Pelvic presentation of the fetus

Update: October 2018

Every day, obstetricians are becoming more interested in the pelvic issue.
presentation of the fetus, which is understandable. Not long ago, the birth in the pelvic
previa related to physiological, but today
the opinion of doctors has changed dramatically and pelvic presentation are considered
pathology. First, this is due to the high risk of
perinatal complications and death of children in pelvic presentations, well,
secondly, it is associated with a high percentage (up to 6) of serious
congenital developmental abnormalities. In addition, pelvic presentation of the fetus
does not exclude the consequences for women.

Pelvic presentation: how to understand the term

Not all future moms understand what pelvic presentation means.
fetus. In general, it is simple. The baby in the uterus is normal should
be positioned longitudinally (that is, along the uterine axis), and to the entrance
Bring the largest part, that is, the head.

Pelvic previa is spoken of when an unborn child lies in
the uterus is correct, that is, longitudinally, but pelvic
end (buttocks) or legs. Pelvic previa occurs wrong
rarely, in 3–5% of births.

Classification

According to the national classification, the following types are distinguished.
pelvic presentation:тазовое предлежание плода

  • Buttocks or flexor
    • purely buttock – when the buttocks are attached to the entrance, and
      legs bent at the hip joints, but extended along the body
      fetus and press the handle to the chest, and the head is also pressed to
      breasts;
    • mixed buttock – when the buttocks and the foot are attached to the entrance
      (one or both);
  • Foot or extensor
    • incomplete foot – when only one leg is attached to the entrance (and
      nothing else);
    • full foot – accordingly, both legs adjoin;
    • knee – the fruit as it stands on his knees, occurs
      rarely, in the process of childbirth goes into the foot.

Pure buttock abnormalities (up to 68% of all
pelvic previa), mixed buttock in 25%, and foot in 13%. AT
In childbirth, one type of pelvic presentation can be transferred to another.
Complete foot is diagnosed in 5 – 10%, and incomplete foot
observed in 25 – 35% of births.

Expectant mothers should not be immediately upset that
baby lies wrong. A lot of fruits, predlagayuschih pelvic
end by the end of pregnancy turn over and present
head.

Such a spontaneous turn is more often observed with
previa butchek, and in repetitive it happens in 2
times more often than the “pervorodok”. And what pleases if the child
overturned on its own, its reverse is unlikely
�”Somersault”.

Etiology

With pelvic presentation of the fetus, the causes are not fully understood. But
all predisposing factors are divided into three groups, in
depending on who or what they are.

Maternal factors

This group includes state-dependent factors.
mother’s body:

  • Uterine malformations – due to improper development of the uterus fetus
    takes a pathological position or presentation. It may be
    saddle or two-horned uterus, septum in the uterine cavity,
    hypoplastic uterus and others
  • Tumor formations in the uterus – various tumors (like
    usually myomatous nodes often interfere with the fetus correctly
    turn around and take the necessary headache. Not
    uterine polyps (fibrous) and adenomyosis are excluded
  • Increased or decreased uterine tone
  • Uterine scars
  • Overstretching of the uterus – in this case may affect
    polyhydramnios or a large number of births in history
  • The narrowing of the pelvis – significantly narrowed pelvis (3-4 degrees) or
    crooked and irregularly shaped pelvis also hinder
    the physiological location of the baby in the uterus
  • Pelvic tumors
  • Burdened gynecological and / or obstetric history –
    numerous abortions and scraping, childbirth with complications,
    inflammation of the uterus and cervix and other pathologies.

Fruit factors

Of the etiological factors associated with the fruit, there are:

  • Low fetal weight or prematurity – in 20% of cases it leads to
    pelvic presentation due to excessive fetal mobility
  • Multiple fertility – pregnancy is not the same fetus often (13%)
    complicated by the wrong position and the presentation of either one,
    or both kids
  • ATрожденные аномалии развития — в эту подгруппу входят пороки
    CNS (brain edema, anencephaly, tumors and hernias of the brain), malformations
    urinary system (Potter syndrome), abnormalities
    cardiovascular and musculoskeletal system (hip dislocation,
    myotonic dystrophy). Also play the role of chromosomal pathology and
    multiple fetal malformations.

Placental factors

How the organs of the placental system develop also
depends on the location of the fetus in the uterus:

  • Placenta previa – inhibits larger part of the fetus
    (head) located at the entrance to the pelvis
  • Short umbilical cord – limits fetal mobility
  • An excess or lack of amniotic fluid – contributes to either
    increased activity of the baby, or reduces its mobility
  • Placental insufficiency – leads to intrauterine
    developmental delay of the fetus and its malnutrition, which increases its
    motor activity
  • Cord entanglement – not gives the fetus a right turn in
    uterus.

