pelvic misalignment of the fetus: the buttock, buttock-buttock and foot. In breech presentation, both legs of the child are bent at the hip joints and unbent at the knees, and at the buttock-foot - both legs of the child are bent at the hip joints and one or both at the knee (squatting position). With a foot previa, one or both legs of the child are extended in the hip joints and one or both knees or both feet are located below the level of the buttocks. By the time of birth, 65% of the pelvic appearances become purely gluteal, 25% - buttock-foot and 10% - foot.
The diagnosis of pelvic presentation is often based on the use of Leopold's techniques, when a dense head of the fetus is palpated in the bottom, and a softer pelvic end is occupied by the lower uterine segment above the symphysis. When breech presentation during childbirth through the vagina, it is possible to palpate the buttocks, anus, sacrum and sciatic hillocks of the fetus, for the buttock-buttock, buttocks, feet and ankles, and with the foot, one or both feet. An ultrasound scan is required to establish a diagnosis of abnormal fetal position.
Exception of anomalies of the fetus and uterus. If before the 34th week of pregnancy there is a suspicion of pelvic presentation, in order to detect fibroids, uterine abnormalities or structural fetal abnormalities, the results of all previous studies should be examined. Then the woman should be sent to the ultrasound.
An outer turn on the head is a procedure during which the obstetrician, under ultrasound control, with his hands turns the fetus outside so that it turns over into the head presentation. An outer turn on the head is permissible before urgent delivery before the onset of labor. The turn does not take place until the 36-37th week of pregnancy, since the premature fetus often spontaneously returns to the pelvic presentation. The procedure should be performed in a hospital equipped for emergency cesarean section, since there is a small risk of placental abruption and umbilical cord compression. Due to the likelihood of emergency surgery, the patient should refrain from eating for 8 hours before turning. In addition, it is necessary to provide intravenous access in advance. Contraindications to the rotation of the fetus on the head: uteroplacental insufficiency, placental presentation, deterioration of the fetus, hypertension, IUGR, lack of water and scar on the uterus. From the first turn it is possible to carry out the turn in 35-76% of cases. Although the external rotation of the fetus on the head reduces the frequency of cesarean section, it does not affect the rate of perinatal mortality. Only 2% of the inverted fruit returned to the pelvic presentation at the time of birth.
Childbirth in the wrong position of the fetus through the birth canal. Prior to the publication of the results of randomized studies, where it was shown that labor in pelvic presentation is not accompanied by an increase in perinatal mortality compared with the planned cesarean section, vaginal delivery was carried out only in some centers and only according to strict criteria. In most institutions, pelvic presentation is considered an indication for a cesarean section, which is due to the risk of umbilical cord loops, subsequent head injuries, birth asphyxia and birth trauma.
Criteria required for vaginal delivery with pelvic misalignment
Gluteal or buttock and foot previa.
The gestation period is more than 36 weeks.
Estimated fruit weight 2500-3800 g.
tin in a bent position.
Normal pelvic size according to radiographic pelviometry or history (large fetus).
The absence of other indications for cesarean section.
The presence of an assistant to direct the head towards the pelvis.
Since a cesarean delivery can be difficult with pelvic presentation, possession of skills to perform benefits in case of pelvic incorrect position of the fetus remains relevant. After the fetus has been born to the navel, lowering traction is carried out until the corners of the shoulder blades appear in the genital slit. After their birth, each shoulder is removed using a washing motion along the chest, so that only the head remains in the pelvic cavity. After the birth of the shoulders with a finger inserted into the mouth of the fetus, the head is kept in a bent position. The index and middle fingers of the other hand capture the fetal shoulder girdle. Tractions are carried out with the outer hand, first down and on themselves, then. Some obstetricians use the Piper forceps, and this method is accompanied by minimal trauma to the fetus.
During childbirth in the pelvic wrong position of the fetus, the largest part is born - the head of the fetus. If the fetus is premature, then its abdomen (in premature babies it is much smaller than the head), legs and trunk can be born through an incompletely dilated cervix, causing the subsequent head to linger, the fetus develops asphyxiation and increases the risk of birth trauma. Premature fetus in pelvic presentation is an indication for cesarean, which is associated with a mismatch between the size of the head and the abdomen. Currently, caesarean with pelvic presentation is performed both for premature and full-term fetus, but if you do not pay due attention to the birth of the handles and head, the risk of significant injury is still there.
Complications and outcome
Even with the optimal tactics, perinatal mortality with pelvic presentation is about 25 cases per 1000 live births (during births in the head presentation - 12-16 cases). If we exclude premature babies and children born to multiple pregnancies, the mortality rate for pelvic abnormal fetus is still higher than for the occipital. Factors affecting perinatal morbidity and mortality include fatal congenital malformations, prematurity, birth trauma, and asphyxia. The latter is more often associated with the loss of umbilical loops in labor or compression by its subsequent head. Birth injury can occur with excessive traction: possible damage to the brachial plexus (Erb's palsy), the pharynx and liver of the fetus.
