Malposition

An incorrect position of the fetus is a position where the fetal axis does not coincide with the axis of the uterus. In those cases when the fetal and uterus axes, crossing, form an angle of 90 °, the position is considered transverse (situs ransversus); if this angle is less than 90 °, then the position of the fetus is considered oblique (situs obliguus).

In practice, the transverse position of the fetus can be said in the case of the location of its head above the crest of the ilium, the oblique - below. Incorrect positions of the fetus are found in 0.2-0.4% of cases. It should be noted that the position of the fetus is of interest to the obstetrician from 22 weeks. Pregnancy, when premature birth may begin.

[1], [2], [3], [4], [5], [6]

Causes of improper fetal position

Among the reasons for the formation of incorrect positions of the fetus, the most important is the decrease in the tone of the musculature of the uterus, changes in the shape of the uterus, excessive or severely restricted mobility of the fetus. Such conditions are created in the case of developmental abnormalities and uterine tumors, fetal development abnormalities, placenta previa, polyhydramnios, infertility, multiple pregnancy, flabbiness of the anterior abdominal wall, and also in conditions that make it difficult to insert the present fetal part into the small pelvis, for example, segment of the uterus or with a significant reduction in the size of the pelvis. Abnormal position, especially oblique, can be temporary.

[7], [8], [9], [10]

How to recognize the wrong position of the fetus?

The transverse and oblique position of the fetus is diagnosed in most cases without special difficulties. When examining the abdomen, the shape of the uterus, which is elongated in the transverse direction, attracts attention. The circumference of the abdomen always exceeds the norm for the corresponding pregnancy period at which the examination is carried out, and the height of the standing of the uterine fundus is always less than the norm. When using Leopold's techniques, the following data is obtained:

• in the bottom of the uterus is missing any large part of the fetus, which is found in the lateral parts of the uterus: on the one hand - round tight (head), on the other hand - soft (pelvic end);
• the presenting part of the fetus over the entrance to the small pelvis is not determined;
• the palpitation of the fetus is best audited in the navel;
• position of the fetus is determined by the head: at the first position the head is determined on the left side, at the second - on the right;
• the type of fetus is recognized on the back: the back is facing forward - the front view, the backrest - the back. If the fetal back is turned down, then there is an unfavorable version: it creates unfavorable conditions for the extraction of the fetus.

Vaginal examination done during pregnancy or at the beginning of labor with a whole fetal bladder does not give much information. It only confirms the absence of the presenting part. After the outflow of amniotic fluid with sufficient opening of the cervix (4-5 cm), you can determine the shoulder, shoulder blade, spinous processes of the vertebrae, inguinal cavity.

Ultrasound is the most informative diagnostic method that allows you to determine not only the wrong position, but also the expected body mass of the fetus, the position of the head, placental location, the amount of amniotic fluid, the cord embryos, the presence of an abnormality in the development of the uterus and its tumor, fetal development anomaly, etc. .

The course and tactics of managing pregnancy

Pregnancy in the wrong position of the fetus passes without any deviations from the norm. Increased risk of premature discharge of amniotic fluid, especially in the III trimester.

Preliminary diagnosis of the wrong position of the fetus is established in the gestation period of 30 weeks, the final - in 37-38 weeks. Starting from the 32nd week, the frequency of spontaneous turning sharply decreases, therefore it is advisable to correct the position of the fetus exactly after this period of pregnancy.

In the women's consultation in the period of 30 weeks. To activate the self-rotation of the fetus on the head of the pregnant woman, it is necessary to recommend corrective gymnastics: the position on the side opposite the position of the fetus; knee-elbow position for 15 minutes 2-3 times a day. From 32nd to 37th week a set of corrective gymnastic exercises is prescribed according to one of the existing methods.

Contraindications to performing gymnastic exercises are the threat of premature birth, placenta previa, low attachment of the placenta, an anatomically narrow pelvis of II-III degree. Do not under the conditions of the female consultation an external preventive turn of the fetus on the head.

