Obstetrics and gynecology. Childbirth with breech presentation of the fetus (lecture notes)

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Obstetrics and gynecology. Childbirth with breech presentation of the fetus (lecture notes)

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Lecture number 10. Childbirth with pelvic presentation of the fetus

Breech presentation is more common in multiparous women, with preterm birth and accounts for 3,5% of all births. Distinguish:

1) pure breech presentation, when the buttocks are facing the entrance to the pelvis, and the legs are bent at the hip joints, unbent at the knee joints and extended along the body;

2) mixed breech presentation, when both (or one) legs are presented, bent at the hip and knee joints, crossed with each other and unbent at the ankle joints;

3) foot presentation, if the legs of the fetus are facing the entrance to the pelvis, and a full foot presentation is distinguished if both legs are presented, and incomplete if one leg is presented.

Recognition of breech presentations is based on the ability to palpate the head from the buttocks. The buttocks are less dense, less rounded, have less volume and do not ballot. The diagnosis of breech presentation is easier to make if a dense, rounded, movable head can be found in the bottom of the uterus. Breech presentation is characterized by high (above the xiphoid process) standing of the fundus of the uterus, high (at the level of the navel or above) the location of the place of the most distinct listening to the heart sounds of the fetus. In childbirth, especially after the outflow of amniotic fluid, the vaginal examination specifies the presenting part by determining the sacrum, coccyx and legs of the fetus. By the location of the sacrum determine the position, its appearance. The buttocks of the fetus are located in a transverse dimension (linea intertrochanterika) in one of the oblique dimensions of the entrance to the pelvis. After the outflow of water and in the presence of labor, the fetus begins to move along the birth canal of the mother. In the biomechanism of childbirth with breech presentation, six points are distinguished.

First moment. In this case, the buttocks make an internal rotation when moving from the wide part of the pelvic cavity to the narrow one. At the outlet of the pelvis, the diameter of the buttocks is set in a straight size, and the anterior buttock fits under the pubic arch. In accordance with the longitudinal axis of the pelvis, some lateral flexion of the fetal torso is observed.

Second moment consists in lateral flexion of the lumbar region of the fetus. Under the influence of contractions, the fetus makes a forward movement. In this case, lateral flexion of the fetal spine occurs. From the genital gap, the posterior buttock is shown first, and then the anterior one. At this moment, the shoulders of the fetus enter the entrance to the pelvis in the same oblique size as the diameter of the buttocks.

Third point. The internal rotation of the shoulders and the associated external rotation of the body ends at the exit from the pelvis and is characterized by the fact that the shoulders are installed in a straight size. The front shoulder fits under the pubic arch, and the back one is located at the tailbone.

Fourth moment - this is the lateral flexion of the cervicothoracic spine of the fetus. It ends with the birth of the shoulder girdle and handles.

Fifth moment - internal rotation of the head. The head enters one of the oblique dimensions of the entrance to the pelvis with its small oblique size (9,5 cm), depending on the position of the fetus and its type, but this oblique size is always opposite to that into which the shoulders of the fetus enter. With translational movement, the head performs translational movement and internal rotation at the entrance to the narrow part of the small pelvis from the wide one. The sagittal suture rises in the direct size of the exit of the pelvis. The region of the suboccipital fossa fits under the pubic arch.

Sixth point. Bending of the head involves the gradual eruption of the head from the birth canal (the mouth is born first, then the nose, forehead and crown of the fetus). In a breech presentation, the head erupts in a small oblique size, as in the anterior view of an occipital presentation.

Conducting childbirth in breech presentation

Childbirth with a breech presentation stands on the verge between physiological and pathological. All pregnant women with breech presentation are hospitalized 2 weeks before the expected date of birth. In the first period, a woman is observed. During the period of exile from the moment of eruption of the buttocks, there is a danger of fetal hypoxia. After eruption of the buttocks, an obstetric (manual) allowance is provided according to Tsovyanov or in the classical way. Manual assistance according to Tsovyanov with a pure breech presentation begins to be provided after the eruption of the buttocks, which are grasped with hands in such a way that the thumbs are located on the hips of the fetus pressed to the stomach, and the remaining four fingers of both hands are located on the surface of the sacrum. During the birth of the torso, it is necessary that the legs of the fetus be pressed against its abdominal wall all the time (to prevent the arms from tipping over). The obstetrician advances his hands to the genital slit of the woman in labor, thereby preventing the legs from falling out and the fetal arms throwing back behind the head. Subsequent attempts contribute to the birth of the fetus to the umbilical ring, and then to the lower corners of the shoulder blades. The diameter of the fetus, having passed one of the oblique dimensions at the exit of the pelvis, is set in direct size. The doctor, holding the buttocks, directs them somewhat towards himself, so that the anterior handle can be born from under the pubic arch without complications. Raising the fetus upwards, the back handle is released from the sacral cavity. By further direction of the fetus towards itself and upwards, the head is released. The method of manual assistance in mixed breech presentation begins to be applied from the moment the fetus is born to the lower corners of the shoulder blades, after which the arms and head are released according to the rules of the classic manual assistance. The method of manual assistance with foot presentation is to prevent premature birth of the legs of the fetus until the uterine os is fully opened by holding the legs in a bent state for a long time. In this case, a mixed breech presentation is artificially formed. Due to the good preparedness of the birth canal by the buttocks, the fetus is usually born without difficulty.

Author: Ilyin A.A.

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