Lateral position fetus: тактика ведения,the reasons

Update: October 2018

If we talk about literature, I will recall many examples when
mothers in labor died, and often with the unborn
a child. One of the causes of high mortality in the 17th – 19th centuries and
ранее являлись тяжелые роды, вызванные поперечным положением fetus.
Currently, this complication of pregnancy, though retains
danger, both for the life of the woman and for the baby, but the risk of death
both members of labor decreased significantly. Incorrect provisions
fetus, в том числе и поперечное положение, встречаются в 1 случае
200 births, which is a percentage of 0.5 – 0.7%.
Tellingly, the situation with the wrong arrangement of the child in
uterus is more often seen in multiparous (10 times) than in women,
giving birth for the first time.

Determine the terminology

Depending on how the fetus is located in the uterus,
determined and tactics of delivery women. For understanding
terms we define the following concepts:

  • ось fetus – продольная линия, соединяющая ягодички и головку
    baby;
  • the axis of the uterus is a longitudinal line connecting the bottom of the uterus and cervix,
    or longitudinal uterus.

Положением fetus называют отношение оси малыша к длиннику матки.
Различают правильное положение fetus и неправильное. Correct
position is considered longitudinal when the axis of the uterus and the child
coincide, but simply when the baby and the mother’s body are in
one direction (if the mother is standing, then the child is located
vertically with her). With этом одна из крупных (голова или
the pelvic end of the baby’s parts “looks” into the entrance of the small pelvis, and
another rests on the uterus.

Incorrect positions are transverse and oblique positions.
fetus. But следует помнить, что плод большую часть беременности
очень подвижен и постоянно меняет свое position. Stabilizing it
provisions occurs by 34 weeks, so talking about the wrong
position to a specified time does not make much sense.

Lateral position

When поперечного положения (situs transverses) ребенка он
located not along, but across the uterus, that is, the uterine axis and the axis
fetus расположены друг к другу перпендикулярно и составляют угол в
90 degrees. Since the baby is located across, respectively, no
и предлежащей части – крупные части fetus прощупываются по бокам
the uterus is to the right and left and above the iliac crests.

What is called an oblique position

О косом положении fetus (situs obliguus) говорят, когда ось
fetus смещена по отношению к длиннику матки, что образует острый
angle (less than 45 degrees). With этом головка или ягодицы находится
below the iliac crest. You can still select the cross-oblique
положение (не играет большой роли), когда оси fetus и матки
located at an angle, but do not reach 90 degrees, but more than 45
degrees

Также стоит упомянуть и о неустойчивом положении fetus. With
значительной подвижности fetus он периодически меняет свое
position from longitudinal to transverse or oblique and vice versa.

Предлежание fetus

Предлежанием fetus называют отношение крупной его части (это
may be the head or pelvic end) to the entrance to the pelvis.
Accordingly, distinguish head previa (at the entrance to the pelvis
there is a head) and pelvic (can be foot, buttock or
mixed).

Что способствует неправильным положениям fetus

Withчины поперечного положения fetus могут быть обусловлены либо
uterine factors (the presence of obstacles in it) either increased or
сниженной двигательной активностью fetus:

  • Uterine myoma

поперечное положение fetusRisk of wrong position
baby grows significantly with myomatous / fibrous
uterus nodes. It is especially great when localizing nodes in the neck,
isthmus or lower uterine segment or for large sizes
nodes located in other places that prevents the child from taking
правильное position. Uterine tumor growth during the period is not excluded.
gestation, which also deforms the uterine cavity and the fetus is forced
do not settle down correctly.

  • Congenital malformations of the uterus

Uterine anomalies contribute to the transverse position,
for example, the septum in the uterus is either saddle or
two-horned uterus.

  • Incorrect localization of the placenta

Low placentation or low location of the placenta (5 and below
see from the inner throat) or its presentation (when the placenta
partially or completely overlaps inner throat)
выступает причиной неправильного положения baby in the womb.

  • Constricted pelvis

As a rule, the narrowing of the pelvis 1 – 2 degrees does not create obstacles
ни для развития fetus, ни для его рождения. But более тяжелые
the degree of contraction of the pelvis, especially asymmetrical forms of narrowing
(skewed, twisted bone exostoses) serve
предпосылкой расположения fetus не вдоль оси матки, а поперек или
askew.