Practical example

Late in the evening, a woman came into the maternity ward.
contractions. Vaginal examination revealed the opening
маточного зева до 5 см, в котором хорошо прощупывались ножки fetus.
After making a diagnosis: Pregnancy 38 weeks. First period 5
urgent delivery Butжное предлежание. It was decided immediately
to complete the delivery of cesarean section. I must say that the woman was
not young, about 40 years old, childbirth 5 (at home 4 children are waiting for the mother), and
it was not registered. Never even on the ultrasound was not. After
uterine incision and fetal extraction revealed that he is missing
brain (anencephaly). The child died immediately. Operation
finished suturing the uterus and ligation of the fallopian tubes, that is,
sterilization.

It should be noted that such mom’s disorder could
end badly Childbirth in a natural way is much safer (during
many cases) for a woman than operative delivery. AT
in this case, the postoperative period was uneventful, and
the “not needed” caesarean section justified
 sterilization. And if the birth was the first? If a бы после
surgery or during her something happened? Therefore, this
I cite an example for future mothers as a science. Never be treated
disregard for their own health (not to be observed by a doctor, not
To be tested and not to attend ultrasound).

Course of pregnancy

The final diagnosis of pelvic presentation is taken out at week 36,
when the fetus firmly occupied a position in the uterus, although it is not excluded
spontaneous turn. Pregnancy with the presentation of the fetus
the pelvic end is much more likely to occur with complications than with
head previa. The main complications are:

  • threat of termination or premature birth;
  • preeclampsia;
  • placental insufficiency.

ATсе перечисленные осложнения приводят к кислородному голоданию
fetus, and, accordingly, to its developmental delay (hypotrophy and
abnormal amount of amniotic fluid (low or
polyhydramnion), entwined with umbilical cord. In addition, pelvic presentation
often accompanied by placenta previa, unstable
fetal position and prenatal discharge of water.

Similar presentation also affects fetal development and function.
placental system:

  • Maturation of the medulla oblongata

By 33 – 36 weeks the maturation of the medulla begins
to slow down, which is manifested by pericellular and perivascular edema
brain, which leads to “swelling” and impaired blood circulation
in the brain, and, consequently, to the breakdown of its functions.

  • Adrenal glands

Depleted adrenal function, and
hypothalamic-pituitary system, which significantly reduces
adaptive protective reactions of the fetus during childbirth and after.

  • Sexual gonads (testicles and ovaries)

There is a violation of blood circulation and tissue edema, partially
mature gonad cells die, which subsequently affects
reproductive function (hypogonadism, oligo-and azoospermia) and
leads to infertility.

  • ATрожденные пороки развития

When previa pelvic end в 3 раза чаще, в отличие от
headache found congenital malformations. AT первую
queue defects of the central nervous system and heart, as well as abnormalities of the digestive
tract and musculoskeletal system.

  • Violation of uteroplacental blood flow

Leads to fetal hypoxia, increased heart rate and decreased
motor activity.

ATедение беременности

Given the high risk of complications in pregnant women with pelvic
previa, with a preventive purpose, measures are assigned to
improve uteroplacental blood flow, prevent threats
прерывания и гипоксии fetus. Previa pelvic end at 21
week is considered physiological, and setting the fetus head down
occurs by 22–24 weeks. Pregnant recommend
balanced diet (prevention of hypo- or hypertrophy
fetus), and also sparing mode (proper sleep, rest).

Special gymnastics

Exercises with pelvic presentation of the fetus is recommended to start
hold from 28 weeks. But выполнение специальной гимнастики имеет
a number of contraindications:

  • scar on the uterus;
  • bleeding;
  • threat of interruption;
  • preeclampsia;
  • severe extragenital pathology.

Apply techniques on Dikanyu, on Grischenko and Shuleshovoy, and also
according to Fomicheva or Bryukhina. The simplest gymnastics is
Dikan exercises. Pregnant lies on one thing, then on the other
side turning over every 10 minutes. For one session you need
make 3 – 4 turns, and the gymnastics itself to perform three times in
day. After того, как плод установился в головном предлежании,
the stomach is fixed with a bandage.

External rotation of the fetus

AT случае отсутствия эффекта от гимнастических упражнений в 36
недель рекомендуется проведение наружного поворота fetus.
Manipulation is not performed in the following situations:

  • имеющийся scar on the uterus;
  • planned cesarean section (there are other indications);
  • uterine defects;
  • deviations on CTG;
  • premature discharge of water;
  • fetal defects;
  • small amount of water;
  • failure of a pregnant woman;
  • pregnancy is not one fetus;
  • placenta previa;
  • oxygen starvation of the fetus;
  • unstable fetal position.

