Until this time, its largest part, the head, is located at the top, in the most spacious area near the fundus of the uterus. But, having become heavier, the baby’s head forces him to turn over with his buttocks up.

It is this kind of presentation - cephalic - that is considered the optimal position for the birth of a child.

There are several types of cephalic presentation.

• Flexion occipital- the optimal and most common position for the birth of a child. The baby moves along the birth canal with the neck slightly bent, the back of the head forward, the leading point is the small fontanel, o
• Extensor anterocephalic (anteroparietal)- the child moves along the birth canal, moving forward with most of the head, the point of expulsion is the large fontanel. The reasons for the formation of this position of the child may be a discrepancy between the sizes of the mother’s pelvis and the fetal head, as well as weakness of the pelvic floor muscles. The risk of injury is slightly increased, and labor may be prolonged.
• Extensor frontal- the child’s neck is straightened, he moves his forehead forward and the area of ​​the presenting part increases significantly. The baby usually takes this position either just before the onset of labor or already in the process. It is considered an indication for caesarean section.
• Extensor facial- the most dangerous position of the child - the fetal neck is maximally extended and his face is facing the exit, the leading point is the chin. The risk of injury to the baby's neck is very high; a favorable outcome of birth is possible with the anterior type of facial presentation, small size of the fetus and normal dimensions of the mother's pelvis; in other cases, it is usually recommended C-section.

Doctors also take into account which side of the mother the baby’s back is turned to. The position with the back to the left is called the 1st position and is the most common, the position on the right is 2-1 position.

However, 3 - 5% of babies occupy a different position, very rarely - transverse (shoulder), much more often - pelvic.

Doctors include factors such as low tone and excitability of the uterus, tumors or structural anomalies of this organ, a large number of amniotic fluid, short umbilical cord in the fetus, low-lying placenta and some others.

Breech presentation has several varieties - gluteal, gluteal-foot (mixed), foot and knee. The child’s buttocks together with the feet can be facing the entrance to the woman’s pelvis (breech presentation), or the child’s legs can be bent at the hip joints and extended along the body (breech presentation).

The presentation of a child is usually easily determined by a doctor during an external examination of a pregnant woman, starting from 28 weeks. To clarify the diagnosis, an ultrasound examination is performed, which gives reliable results.

In previous years, to transfer a child from a breech presentation to a cephalic presentation, an external obstetric turn was used, during which the doctor used his hands through the abdominal wall expectant mother I tried to guide the baby into the right position.

Usually the expectant mother, whose child does not occupy by a certain date correct position, receives recommendations from the doctor for special gymnastics. These exercises are considered quite effective and for the most part have no contraindications.

If your baby doesn't want to turn head down, you can try classes with an instructor in the pool. There are certain types of exercises that can only be done in water; they often give positive results.

Most psychologists working with pregnant women are inclined to believe that the bond between the expectant mother and her unborn baby is so strong that the woman should simply try to coax her baby and convince him to take the right position!

Talk to him, mentally or out loud, tell him how easy and simple it will be for him to be born head first, but do not allow any negative thoughts. And no matter how funny it may sound, there are often cases when, after lengthy admonitions from the parents, the baby makes a revolution even at a fairly advanced stage of pregnancy.

When deciding on the optimal method of labor management, the doctor observing the expectant mother will necessarily take into account a number of factors. Of great importance are the dimensions of a pregnant woman’s pelvis and its relationship with the size of the fetus, her general health, the absence of chronic diseases or complications of pregnancy, as well as the condition of the child.

As a rule, even with foot presentation, doctors recommend a cesarean section, since such a birth is possible, but it is very difficult to manage. But most of the babies who are going to be born with their buttocks forward are born naturally.

In general, the incorrect position of the child, as a rule, does not affect the course of pregnancy, but can cause certain problems during the onset of labor. Naturally, when the baby is in a transverse position, women prepare for a planned caesarean section. With breech presentation certain conditions completely allows the child to be born on his own.