External rotation of the fetus on the head

Further tactics of pregnancy management is to perform an attempt to externally turn the fetus on the head in term of pregnancy and further induction of labor or expectant pregnancy and attempt to rotate the fetus with the onset of labor if its wrong position persists. In most cases, with expectant management of pregnancy, the fruits that have incorrect position, are located longitudinally to the beginning of childbirth. Only less than 20% of the fruits, which were located transversally up to 37 weeks. Pregnancy, remain in this position at the beginning of labor. In the period of 38 weeks. Determine the need for admission to a midwifery hospital III level for such indications: the presence of a burdened obstetric-gynecological history, complicated course of this pregnancy, extragenital pathology, the possibility of an external turn of the fetus. In an obstetric hospital, ultrasound is performed to determine the diagnosis, the fetus status is assessed (BPP, if necessary, dopplerometry is performed), the possibility of an external turn of the fetus on the head, the readiness of the female organism for childbirth is determined.

The plan of conducting labor is developed by a consultation of doctors with the participation of an anesthesiologist and a neonatologist and coordinates it with a pregnant woman. In the case of full term pregnancy in the hospital of the third level, the beginning of labor can be performed by turning the fetus to the head with the informed consent of the pregnant woman. External turn of the fetus on the head in case of full term pregnancy leads to an increase in the number of physiological births in the head presentation.

Conduction of an external turn on the head in a full-term pregnancy makes it possible to carry out spontaneous turning of the fetus more often. Thus, the expectation of the delivery period reduces the number of unnecessary attempts of external rotation. With full term pregnancy, in case of complications of the turn, you can perform an emergency abdominal delivery with a mature fetus. After a successful external turn on the head, reverse spontaneous turns are less common. The disadvantages of external turning of the fetus in term of full-term pregnancy is that it can be prevented by premature rupture of the bladder or delivery that started before the planned attempt to perform this procedure. The use of tocoliths in the external turn reduces the level of failure, facilitates the procedure and prevents the development of bradycardia in the fetus. These benefits of using tocolytics should be compared with their possible side effect on the mother's cardiovascular system. It should be noted that the risk of complications during the external turn is reduced, as the procedure takes place directly in the delivery ward with continuous monitoring of the fetus.

[11], [12], [13]

Conditions for an external turn

Estimated fetal body weight <3700 g, normal pelvic size, emptied bladder of a pregnant woman, possibility of ultrasonic evaluation of the position and condition of the fetus before and after the turn, satisfactory fetal status according to BPP data and absence of developmental anomalies, sufficient fetal mobility, ample amniotic fluid , the normal tone of the uterus, a whole fetal bladder, the willingness of the operating room to provide emergency assistance in case of complications, the presence of an experienced qualified th specialist who owns the technique of rotation.

[14], [15]

Contraindications to the external turn

Complicated during pregnancy at the time of making a decision about the external turn (bleeding, distress of the fetus, pre-eclampsia), weighed obstetric-gynecological history (habitual miscarriage, perinatal loss, infertility in the anamnesis), many- or little-watered pregnancy, multiple pregnancy, anatomically narrow pelvis, changes in the vagina or cervix, placenta previa, severe extragenital pathology, scar on the uterus, adhesions, fetal development abnormalities, abnormalities of the uterus, tumors of the uterus and its adder in.

[16], [17], [18]

Equipment

The doctor sits on the right side (face to face pregnant), one hand is located on the head of the fetus, the second - at his pelvic end. With cautious movements, the fetal head gradually shifts to the entrance to the small pelvis, and the pelvic end to the bottom of the uterus.

[19], [20], [21],

Complications of an external turn

Premature detachment of the normally located placenta, fetal distress, rupture of the uterus. In the case of careful and qualified performance of the external rotation of the fetus on the head, the incidence of complications does not exceed 1%.