Pelvic fetal overturn must be controlled
on ultrasound and CTG, the procedure itself is carried out “under cover”
tocolytics (ginipral, partusisten), and after manipulation perform
Non-stress test and repeat ultrasound.

Complications of the procedure include:

  • fetal hypoxia;
  • placental abruption;
  • rupture of the uterus;
  • trauma of the brachial plexus in the fetus.

Hospitalization pregnant

A woman is hospitalized with a pelvic presentation of the fetus at 38 – 39
a week In-hospital examination is carried out pregnant:

  • clarification of obstetric history;
  • elucidation of extragenital pathology;
  • ultrasound (specification of presentation, size
    fetus and degree of extension of the head);
  • radiography of the pelvis;
  • amnioscopy;
  • assess the readiness of the body of a pregnant woman for childbirth and
    fetal condition.

Then determined with the method of delivery. Cesarean section
in the case of pelvic presentation of the fetus, according to plan
following indications:

  • fruit weight less than 2 and more than 3.5 kg;
  • constricted pelvis, regardless of the degree of constriction;
  • curvature of the pelvis;
  • excessive extension of the head;
  • delayed fetal development;
  • fetal death or birth trauma in history;
  • retouching;
  • placenta previa;
  • pelvic previa of the first baby with multiple fetuses;
  • scar on the uterus;
  • foot previa;
  • �“Old” primipara (more than 30);
  • pregnancy after in vitro fertilization;
  • extragenital pathology requiring elimination of the second
    period of birth.

Diagnostics

To diagnose pelvic presentation is not difficult.
For this purpose, external and internal inspection, as well as
additional research methods.

External examination

For this purpose, Leopold’s methods are used (determination of the position
and the baby’s previa) and abdominal measurement:

  • Height of uterine bottom

The bottom of the uterus with this type of presentation is high, that is,
exceeds the physiological norm. This is due to the fact that the pelvic
the end is not pressed against the entrance to the small pelvis before the onset of labor.

  • Receptions leopold

When probing the abdomen, it is clearly defined that the dense and
the rounded part (head) is in the bottom of the uterus, and the buttocks
(large, soft, irregularly shaped and not ballot, i.e.
the fixed part is located at the entrance to the basin.

  • Fetal heartbeat

With headache presentation, the heartbeat is clearly heard.
or on the left, but below the navel. When previa pelvic end
palpitations can be heard at or above the navel.

Vaginal examination

This method is most informative when carrying out in childbirth:

  • in the case of the previa of the buttocks, the soft part and the slit are palpable
    between the buttocks, as well as the sacrum and genitals;
  • if the presentation is purely gluteal, inguinal
    fold;
  • in the case of a mixed buttock previa next to the buttocks
    palpable foot;
  • in the case of a foot, the legs of the fetus are determined, and in the event of a leg falling out
    its main difference from the dropped pen is a sign that with a pen
    maybe say hello.

Additional methods

  • Fetal ultrasound

The presentation of the fetus is clarified, as well as its mass, presence or
absence of congenital malformations and umbilical cord, degree
head extension.

  • CTG and fetal ECG

Allow to assess the condition of the baby, hypoxia, entanglement or
pressing the loops of the umbilical cord.

Childbirth

Deliveries with pelvic presentation of the fetus, as a rule, occur with
complications. Perinatal mortality in this kind
significantly increases compared with childbirth in headache
(four to five times).

Complications during contractions:

Premature discharge of water

Since the pelvic end is not fully compared with the head
заполняет полость таза, что ведет к  недостаточному
relaxation of the neck, resulting in the discharge of water, and
often, the loss of the umbilical cord. Pelvic cord compression occurs
the end and the wall of the cervix or the wall of the vagina that violates
placental blood flow and leads to fetal hypoxia. If a
compression continues for a considerable time
the brain of a child or his death.

Weakness of generic forces

Weak contractions result from delayed discharge.
water, as well as insufficient pressure of the pelvic end to the entrance to the pelvis,
which does not stimulate cervical dilatation. Weakness of contractions in turn
leads to prolonged labor and causes oxygen deficiency in
fetus.

Complications during the exile period:

Difficult head birth

Данное осложнение нередко приводит к асфиксии или смерти fetus.
Difficulties in the birth of a head are determined by three factors.
First, the pelvic end of the baby is substantially smaller than the head,
therefore, the birth of the buttocks passes quickly and without difficulty, and
head “stuck.” In case of preterm labor, pelvic end
can be born and with incomplete disclosure of the cervix, and the subsequent
cervical spasm aggravates the situation at the birth of the head. Secondly,
Difficulties in the birth of the head may be caused by its over-bending. BUT,
thirdly, obstructed birth of the head may be due to
запрокидыванием ручек fetus. This is observed more often when
preterm labor, when the body is born too fast, and
pens “do not have time.”