If, at the beginning of the birth of a child in a cephalic presentation, after rupture of the amniotic sac, its head is inserted into the mother’s pelvis and prevents premature effusion all fluid, then in the case of breech presentation, the child’s buttocks or legs, which are smaller in size compared to the head, cannot prevent the outflow of water.

The newborn's head is the largest and hardest part of his body, therefore, passing through the birth canal first, it expands them to such an extent that the baby's entire body moves more freely in them: after the birth of the head, the baby is completely born as a result of one or two attempts. The baby’s buttocks cannot provide the same easy passage of the head, therefore, in order to avoid problems such as prolapse of the umbilical cord, extension of the head, throwing back of the arms or pinching of the baby’s neck, leading to asphyxia, such births are carried out under the strict supervision of a doctor.

Good preparation for childbirth for the expectant mother and qualified obstetric care lead to the birth of a healthy baby!

From this time on, his situation will not change significantly, so the diagnosis is carried out precisely at the 8th month. Fetal presentation is determined by palpating the abdomen; in case of doubt, ultrasound or radiography is used.
For normal labor it is very important that the fetus is positioned vertically.

Currently, several variants of fetal presentation are known: cephalic, transverse and pelvic. The location of the fetus in the uterus is determined by direct examination by an obstetrician-gynecologist (at longer stages of pregnancy you can feel where the fetal head is) and by ultrasound examination. Depending on the duration of pregnancy, the position of the fetus in the uterus changes significantly. If during the first 6 months the fetus is still quite small in size and has enough room for movement, then by the time of birth it occupies a stable position and its presentation can already be accurately determined. If we compare ultrasound data performed during pregnancy, we can note that in approximately 25% of women the fetus is first located in a breech presentation, which later progresses to a cephalic presentation.

Head presentation of the fetus

The child completely occupies the space of the uterus and is best adapted to its shape. In 95% of cases, the largest part of his body (torso) is located in the widest part of the uterus. This means that the baby is positioned head down, with the back most often facing to the left.

This position is considered the most comfortable for mother and baby during childbirth. It is characterized by the position of the fetus head first (the front part is directed towards the mother's back), which is the most voluminous and plastic part of the fetus, due to the unfused bones of the skull. The baby's head will be the first to pass through the woman's birth canal (this includes the cervix, vagina, external genitalia), which determines a faster course of labor. After the head has passed, the remaining torso and limbs are born without any difficulty. In this case, the child is born with his head bent, pulled into his shoulders and slightly turned to the left side. However, there are cases when a baby who is in a cephalic presentation may have his head turned to the right side, which will significantly complicate childbirth. There is also a frontal and facial position of the fetus in cephalic presentation. The causes of these head positions may be decreased muscle tone and weak uterine contractions during childbirth, close location the mother's pelvic bones, the size of the fetal head is not normal (large or small), a congenital tumor of the child's thyroid gland, as well as difficulty moving when turning the fetal head. The frontal position may be associated with anatomical changes in the structure of the mother’s uterus, with a wide pelvis, and also most often occurs in multiparous women, since the stretched muscles of the uterus cannot ensure a stable position of the fetus. When this situation is determined, the woman in labor is transferred to the operating department. Childbirth in this position of the child is possible only if the fetus is small. In most cases, a caesarean section is used to deliver the baby. The facial position of the fetus can be determined even during the first ultrasound examinations. A characteristic feature of this position is the specific position that the child takes in the womb. By carefully palpating, it is necessary to determine in which direction the chin is directed. If it is directed forward, then labor will proceed independently. During childbirth, passing through the mother's pelvic bones, the baby's head encounters resistance and tilts back, so the front part of the head appears first, not the occipital part. In the facial position, a characteristic sign of a newborn baby is the elongated lips and chin of the fetus. If the chin is turned back, during childbirth the head may be pinched by the pelvic bones, which will lead to the impossibility of further delivery. This position of the fetus is very rare, but if it is detected, a caesarean section is always performed.