  • Пороки развития fetus

Some malformations manifest themselves already in utero.
For example, with anencephaly (absence of the brain) or
гидроцефалии – watersянке мозга (головка fetus становится очень
большой) может наблюдаться поперечное/косое положение fetus.

  • Патология околоплодных waters

Excess amniotic fluid leads to excessive expansion
uterine cavity, which in turn provokes excessive
movement activity of the baby. He becomes very mobile, not
feels the boundaries of the uterus and “fit” in it across or obliquely. With
lack of amniotic fluid situation is reversed. Uterine Cramp
spaces and a small amount of amniotic fluid is not
allows the child to actively move and take the necessary
longitudinal position.

  • Multiple pregnancy

When there are several fruits in the womb, it becomes cramped,
what prevents one from taking the correct position
to babies.

  • Large fruit

Considerable size and weight of the fetus (more than 4 kg) reduces its
locomotor activity and provokes improper location
baby in the womb.

  • Increased uterine tone

In the case of threatened abortion, especially permanent
the uterus is almost always in hypertonus and limits
движения fetus.

  • Flabbiness of the muscles of the anterior abdominal wall

This situation is often characteristic of women with multiple births (4
– 5 genera). Permanent extension of the anterior abdominal wall of the abdomen
pregnant uterus contributes to excessive motor activity
child (the abdominal muscles do not restrain movement), his
coups and rolls, which ends with the location of the fetus in
uterus transversely.

  • Fetal hypotrophy

Insufficient weight and size of the fetus also cause it
constant movement and upheavals in the uterus (the baby is small and
there is too much space in the womb).

How to determine the lateral position of the fetus

To determine the wrong position of the fetus is carried out
comprehensive examination of pregnant women:

Examination of the abdomen

During the examination of the abdomen of a pregnant woman, his abnormality is revealed.
the form. The abdomen is stretched in transverse size with transverse
the location of the fruit or is obliquely stretched in the case of oblique
position of the baby. The uterus takes the form of a ball instead of
ovoid-elongated. With измерении размеров живота устанавливается,
that its circumference significantly exceeds the norm, although the height
the uterus does not coincide with the period of gestation (less).

Palpation of the abdomen

During palpation of the abdomen, it is not possible to determine the presenting
(large part of the fruit) part at the entrance to the pelvic bone ring. In the bottom
the uterus also does not palpate the head or the pelvic end. Large
parts of the baby are felt on the right or left side of
midline of the uterus. The position of the fetus is set on the head.
If the head is on the left – they say about the first position, with
the location of the head on the right – about the second. Fetal heartbeat good
is heard in the navel, not left or right, as with
longitudinal position. Difficulties may arise
establish the position and position of the baby in case of hypertonicity of the uterus
(the threat of premature birth) and with an excess of amniotic fluid.

Obstetric Ultrasound

Obstetric Ultrasound со 100%-гарантией определяет положение fetus в
any period of gestation. But, как уже говорилось, поперечное положение
baby in the period of 20 weeks should not be cause for panic, until
due date of birth, the fetus will have time to take the “right”
position.

Vaginal examination

Vaginal examination, которое проwatersится в конце
pregnancy or at the beginning of labor, but the whole bladder,
provides some information. A midwife can only determine that
Presenting part of the fetus at the entrance to the small pelvis is missing. When
use of water and the opening of uterine throat to 4 or more cm vaginal
research is conducted with caution, so it can provoke
loss of the handle, the legs of the fetus or the umbilical cord loop. With излившихся
the waters of the doctor can feel the side of the fetus (ribs with intercostal
gaps), scapula or axilla, in some cases
elbow or brush handles.

How are pregnancy and childbirth

Pregnancy with the transverse position of the baby, as a rule,
proceeds without features. But отмечено, что почти в 30% случаев
begin preterm labor. Untimely outpouring
amniotic fluid is among the most frequent complications of this
pathology that can happen both during pregnancy and become
the cause of the onset of preterm labor and during the birth process
of the act.