Damage to the soft tissues of the birth canal

Birth of fetus in pelvic presentation is fraught with not only
complications for him, but also for the mother. All difficulties associated with
the birth of the body and the removal of the head often lead to ruptures
cervix, vaginal walls or perineum.

Conducting childbirth

Conducting childbirth в случае тазового предлежания имеет существенную
difference compared with childbirth in headache.

Conducting the period of labor

  • Bed rest

If a при нормальных родах роженице в первом периоде настоятельно
recommend to be active (walk), then in the case of pelvic
previa woman relies to lie, with the foot end of the bed
better lift. This tactic prevents premature
or early discharge of water. It relies on the side where
the back of the baby is facing, which stimulates uterine contractions and
warns of weakness of contractions.

  • After the discharge of water

As soon as the water is removed, it is necessary to hold a vaginal
study to eliminate the loss of the legs or the umbilical cord loop.
If a предлежание чисто ягодичное, можно попытаться заправить
dropped loops. When foot previa this method does not apply.
If a петля не заправляется или предлежат ножки, проводится
emergency caesarean section.

  • Monitoring

The first period of labor is supposed to be kept under the control of CTG, in
last resort, to conduct auscultation of the fetus every half hour (with
giving birth in headache every hour). You should also follow
contractile activity of the uterus, maintain a partograph (graph
disclosure of uterine throat).

  • Prevention of fetal hypoxia

The timely provision of drug sleep-rest (in
the beginning of the first period) and the introduction of the triad in Nikolaev every 3
hours

  • Anesthesia

In the case of pelvic presentation, the first stage of labor is recommended.
pain relief (epidural or pudendal anesthesia).

  • Antispasmodics

Timely administration of antispasmodics (no-spa, papaverine)
starts with a neck opening of 4 cm and repeats every 3 – 4
hours, which prevents her spasm.

Maintaining the second period

  • Oxytocin

At the end of the contractions period and the beginning of the second period intravenously
Oxytocin Cabin, which warns of weakness and pains and
retains the correct articulation of the baby. With the beginning of the attempts on
the administration of oxytocin is administered intravenously atropine for
cervical spasm warnings.

  • Monitoring

Monitoring of fetal heartbeat and contractions (CTG) continues.

  • Episiotomy

As soon as the buttocks emerged from the genital slit (teething
buttocks) dissection of the perineum – episiotomy.

  • Manual allowance

Depending on the situation, when teething or birth
the legs of a manual benefit (for Tsovianova 1 or 2,
fetal extraction for the pelvic end, taking
Morisso-Levre-Lyashepel).

The third stage of labor is carried out as in normal, physiological
childbirth.

Practical example

In the maternity hospital received a young womanbeard woman complaining of
contractions. Registered in female consultation was not (our
women see a doctor). The mother was about 32
week of pregnancy. Palpation of the abdomen revealed that
twin pregnancy (2 heads and both in the bottom of the uterus) and 2 heartbeats
above the navel. When vaginal examination revealed a discovery
cervix 8 cm, there is no fetal bladder, there are legs, one is right there
fell out. A woman complains about the attempts. Cesarean section делать поздно.
Immediately took the generic table. I must say that during the attempts
the woman behaved rather inadequately. Screamed, tried to escape
from the table and hands stretched to the crotch while I tried to extract
first baby. The birth of legs and torso has passed more or less.
normally, and the head, of course, “stuck.” Putting on the left hand
child as a rider and inserting a finger in his mouth, fingers of his right hand
like a fork wrapped around the neck of a child (reception by Moriso-Levre-Lyashepel),
trying to pull the head. The process took about 3 – 5 minutes, I no longer
waited for the birth of a live baby. But he was born alive, albeit in severe
asphyxia. The second child also “walked” with the legs. But with his birth
things went faster, since the “path is laid”, although
difficulty with breeding heads. Sequel period without features.
A neonatologist and an anesthesiologist attended the birth, who immediately
rendered resuscitation to the children. After discharge from the hospital
the woman was transferred to the children’s department for further
nursing babies. In conclusion, I want to say that I saw her and
Children about a year after birth, talked with my mother. Children
With words normal, well develop and grow.

Effects

Deliveries in pelvic presentation often result in complications in
birth injuries and have consequences for children:

  • intracranial injuries;
  • encephalopathy (as a result of hypoxia and asphyxia);
  • dysplasia and / or dislocation of the hip joints;
  • disruption of the central nervous system;
  • spinal injuries.

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