Breech presentation of the fetus

In preparation for his birth, somewhere between the 32nd and 37th weeks the baby turns over, taking a vertical position with his head down - the so-called cephalic, or occipital, presentation. As a result of this rotation, the baby's head is directed downwards, exactly towards the entrance to the birth canal. The head is the heaviest part of the baby's body. When the baby is almost fully formed, he turns over head down under the influence of the natural law of gravity.

In most cases, this somersault occurs completely unnoticed, especially if the baby turns over during mother's sleep. But the change of position may be delayed if the mother experiences fear and stress, or some circumstances in her life cause her grief.

Some women, for various reasons, cannot release stress, because of this, their uterus remains tense and the baby cannot turn over. The baby simply does not have enough space to make a turn, so he remains in his original position with his head up. The baby's buttocks remain at the entrance to the cervix. This position is called “breech presentation.” Sometimes the baby makes only a partial revolution: his shoulder, arm, one or both legs remain in the lower segment of the uterus.

If no change occurs, breech birth requires important decisions to be made. There are several options: direct all efforts to help the baby roll over; give birth to a breech baby or have a caesarean section. Since not many specialists have sufficient knowledge and skills to perform breech births, in most such cases women are referred to have a caesarean section. But this is not an option that you should think about at the very beginning. Many women give birth to breech babies through the normal vaginal route with home midwives.

The child is in a vertical, but incorrect position: the buttocks are located below, and the head is above. This fetal presentation occurs due to a very small uterus or its irregular shape.

Expulsion of the fetus during labor is difficult and general anesthesia may be necessary.

Breech presentation is characterized by the passage of the fetal legs and buttocks first through the birth canal, and then the head, and difficulties may arise due to the fact that the head is the most voluminous part of the fetal body, and there is also a risk of compression of the umbilical cord between the mother’s pelvic bones and the baby’s head.

Risk factors for breech presentation

This position of the fetus most often occurs during repeated pregnancy, when the muscles of the uterus and the front of the abdomen are most stretched and poorly fix the position of the child. However, this can also happen during the first pregnancy, in the case of a low position of the uterus in the small pelvis or in case of low placenta previa (baby place) in the uterine cavity, in which it is located in its lower part; at large quantities amniotic fluid, in which the baby is more mobile and can often change its position; with a narrow pelvis, when closely spaced bones interfere with the correct positioning of the child’s head. Risk factors also include the abnormal structure of the mother’s uterus and tumor processes located in its lower part, which do not leave enough space for the head to enter the pelvis, and fetal malformations. According to the latest data, it has been possible to prove that heredity is a predisposing factor for breech presentation. It has been found that a mother who is born with this presentation has a 95% chance of having babies in the breech position. In first place among the causes of breech presentation is premature pregnancy (birth of a child starting from the 28th week of pregnancy). In this case, with premature birth, a large ratio arises between the size of the child and the uterine cavity, in which he can move freely. The shorter the gestational age at which the birth process occurs, the greater the risk of breech presentation.

With breech presentation, there are several characteristic positions for it: gluteal, leg and knee. A breech presentation can be true, in which the child is positioned with his buttocks towards the entrance to the small pelvis, and his legs, bent at the hip joints, are parallel to the body, and mixed, in which, in addition to the child’s buttocks, the legs bent at the knee joints are also directed towards the birth canal. The leg position can be complete, in which both legs are presented, slightly extended at both the hip and knee joints, and incomplete, when only one leg is presented, while the other remains in a bent position and is located much higher. The kneeling position is characterized by the fact that the child is positioned forward with his legs bent at the knee joints. In most cases, the fetus is breech. Breech presentation occurs in approximately 5% of pregnancies.