Why labor is complicated in the case of lateral position
fetus

It is rarely possible to complete childbirth with a transverse position.
fetus самостоятельно и рождением живого малыша. In such cases
there is an independent turn of the child in the longitudinal position and
the birth of his head or pelvic end. Self-tort is possible with
незначительных размерах fetus либо его недоношенности. Basically
the course of labor develops adversely and is complicated by the following
processes:

  • Untimely discharge of water

With поперечном расположении fetus происходит раннее или
premature rupture of water (almost 99% of cases). it
causes the absence of the presenting part, which is pressed to
entering 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 waters
the mobility of the child is severely limited and occurs either
vkolachivanie shoulder in the pelvis, or the loss of small parts
(handles or legs). With выпадении пуповинной петли происходит ее
clamping, the blood flow is disturbed and the fetus dies.

  • Uterine rupture

Threatening rupture of the uterus accompanies neglected transverse
положение fetus. После того, как отошли watersы, плечевой пояс
vkolachivaetsya into the entrance of the pelvis, and the uterus begins rapidly
сокращаться, что приwatersит к перерастяжению нижнего сегмента и
the threat of its rupture. If you do not perform a cesarean operation in a timely manner
section of the uterus is torn.

  • Chorioamnionitis

Преждевременное отхождение waters и длительный безwatersный промежуток
contribute to the penetration of the infection into the intrauterine cavity and
формированию хориоамнионита, что приwatersит к развитию перитонита и
sepsis.

  • Гипоксия fetus

Затяжное течение родов на фоне продолжительного безwatersного
промежутка провоцирует развитие гипоксии fetus и рождение ребенка в
asphyxia.

  • Double body birth

Вследствие интенсивных схваток и излившихся waters стенки матки
плотно соприкасаются с плодом, что приwatersит к его сгибанию пополам
in the thoracic region. In this case, childbirth ends spontaneously.
First the chest is born with its neck pressed to it, then the belly
and the head pressed into it, and then the buttocks and legs. Birth
живого fetus в подобной ситуации маловероятно.

How to give birth and pregnancy

Тактика ведения беременной с поперечным положением fetus
includes careful observation of women, limiting physical
loads and the appointment of corrective gymnastics (in the absence of
contraindications). Up to 32 – 34 weeks transverse or oblique
the position of the child is considered unstable, as the probability is high
adoption of the fruit of the longitudinal position.

Раньше широко практиковался наружный поворот fetus с целью
приведения его в longitudinal position. Obstetric turn
performed in terms of 35 – 36 weeks in satisfactory condition
pregnant and no contraindications. To date
данный способ исправления положения fetus считается неэффективным и
it is used very rarely due to the many contraindications and
emerging complications. Peeling is possible during the procedure.
плаценты и возникновение гипоксии fetus, а также велика вероятность
uterine rupture.

Corrective gymnastics

Special exercises are appointed in case of improper
the position of the child in the absence of contraindications:

  • abnormal localization of the placenta (low placentation or
    previa);
  • umbilical cord disease;
  • pregnancy is not one fetus;
  • scar on the uterus;
  • severe somatic pathology of women;
  • hypertonicity of the uterus;
  • uterine fibroids;
  • мало- или многоwatersие;
  • bleeding from the genital tract.

With success applied gymnastics on Dikanyu. A woman
It is recommended to perform simple exercises three times a day:
roll over from one side to the other and lie down after turning on
each side for 15 minutes. Turns are performed up to 3 times.

A set of exercises that provides a rhythmic reduction
abdominal muscles and torso and combined with deep breathing:

Pelvic slopes

The woman fits on a hard surface and raises her pelvis.
The pelvis should be above the head by 20–30 cm. In a position with
raised pelvis up to 10 minutes.

Exercise “cat”

In a standing position on your knees, you should rest your hands on the floor. With
inhaling the head and tailbone rise, and the loin bends. With
exhale to lower the head and back to bend. Repeat exercises 10
time.

Knee-elbow pose

Elbows and knees abut the floor, with the pelvis should be higher
heads. In this position to be 20 minutes (you can read
little book).

Half bridge

Lie down on a hard surface and lay a couple under the buttocks
pillows. Taz rises to 40 cm, legs raised.

Pelvic lifts

Lying on the floor bend the legs at the knees and hip joints and
rest your feet on the floor. With each breath, raise the pelvis and
hold it in that position. With each exhalation, lower the pelvis and
straighten legs. Повторяются упражнения до 7 time.

