Diagnosis of pelvic presentation

Diagnosis of pelvic presentation is sometimes difficult. High standing of the bottom of the uterus, reaching the level of the xiphoid process, is one of the signs of pelvic presentation. In the bottom of the uterus a rounded, dense, balloting head is defined. In the lower part of the uterus, above the entrance to the pelvis, the palpable irregular shape is soft, sometimes denser, larger, less moving, not balloting, directly passing into the plane of the back. The palpitation of the fetus is more distinctly heard above the navel according to the position.

The position and the type of pelvic presentation are determined in the same way as in the head, ie, on the fetal back.

For the purpose of diagnosis, it is advisable to use phono-and electrocardiography of the fetus, ultrasound. In unclear cases in the presence of a complicated course of pregnancy (polyhydramnios, obesity, tension of the abdominal muscles, toxicosis, etc.), especially when deciding the issue of delivery by cesarean section, at the end of pregnancy, it is advisable to perform a radiograph of the abdominal cavity in order to clarify the presenting part and position of the fetus, determination of fetal mass.

The diagnosis of pelvic fetal presentation in labor is established with vaginal examination, especially with sufficient opening of the uterine throat (not less than 4-5 cm) and the absence of a fetal bladder. The nature of pelvic presentation (gluteal, foot) is determined by the location of the ischial tubercles and coccyx, and the position and type of the fetus are specified.

Vaginal examination should be carried out very carefully, as a rough study can injure the genitalia and the anus of the fetus. Gluteal presentation can sometimes be mistaken for a facial. A differential sign is the presence (palpation) of a large trochanter on the anterior buttock, which first descends into the small pelvis. Do not conduct a study during attempts.

It is also very important to distinguish the present leg from the handle of the fetus. Thus it is necessary to be guided by the big finger which on a hand is left, and presence or absence of a calcaneal hillock. The knee from the elbow is more round in shape.

Given that the weight of the fetus with pelvic presentation is essential in deciding whether to administer labor, it should be in all parturient women with a full term pregnancy to determine the estimated weight of the fetus according to AV Rudakov or by hardware methods (echography, magnetic resonance, pelvimetry using computed tomography and other).

The management of pregnant women with pelvic fetal presentation has changed in recent years. Until 1970, most pregnant women with pelvic presentation had vaginal delivery. After 1970, most pregnant women with pelvic presentation of the fetus are given an abdominal, way.

Compared with the head, the birth in pelvic presentation is complicated by a fetal injury 13 times, the prolapse of the umbilical cord 5-20 times, intrauterine hypoxia - 3-8 times more often. The incidence of prematurity is 16-33%. With mixed breech presentation, perinatal mortality is higher than with pure breech, due to an increase in the frequency of prolapsed umbilical cord. In addition, with a mixed presentation 2 times more often small babies are born than with a pure breech presentation. It should be considered that for a doctor who does not have sufficient experience, operative delivery is more justified, since inadvertent delivery of breech delivery can lead to an increase in the frequency of fetal injuries, in connection with which it is necessary to strengthen the practical training of young obstetrician-gynecologists. Perinatal mortality is 5 times higher in vaginal delivery in the pelvic delivery than in the head presentation.

Analysis of literature data over the past 30 years shows that, in general, there are 4 main causes of perinatal child loss:

• prematurity with the birth of children with low weight in 25% of cases of all pelvic fetal presentation (fetal weight less than 2500 g);
• congenital malformations - up to 6% of newborns have fetal malformations;
• prolapse of umbilical cord loops - up to 10% with leg presentation and up to 5% with pure pelvic presentation in childbirth;
• birth trauma - paralysis of the brachial plexus, fractures of the clavicles and long bones, soft tissue injuries, intraventricular hemorrhages due to difficulties in extracting the fetus from the pelvic end. Vaginal delivery with an unbent head in the uterus is also associated with a significant perinatal morbidity and mortality. Until relatively recently, obstetricians tried to reduce perinatal mortality by improving the technique of taking breech delivery with pelvic presentation, the technique of extracting the fetus from the pelvic end, performing a preventive external turn on the head both in the conditions of tocolysis with alpha-adrenomimetics, and without them in term of pregnancy, the use of X-ray pellvimetry, evaluation of risk factors at the end of pregnancy.