If after the second ultrasound examination a pregnant woman is diagnosed with a breech fetus, this does not mean that by the time of birth the baby will not be in the correct position. A set of exercises can help turn the fetus with its head end toward the birth canal. A woman should alternately lie on a hard surface on her left and then on her right side for 10-15 minutes several times a day. Also, the knee-elbow position and the lying position with a raised pelvis have a great effect. To do this, you need to place a cushion or pillow under the buttock area and raise your legs 20-30 cm above your head. All exercises are performed on an empty stomach for several weeks so that their effectiveness can be assessed before the final ultrasound examination. Also, after the first week from the start of exercises, the doctor can evaluate them by palpating the location of the fetal head. Pregnant women are recommended to sleep on the side where the baby's head is located. With the correct and constant implementation of all the above exercises, the pelvic part of the fetus moves away from the mother’s pelvic bones, motor activity increases, which contributes to the spontaneous turning of the child. According to reliable research data, exercises, as well as swimming, allow the child to take the correct position before childbirth in 75-96% of cases, and the mother to avoid surgical intervention. However, it should be remembered that you cannot self-medicate; in this case, you must urgently consult with the doctor monitoring this pregnancy, since there are a number of categorical contraindications to performing gymnastic exercises. These include postoperative scars on the uterus, tumor processes in it, severe systemic diseases (not combined with the reproductive system), placenta previa (in the case when it is located in the lower part of the uterus), gestosis during pregnancy (the occurrence of edema, increased blood pressure , visual impairment).

To obtain a positive result, you can use non-traditional methods of treating breech presentation in combination with physical exercises. Before combining these methods, you must consult a specialist. In most cases, acupuncture is recommended - influencing the activity of the child and the uterus by stimulating certain areas with the shallow introduction of special needles and aromatic agents. The mother's psychological influence can also contribute to the child's turning over. A pregnant woman needs to imagine a correctly positioned baby, you can persuade or ask him to turn over, look at drawings and photographs of the child in the womb. The effects of music and light are often used. Many scientists argue that the child, while in the uterine cavity, moves towards a sound or light source. According to this theory, you can place a flashlight or small lamp closer to the lower abdomen or put headphones on this area with calm music. When a positive result is achieved using these methods, it is necessary to fix the correct position of the fetus. This can be done with the help of a special prenatal bandage and exercises aimed at increasing the elasticity of the ligaments and muscles of the pelvis, as well as the correct entry of the fetal head into the pelvic area. The most effective position is sitting with your legs apart, bent at the knee joints and the soles of your feet pressed together. In this case, you need to try to bring your knees as close as possible to the floor and fix this position for 10-15 minutes several times a day. The prenatal bandage provides support for the abdomen, thereby relieving the load on the spine, which prevents or significantly reduces pain in the lumbar region, and also reduces the risk of stretch marks. Currently, the most common bandages are in the form of an elastic band that is worn over underwear. Such a bandage can be worn in any position of the body; it does not put pressure on the uterus, due to the possible change in its diameter (with an increase in the volume of the abdomen) using special “Velcro” on the sides. It is recommended to remove the bandage every 3 hours for 30 minutes. It is also possible to use bandage underwear in the form of panties with a wide support belt. The disadvantage of this type of bandage is that to maintain body hygiene, it requires frequent washing, which makes it difficult to wear it constantly.

If it is not possible to independently correct the position of the fetus, at 36-38 weeks the doctor may perform external rotation of the fetus. This procedure is performed in a hospital setting under ultrasound monitoring and constant listening to the fetal heartbeat. The purpose of this manipulation is for the doctor to gradually move the baby's head down to the birth canal. Absolute contraindications to this measure are: postoperative scars on the uterus, excess body weight (weight increase by more than 60% of the initial condition), threatened miscarriage (increased excitability, increased tone of the uterine muscles), age of the pregnant woman (over 30 years old with first pregnancy), a history of miscarriages or infertility, gestosis in the second half of pregnancy, location of the placenta in the lower part of the uterus, abnormal structure and development of the uterus, large or too small amount of amniotic fluid, entanglement of the child with the umbilical cord, close proximity of the pelvic bones, heavy internal diseases of a woman, pregnancy caused by artificial insemination. Currently, the procedure for external fetal rotation is used in isolated cases due to a large list of contraindications and possible serious complications. After this procedure, it is necessary to constantly monitor the condition of the pregnant woman and the fetus.