[22]

The course and tactics of labor in the transverse position of the fetus

Genera in the transverse position are pathological. Spontaneous delivery through the natural birth can not be a viable fruit. If childbirth starts at home and there is not enough supervision during the childbirth, complications can begin already in the first period. In the transverse position of the fetus, there is no division of the amniotic fluid into the anterior and posterior, so there is often an untimely outflow of amniotic fluid. This complication can be accompanied by the prolapse of the umbilical cord loops or the fetal handle. Deprived of amniotic fluid, the uterus tightly fits the fetus, the fetal transverse position of the fetus is formed. With normal labor, the shoulder of the fetus descends deeper into the cavity of the small pelvis. The lower segment is overstretched, the contraction ring (the boundary between the uterus body and the lower segment) rises and occupies an oblique position. There are signs of a threatening rupture of the uterus and, in the absence of adequate care, there may be a rupture.

To avoid such complications, 2-3 weeks before the expected delivery, the pregnant woman is sent to the obstetric hospital, where she is examined and prepared for the completion of pregnancy.

The only method of delivery in the transverse position of the fetus, which ensures the life and health of the mother and child, is the operation of caesarean section at a period of 38-39 weeks.

Classic obstetrical fetal turn on leg

Previously, the classic external-internal rotation of the fetus on the leg was often used, followed by the extraction of the fetus. But it gives a lot of unsatisfactory results. For today, with a live fetus, it is carried out only in the case of the birth of a second fetus in a double. It should be noted that the operation of classical obstetric fetal turn on the leg is very complicated and therefore, taking into account the trends of modern midwifery, it is very rare.

[23], [24], [25]

Conditions for Obstetric Classic Turning

• full disclosure of the cervix;
• sufficient mobility of the fetus;
• the correspondence between the size of the fetal head and the pelvis of the mother;
• a whole bladder or water has just come off;
• live fruit of medium size;
• exact knowledge of the position and position of the fetus;
• absence of structural changes in the uterus and tumors in the vagina;
• consent of the mother to the turn.

Contraindications for obstetric classic turnaround

• the transverse position of the fetus;
• threatening, started or held rupture of the uterus;
• congenital deficiencies in fetal development (anencephaly, hydrocephalus, etc.);
• immobility of the fetus;
• a narrow pelvis (II-IV degree of constriction);
• water scarcity;
• a large or giant fruit;
• scars or tumors of the vagina, uterus, pelvis;
• tumors that prevent natural delivery;
• severe extragenital diseases;
• severe preeclampsia.

Preparation for surgery includes the activities necessary for vaginal operations. Pregnant is placed on the operating table in a position on the back with legs bent in the hip and knee joints. Empty the bladder Disinfect the external genitalia, the inner surfaces of the thighs and the anterior abdominal wall, and cover the abdomen with a sterile diaper. The hands of an obstetrician are treated as for a cavitary operation. With the help of external techniques and vaginal examination, the position, position, type of fetus and condition of the birth canals are studied in detail. In case the amniotic fluid is intact, the bladder is ruptured immediately before the turn. A combined turn should be performed under deep anesthesia, which should provide a full relaxation of the muscles,

[26], [27], [28], [29], [30], [31], [32], [33], [34], [35]

The technique of obstetric classic turnaround includes the following steps:

• insertion of the hand into the vagina:
• the introduction of the hand into the uterine cavity;
• search, select and grasp the legs;
• actually turning the fetus and extracting the stem to the popliteal fossa.

After completion of the rotation, the fetus is removed by the foot

[36], [37], [38], [39], [40]

Stage I

Any hand of the obstetrician can be introduced into the uterus, however, it is easier to rotate with the introduction of the hand, the same position of the fetus: in the first position - the left hand, and the second - the right one. The hand is injected in the form of a cone (the fingers are stretched, the ends are pressed against each other). With the second hand, the sex slit is bred. The folded inner arm is inserted into the vagina in the direct size of the exit from the small pelvis, then it is transferred from the forward dimension to the transverse one, while moving towards the inner throat with light screw-like movements. As soon as the inner hand is fully inserted into the vagina, the outer arm is moved to the bottom of the uterus.

Phase II

Promotion of the hand in the uterine cavity can interfere with the fetal shoulders (in the transverse position) or the head (with oblique fetal position). In this case, it is necessary to move the fetal head towards the back with an inner hand or grab the shoulders and gently push it towards the head.