Abdominal delivery allowed to solve the problem of compression and prolapse of the umbilical cord and birth trauma, but did not eliminate perinatal mortality associated with severe congenital malformations or pronounced prematurity. Therefore, modern obstetricians have come to the general conclusion that careful selection of pregnant women with pelvic fetal presentation for delivery through natural birth canals, as well as cesarean section, gives a minimal risk to both the mother and the fetus and the newborn.

In the domestic literature, the features of the readiness for delivery in pregnant women with pelvic presentation of the fetus depending on the results of the corrective gymnastics are studied, and a complex method of prenatal corrections of incorrect positions and pelvic presentations of the fetus is proposed. A variant of the complex of therapeutic exercises is developed.

The technique of external preventive rotation of the fetus on the head. Conditions for the operation:

• term not less than 35-36 weeks;
• sufficient mobility of the fetus;
• absence of tension of the uterus and abdominal wall;
• accurate diagnosis of the fetal position.

It should be remembered that the frequency of pelvic presentation is proportional to the duration of pregnancy. Up to 30 weeks of pregnancy, it reaches 35%, while at the end of pregnancy only 3%. The greatest number of turns is carried out with a gestation period of 34 weeks. If the gestation period is more than 34 weeks, it is necessary to perform an echography to determine congenital malformations of the fetus, such as anencephaly, hydrocephalus, fetal hypotrophy. External fetal rotation should be performed by an experienced obstetrician one or more times between 32 and 36 weeks of gestation.

According to ultrasound, it is necessary to determine the nature of pelvic presentation, the localization of the placenta. After the 33rd week, the position of the fetus remains stable in 95% of cases. The frequency of successful fetal turn on the head without tocolysis up to 34 weeks of pregnancy is 75%, after 34 weeks - only 45%. The overall frequency of a successful turn is about 60%. Therefore, in modern conditions, about 75% of pregnant women with breech presentation are given birth by the operation of cesarean section.

A number of modern obstetricians use an external obstetric fetal turn on the head with the use of tocolysis, especially in terms of 37 weeks and more. Prior to the rotation, intravenous drip infusion of beta-adrenomimetics (for example, terbutaline at a dose of 5 μg / min or ritodrin at a dose of 0.2 mg / min) is performed. Relaxation of the uterus is considered adequate if unimpeded palpation through the uterine wall of the fetal parts is ensured. The most unfavorable prognostic factors are lowering the buttocks into the cavity of the small pelvis and turning the frontal backside.

We prefer the following procedure for turning the fetus in reducing the frequency of pelvic presentation: after the 30th week of pregnancy, twice a day on an empty stomach (morning and evening), the pregnant woman is placed in a position on the back with an uplifted pelvis. For this purpose, a polster with a height of up to 30 cm is placed under the sacrum and a moderate Trendelenburg is created with a slight dilution of the hips. In this position, the pregnant woman is within 10-15 minutes in the state of maximum relaxation, deep and uniform breathing, this exercise takes 2-3 weeks at home (up to 35 weeks of pregnancy). The high efficiency of the method was established (90%). Simplicity and absence of complications that can be observed with a preventive external turn (with or without tocolysis) allow us to recommend it as the most effective, simple and affordable at home.

One of the frequent complications during pregnancy with pelvic presentation of the fetus is the prenatal (premature) outpouring of amniotic fluid, caused by the absence of a girdle of contact. Therefore, pregnant women with pelvic presentation of the fetus in the normal course of pregnancy and the absence of extragenital diseases must be hospitalized in the department of pathology 7-10 days before delivery. Pregnant women with a burdened obstetric anamnesis, with a narrowing of the pelvis I-II degree, with a large fetus, with extragenital and other pathology, primiparous over 30 years must be hospitalized 2-3 weeks before delivery.

Prenatal hospitalization allows for a number of diagnostic, prophylactic, and therapeutic measures for pelvic presentation of the fetus. In addition, in the absence of biological readiness for childbirth in the full-term pregnancy, appropriate training of pregnant women is conducted and a plan for the most rational management of labor is made.

A number of authors suggest - when deciding on the method of delivery by a natural or abdominal route, be guided on the basis of a scoring score of the prognostic index.

[1], [2], [3], [4], [5]