In cases where the measures taken are not enough, the question arises about the method of delivery. Basically, a caesarean section is performed, but in case of a pregnancy that proceeded safely and occurred naturally, if the child weighs no more than 3500 g, there are no malformations of the female genital organs and the woman has sufficient width of the pelvis, a natural birth is carried out with a breech presentation of the fetus (in the breech position). position). Such childbirth will take place in three stages. The buttocks are born first, then the torso, and lastly the head, which is the most voluminous part of the fetus. By combining data from X-ray examinations and a control prenatal ultrasound examination, an obstetrician-gynecologist can determine the method of delivery for a breech fetus. The passage of the child through the mother's birth canal in the pelvic position can be favorable, but more careful monitoring is required here, which requires the presence of a pediatric resuscitator, since birth injuries, suffocation and stillbirth of the fetus are possible. Such births are in a borderline state between normal and pathological. The frequency of natural births with a breech presentation is approximately 5%. In the initial stage of labor, the woman in labor must observe strict bed rest. It is advisable to be in a supine position, on the side of the body where the back of the fetus is located. This is done to prevent early discharge of amniotic fluid and loss of fetal parts. A pregnant woman is under the supervision of obstetricians and is being prepared for childbirth. She is given labor stimulants (oxytocin) and anesthetized. All stages of labor take place under monitoring (with constant monitoring of the fetal heartbeat). The final stage of labor remains similar to that of a normal cephalic birth. However, to prevent postpartum hemorrhage, drugs that enhance muscle contractions of the uterus (methylergometrine, oxytocin) are administered intravenously.

Presentation during multiple pregnancy (twins)

Depending on the number of fertilized eggs (female gametes) and fertilizing sperm (male gametes), both fraternal and identical twins can be located in the uterus. Fraternal (developed from two or more eggs) twins occupy separate amniotic sacs (a limited cavity in the uterus that contains the baby, surrounded by amniotic fluid) and have separate placentas. Identical (developed when several sperm enter one egg) twins can also occupy separate amniotic sacs (only in rare cases is there one for two), but they are connected by one common placenta.

The presence of two or more fetuses in the uterus leads to its significant stretching, and therefore the presentation of twins in most cases is incorrect. This is also influenced by the fact that each child must adapt not only to the passage into the pelvis, but also to the position of the other child.

During a multiple pregnancy, the woman is placed in advance in the maternity hospital, where a control ultrasound examination is performed to assess the condition of the placenta.

Twins can be positioned longitudinally. In this case, both of them can be located either in a cephalic presentation, which is the most optimal for childbirth, or it is possible that one of the children will be in a cephalic presentation and the other in a pelvic presentation. When positioned longitudinally, twins can obscure each other. It is also possible for the fetuses to have different positions in the uterus: one of them occupies a vertical and the other a horizontal position in relation to the birth canal. In rare cases, the transverse position of both twins, as well as their pelvic presentation, is noted. The baby's position may change during labor. In case of cephalic presentation of both twins, after the birth of the first child, the second child may change its position to transverse or oblique due to the increase in space in the uterine cavity. In this case, external or internal rotation of the fetus is performed to correct the position of the child. The rarest occurrence during the birth of twins is their collision (coupling), which occurs when one child is positioned in the pelvic position and the other in the cephalic position. In most cases, the birth of twins occurs through surgery (cesarean section or the use of obstetric forceps to extract the second fetus).

Transverse presentation of the fetus

The child is positioned across the entrance to the pelvis, covering it with his back. During childbirth, the shoulder is shown first. In this case, it is necessary to perform a caesarean section.

Transverse presentation is defined when the baby is positioned horizontally in relation to the woman's birth canal. There are several fetal positions. The first position is in which the child's head is turned to the left, the second - in which the head is turned to the right. If the child's back is turned forward, this is an anterior view, and if it is backward, this is a posterior view.