Stage III

Performing the third stage of the operation, it should be remembered that today it is customary to make a turn on one leg. Incomplete leg presentation of the fetus is more favorable for the course of the birth act than the full leg, as the bent leg and buttocks of the fetus represent a more voluminous part that better prepares the birth canal for the passage of the subsequent head. The choice of the leg to be seized is determined by the type of the fruit. At a forward view the bottom leg is grasped, at back - the top. In the case of compliance with this rule, the turn is completed in the forward form of the fetus. If the leg is not chosen correctly, the birth of the fetus will occur in the rear view, which will require a turn in the front view, since the birth in the back view with pelvic presentations through the natural birth can not be possible. There are two ways to find the legs: short and long. At the first hand, the obstetrician moves directly from the belly of the fetus to the place where the fetal legs are approximately. More precise is the long way to find the legs. The inner hand of the obstetrician gradually slides along the lateral surface of the trunk of the fetus to the sciatic region, further to the thigh and lower leg. With this method, the hand of the obstetrician does not lose touch with the parts of the fetus, which allows one to orientate well in the uterine cavity and to correctly find the desired leg. At the time of the search for the leg, the outer arm lies on the pelvic end of the fetus, trying to bring it closer to the inner arm.

After finding the foot, it is grasped with two fingers of the inner hand (index and middle) in the area of the ankle or with the entire brush. The grip of the entire leg with the brush is more rational, since the leg is firmly fixed, and the hand of the obstetrician does not get tired as quickly as when grasped with two fingers. When the shin is seized by the entire brush, the midwife has an elongated thumb along the tibial muscles in such a way that it reaches the popliteal fossa, and the other four fingers grasp the tibia in front, the shin as it were in the tire along the entire length, which prevents it from fracturing.

Stage IV

The actual rotation is performed, which is carried out by lowering the leg after it is grasped. An external hand simultaneously moves the fetal head to the bottom of the uterus. Tractions are carried out in the direction of the leading axis of the pelvis. The turn is considered complete, when the pedicle is removed from the genital cleft to the knee joint and the fetus takes a longitudinal position. After this, after the turn, the fetus is removed from the pelvic end.

The leg is grasped with the whole hand, placing a thumb along the length of the leg (according to Phenomenus), and the other fingers covering the shin in front.

Then carry the traction down, you can do it with both hands.

Under the symphysis appears the area of the anterior inguinal fold and the wing of the ilium, which is fixed, so that the posterior buttock could erupt above the perineum. The fore-caught hip is lifted up with both hands and the back leg drops out on its own; after the birth of the buttocks, the hands of the obstetrician are arranged in such a way that the thumbs are placed on the sacrum, and the rest on the inguinal folds and hips, then the tractions are carried out, and the trunk is born in an oblique size. The fetus is facing the symphysis. 

Then the fruit is rotated 180 ° and the second handle is also extracted. Release of the fetal head is carried out by the classical method.

When performing an obstetric turnaround, a number of difficulties and complications may arise:

• stiffness of the soft tissues of the birth canal, spasticity of the uterine throat, which are eliminated by the use of adequate anesthesia, antispasmodics, episiotomy;
• dropping the handle, removing the handle in place of the foot. In these cases, a handle is put on the handle, by means of which the handle is moved away during the turn towards the head;
• rupture of the uterus is the most dangerous complication that can occur during the turn. Accounting for contraindications to the operation,
• Examination of the parturient (determination of the height of the standing ring), the use of anesthesia is necessary to prevent this formidable complication;
• abaissement of the umbilical cord after the end of the rotation requires the obligatory rapid extraction of the fetus by the foot;
• acute fetal hypoxia, birth trauma, intrapartum fetal death - frequent complications of the internal obstetric turn that determine the generally unfavorable prognosis of this operation for the fetus. In connection with this, in classical obstetrics, the classic external-internal rotation is rarely performed;
• Infectious complications that may occur in the postpartum period also worsen the prognosis of the internal obstetric turn.

In the case of the launched transverse position of the dead fetus, the birth is terminated by performing a fertile decapitation operation. After a classic turn of the fetus on the leg or after a fruit-destroying operation, a manual examination of the walls of the uterus should be performed.