As a rule, performing corrective gymnastics continues until
7 – 10 дней, в течение которых плод принимает longitudinal position.
Упражнения следует проwatersить трижды в день.

After the fetus takes a longitudinal position in the uterus,
a woman is prescribed wearing a bandage with longitudinal rollers. Butшение
the bandage secures the result and is recommended before the start of the generic
activity or pressing the head to the entrance to the pelvis.

Conducting childbirth

The optimal method of delivery in the case of transverse
положения fetus считается запланированное кесарево сечение.
The pregnant woman is hospitalized in the period of 36 weeks, carefully examined,
and prepare for surgery. Birth ребенка естественным путем
almost impossible, since self-rotation happens extremely rarely.
Births are conducted through the birth canal followed by
наружно-внутренним поворотом fetus на ножку только в двух
cases:

  1. fetus deeply premature;
  2. childbirth twins, if the second baby is located transversely.

Routine operative delivery before contractions
выполняется в следующих cases:

  • the true retouching;
  • prenatal discharge of water;
  • prelying placenta;
  • uterine tumors;
  • uterus with postoperative scars;
  • fetal hypoxia.

In rare cases, with the onset of labor, the fetus may transfer from
lateral position in the longitudinal and completion of labor
on their own. With the oblique position of the baby in labor
placed on the side, at the bottom of which is determined by a large part
fetus. A woman is not allowed to get up and she is in
horizontal position.

In the event of a child’s hand or foot falling out
their reposition is allowed. Firstly, it is absolutely
hopeless, and, secondly, dangerous. In addition to
infection of the uterus is delayed and the time before cesarean
section.

With the child running in the transverse position
immediate cesarean section regardless of its condition (live or
dead). A number of obstetricians in the case of running lateral position and
fetal death offers to perform fruit-destroying operation. But
fructification operation is very dangerous, as it can lead to
rupture of the uterus. If there are signs of infection (jump
temperature, purulent discharge from the uterus) then cesarean operation
cross sections complete hysterectomy and drainage of the abdominal
cavities.

The combined external-internal rotation is carried out at
observance of the following conditions:

  • living fetus;
  • opening of a uterine pharynx full;
  • bladder catheter;
  • woman’s consent;
  • head sizes correspond to the size of the mother’s pelvis;
  • preserved fetal mobility;
  • deployed operating room;
  • there are no tumors of the uterus and vagina, strictures
    vagina;
  • small size of the fruit (up to 3600 gr.).

Difficulties that may arise when committing
combined rotation:

  • rigidity (not stretched) of the soft tissues of the birth canal –
    selection of an adequate dose of narcotic drugs, introduction
    antispasmodics, performing episiotomy;
  • uterine rupture – immediate surgery;
  • the loss of the handle or its removal instead of the legs – putting it on
    loops on the handle and pushing the handle towards the fetal head;
  • the loss of the umbilical cord loop after the completion of the turn –
    mandatory and quick extraction of the fruit by the leg;
  • fetal hypoxia and its intranatal death;
  • birth injury;
  • development of infectious complications in the postpartum period.

Question answer

Вопрос: На втором УЗИ мне установили: Беременность
23 – 24 weeks. Lateral position fetus. What to do to baby
�”Lay down” right?

Gestational age is still small, so no action to take
it does not follow. The child will take the final position to 34 – 35
weeks, and until that time, it can spin and be positioned as
whatever

Вопрос: На последнем УЗИ врач установила, что плод
lies across (term 32 weeks). Do I need to do gymnastics to
baby is located right?

On the need for corrective gymnastics should
talk to the midwife who is leading the pregnancy. Only with his
permissions you can perform special exercises for turning
baby in the longitudinal position, as in some cases their implementation
contraindicated and even dangerous.

Вопрос: У меня двойня, срок 36 недель. The first
the child is put to his feet, and the second lies across. Is i sure
do cesarean section?

Yes, in this situation, a caesarean section is the safest and
a favorable method of delivery for both mom and babies.
If the first child were in purely breech presentation, then
it is possible its independent birth with the subsequent fulfillment
combined rotation of the second fetus on the leg. But в данном
the case of childbirth in a natural way will have difficulties already on
stage of the birth of the first baby, as the legs can be born before
full disclosure of the cervix, making it difficult not only
heads (head is the largest part of the fetus), but also pelvic
the end.

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