Most often, transverse presentation of the fetus occurs when a woman’s pelvis is too narrow, with polyhydramnios (increased amount of amniotic fluid), premature rupture of amniotic fluid, excessive fetal activity, with repeated pregnancy (the muscles of the uterus are not able to support the vertical position of the fetus), with a too large head fetus Transverse presentation of the fetus includes its oblique (shoulder) position. At ultrasound examination It is revealed that the head and pelvic part of the fetus are located in the lateral parts of the uterus, due to which it takes an elongated position in the transverse direction, the fundus of the uterus is below the required level. Upon examination, the baby's heartbeat can be heard only in the navel area. When labor begins, the position of the fetus can be determined by vaginal examination after the discharge of amniotic fluid. In the shoulder position, you can palpate the shoulder, collarbone and rib area (in the posterior view), as well as the scapula and spine (in the anterior view). When in a transverse position, the handle can be felt to fall out.

If one of these positions is detected, it is necessary to perform a cesarean section, since spontaneous childbirth is impossible and complications such as prolapse of the umbilical cord or small parts of the body (upper limbs) often occur. In case of early detection of this type of presentation, the obstetrician-gynecologist can perform external or internal rotation of the fetus. External fetal rotation is performed in a hospital setting. If the shoulder position is maintained, the course of natural childbirth will in most cases be complicated by the loss of small parts of the fetus or part of the umbilical cord. However, despite possible complications, delivery can occur without surgery. Most often, self-inversion occurs or the child appears with his body folded in half.

With spontaneous inversion, a child can be born in several ways. If the fetal head is located above the pelvis, then the shoulder will be born first, followed by the torso and lower limbs, and lastly the head. If the head is in the pelvic area, most often its passage will be hampered by the shoulders; in this case, the torso and lower limbs will appear first, and then the shoulders and head. When folded, the shoulder appears first, then the torso appears with the head pressed into the stomach, and then the buttocks and legs. If the fetus is in a shoulder or transverse position, spontaneous delivery can only be expected in multiparous women or with a low weight of the child. The location of the umbilical cord and small parts of the fetus (upper and lower extremities) below the larger presenting part of the child after the rupture of amniotic fluid is called their prolapse. If the integrity of the fetal bladder is preserved, but small parts are located in the lower part of the uterus near the birth canal, their presentation is established. Only a manual vaginal examination can determine the presenting part of the fetus in more detail. The prolapse of the umbilical cord can be judged by characteristic changes in the condition of the fetus and disturbances in the rhythm of its heart contractions when it is strangulated. If it is impossible to put part of the umbilical cord back and there is no necessary conditions For immediate natural childbirth, surgical intervention is performed. If part of the umbilical cord falls out during the breech presentation of the child and if there are no complications, a natural birth is performed. If one of the upper limbs falls out, the transition of the fetal head to the lower pelvic region, to the birth canal, is impossible. With this position of the child, it is necessary to move the handle behind the child's head into the uterine cavity. If for some reason this is not possible, a caesarean section is performed.

When the lower extremities of the fetus prolapse, the child’s body bends while the prolapsed leg is extended. Most often, this position of the fetus is observed in multiple pregnancies (twins) and in premature pregnancies. Also in this case, the prolapsed part of the fetus is reduced, and if the result is negative, a cesarean section is performed.

Occipital presentation of the fetus

This is the most common type of presentation - about 95%. The crown is located at the entrance to the small pelvis. During childbirth, the head will enter the birth canal with the chin pressed to the chest.

Occipital presentation of the fetus: 95% of cases

Facial presentation of the fetus

In this case, the head is completely thrown back. Childbirth often occurs with complications, sometimes resorting to caesarean section.

Frontal presentation of the fetus

In this case, a caesarean section is mandatory, since the head is facing the birth canal large size, and vaginal delivery is impossible.

With this type of presentation, the baby is located horizontally in the uterus. This position prevents him from going down, so a caesarean section is the only option unless the doctor tries to change the baby's position before delivery.

The baby lies across the uterus; head - below, buttocks - above. The position is called “shoulder” or transverse. Sometimes the doctor is able to change the baby's position by applying external pressure to the abdominal cavity. But this technique is not always successful and in some cases is contraindicated.