Facial presentation of the fetus
The facial abnormal position is the maximum degree of extension of the head, in which the fetal face serves as the preposition. The frequency is one case per 500 deliveries.
The etiology of facial presentation is not clear. In childbirth in the occipital presentation, the fetal head bends and the back of the head becomes the leading point. The factors contributing to the entry of the head into the pelvis in an unbent state include prematurity, many births in history and congenital defects of the fetus (for example, diffuse goiter).
Diagnosis of facial presentation is based on the results of vaginal examination in childbirth, in which you can palpator to determine the soft tissue of the mouth and nose of the fetus, located next to the zygomatic bones and eye sockets. Confirm facial presentation using ultrasound or radiography. Since the fetus is always in facial presentation with anencephaly, first of all, this developmental defect should be excluded.
The position with the facial wrong position is determined by the location of the chin of the fetus. In 60% of cases, it faces anteriorly, whereas in 15% it is transversely and in 25% it is posteriorly. The mechanism of labor in the facial presentation is similar to that in the occipital one: the head enters the transverse dimension of the plane of the entrance to the pelvis with its largest size (from the chin to the superciliary arch). In the process of childbirth, it falls into the pelvic cavity, makes an internal turn, and the front line goes into a straight line size of the exit plane. When the front view of the facial presentation of childbirth through the natural paths are impossible. If necessary, forceps are used to extract the head (under the conditions for applying them), but not a vacuum extractor. If the chin is rotated backwards, the head is still unable to straighten out even more, and the expulsion process itself will not be completed. Thus, when turning the chin back, as well as in the transverse position, a cesarean section is recommended. Since the final twist of the chin from the transverse position occurs only as a result of the effective attempts of the mother, at this stage they use waiting tactics. In about 50% of cases, the rear view of the facial presentation and transverse facial presentation spontaneously transform into a front view. Perinatal morbidity and mortality during childbirth in the facial wrong position, both spontaneous and as a result of the imposition of forceps, are the same as in occipital presentation.
Types of presentation of the fetus
Presentation, as well as the position of the fetus, can change during the whole pregnancy, but starting from week 33 the child remains almost always in a certain presentation. This is due to its size, because it becomes harder to spin, the place every day less and less. And already from the 34th week the fetus is gradually preparing for birth. The future mother begins to feel preliminary (training) contractions, and the baby gradually falls. At the last ultrasound determine the presentation of the fetus, in which he will be born.
Consider the types of presentation of the fetus.
This is the most common position for the birth of a child. According to statistics, almost 95% of women give birth to children with head forward. The child who is in head presentation is in a longitudinal position.
This presentation, in turn, is divided additionally, depending on the level of extension of the head:
Occipital headache presentation of the fetus is the norm in which all women give birth themselves, without additional intervention.
Anteropagia presentation worse by the fact that the head is included in the pelvis the largest size, such genera are much harder. But there have been cases when the child has adapted and changed the position of the head in the process of childbirth, making his way to the light easier. Such a presentation may be an indication for a caesarean section, but this question is very individual. Each case is considered separately, taking into account other aspects.
Frontal presentation is very rare, it is the average degree of extension of the head. With this position of the fetus, natural childbirth is impossible, only with surgery.
Facial presentation - maximum extension of the head. Technically, such childbirth can take place in a natural way, but with injuries for both the child and the mother, which in most cases determines the propensity for cesarean section.
For a better perception of information, we suggest looking at photos of the head presentation of a child with varying degrees of extension of the head.
Transverse or oblique presentation of the fetus
Transverse and oblique presentation of the fetus is an indication for cesarean section. It is impossible to give birth to a child in such a presentation in a natural way.
Previously, during childbirth, turns were used for the limbs of a child, but in our time it is forbidden, because this procedure can cause irreparable harm to both the child and the mother. The only case where these manipulations can apply is only at the birth of twins. Когда первый ребенок рожден, а второй принял неправильное положение в поперечном или косом предлежании.
Низкое предлежание плода
Такое предлежание считается нормой непосредственно перед родами, когда ребенок постепенно опускается, это заметно и внешне — опускается живот.
Но когда об этом женщина узнает во втором триместре беременности — хорошой новостью не назовешь, но и в панику впадать не стоит.
Depending on the general condition of the woman, on the tone of the uterus, the size of the cervix, they can diagnose the threat of miscarriage and prescribe:
- ambulatory treatment,
- put the future mother to be kept in the hospital,
- install pessary
- take the neck.
With a low previa of the fetus recommended:
- eat right,
- take medication, vitamins prescribed by a doctor
- spend enough time in the fresh air
- do not play sports, remove all physical activity,
- Enough to drink during the day and not get drunk before bedtime.