- longitudinal position of the fetus in the uterus with the legs or buttocks facing the entrance to the pelvis. Pregnancy with a breech presentation of the fetus often occurs under conditions of threat of miscarriage, gestosis, fetoplacental insufficiency, fetal hypoxia, and birth injuries. Diagnosis of breech presentation of the fetus is made using external and vaginal examination, echography, Dopplerography, CTG. Treatment of breech presentation includes complexes of corrective gymnastics, preventive external rotation of the fetus, and early selection of the method of delivery.

General information

Breech presentation of the fetus in obstetrics and gynecology occurs in 3-5% of all pregnancies. Management of pregnancy and childbirth with a breech presentation of the fetus requires qualified and highly professional assistance to the woman and child. With a breech presentation of the fetus during childbirth, the baby’s buttocks or legs are the first to pass through the birth canal. At the same time, the cervix is ​​still in an insufficiently smoothed and open state, so the advancement of the head, as the largest and densest part of the fetus, turns out to be difficult. With breech presentation, childbirth can proceed uncomplicated, but there is an increased risk of asphyxia, fetal stillbirth, and birth injuries to the child and mother.

Classification of breech presentations of the fetus

Variants of breech presentation of the fetus include leg and breech presentation. Foot presentations account for 11-13% of cases of all pelvic presentations of the fetus. Leg presentation can be complete (both legs), incomplete (one leg) or knee (fetal knees). Breech births are the most common. In 63-75% of cases, an incomplete (purely breech) presentation is diagnosed, in which only the buttocks are adjacent to the entrance to the pelvis, and the fetal legs are extended along the body. In mixed breech presentation (20-24%), not only the buttocks, but also the legs of the fetus, bent at the knee or hip joints, are facing the entrance to the pelvis.

At various options breech presentation of the fetus, the development of the biomechanism of childbirth has its own characteristics. With a purely breech presentation, a small fetus and normal size of the mother's pelvis, uncomplicated independent childbirth is possible. With foot and mixed presentation, childbirth through the birth canal is associated with significant risks for the newborn - asphyxia, prolapse of the umbilical cord and individual parts of the fetus.

Causes of breech presentation of the fetus

The factors that determine breech presentation of the fetus are numerous and not fully studied. The presence of uterine fibroids, ovarian tumors, anatomical narrowing or irregular shape of the pelvis, anomalies in the structure of the uterus (intrauterine septum, hypoplasia, bicornuate or saddle uterus) can prevent the head from positioning itself at the entrance to the pelvis.

Breech presentation can be observed with increased fetal mobility caused by polyhydramnios, malnutrition or prematurity, hypoxia, microcephaly, anencephaly, hydrocephalus and other factors associated with the pathology of the child. On the other hand, limited mobility of the fetus in the uterine cavity with oligohydramnios, a short umbilical cord or its entanglement also contributes to the formation of malpresentation.

The mother's obstetric and gynecological history, aggravated by repeated uterine curettage, endometritis, cervicitis, multiple pregnancies, abortions, complicated childbirth, can lead to breech presentation of the fetus. These conditions often lead to the development of pathological hypertonicity of the lower segments of the uterus, in which the head tends to take a position in the upper, less spasmodic parts of the uterine cavity. Changes in myometrial tone can also be caused by a scar on the uterus, neurocirculatory dystonia, neurosis, overwork of the pregnant woman, stress, etc. Breech presentation of the fetus is often combined with low location or placenta previa.

In numerous observations carried out by obstetrics and gynecology, it is noted that breech presentation of the fetus develops in those women who themselves were born in a similar situation, therefore the issue of hereditary conditioning of leg and breech presentations is being considered.

Features of pregnancy

With a breech presentation of the fetus, the course of pregnancy, much more often than with a cephalic presentation, is associated with a threat or spontaneous abortion, the development of gestosis and fetoplacental insufficiency. These conditions, in turn, negatively affect the maturation of the nervous, endocrine and other systems of the fetus. With breech presentation in the fetus from 33-36 weeks of gestation, the processes of maturation of the structures of the medulla oblongata slow down, which is accompanied by pericellular and perivascular edema. In this case, the neurosecretory cells of the fetal pituitary gland begin to work with increased activity, leading to premature depletion of the function of the adrenal cortex and a decrease in the protective and adaptive reactions of the fetus.

Changes in the fetal gonads are represented by hemodynamic disorders (venous stasis, pinpoint hemorrhages, tissue edema), which may later manifest as gonadal pathology - hypogonadism, ovarian wasting syndrome, oligo- or azoospermia, etc. With breech presentation, the incidence of congenital malformations increases heart, central nervous system, gastrointestinal tract, musculoskeletal system in the fetus. Disturbances of the uteroplacental blood flow are manifested by hypoxia, high heart rate, and decreased motor activity of the fetus. During childbirth with a breech presentation, the fetus often develops discoordinated or weak labor. The most severe changes are observed in cases of mixed breech or leg presentation.

Diagnosis of breech presentation of the fetus

A stable breech presentation of the fetus should be discussed after the 34-35th week of gestation. Before this period, the location of the presenting part may be changeable. Breech presentation of the fetus is determined by external obstetric and vaginal examinations.

Breech presentation of the fetus is characterized by a higher position of the uterine fundus, which does not correspond to the gestational age. External examination techniques make it possible to identify in the area of ​​the womb a soft, irregularly shaped, inactive part of the fetus that is not capable of procreation. In the area of ​​the uterine fundus, on the contrary, it is possible to palpate a large, round, hard and movable part - the fetal head. The heartbeat can be heard above or at the level of the navel.

Management of pregnancy and childbirth

In patients belonging to high-risk groups for the formation of breech presentation, measures are taken during pregnancy to prevent fetoplacental insufficiency, disorders of uterine contractility, and fetal complications. A pregnant woman is recommended to follow a gentle regimen with a full night's sleep and daytime rest, and a balanced diet to prevent fetal hypertrophy.

Psychoprophylactic work is carried out with pregnant women, aimed at teaching techniques for muscle relaxation and relieving nervous excitability. From the 35th week of gestation, corrective gymnastics is prescribed according to Dikan, Grishchenko and Shuleshova, Kayo, which helps to change the tone of the myometrium and abdominal wall muscles, transferring the fetus from breech presentation to cephalic presentation. In some cases, antispasmodic drugs are prescribed in intermittent courses.

Carrying out external preventive rotation of the fetus on the head according to Arkhangelsky in some cases turns out to be ineffective and even dangerous. The risks of such an obstetric appointment may include the onset of premature placental abruption, rupture of membranes, premature birth, uterine rupture, trauma and acute fetal hypoxia. In recent years, these circumstances have limited the use of external obstetric aids in the practice of treating breech fetuses.

A pregnant woman with a breech presentation of the fetus at the 38-39th week of gestation is hospitalized in an obstetric hospital to plan delivery tactics. In an uncomplicated obstetric situation (satisfactory condition of the fetus and the woman in labor, proportionality of the pelvis and fetus, biological readiness of the maternal body, purely breech presentation, etc.), childbirth through the natural birth canal is possible. This includes prevention of premature opening of the amniotic sac, constant CTG monitoring of the fetus and uterine contractions, and drug prevention of labor anomalies.

Children born in breech presentation often have intracranial injuries, encephalopathy, spinal injuries, hip dysplasia. If fetal asphyxia or aspiration of amniotic fluid is detected, appropriate resuscitation measures are required. Newborns in the early neonatal period are subject to careful examination by a neurologist. Birth injuries typical for breech presentation of the fetus in women include ruptures of the perineum, cervix, vagina and vulva, and damage to the pelvic bones.

The preventive direction involves a thorough examination and correction of disorders in women planning pregnancy; identifying pregnant women at risk for the development of breech presentation of the fetus and conducting timely and adequate preparation for childbirth; early choice of labor tactics and their management under continuous monitoring

If the baby is in a head-down, occiput-to-stomach position (anterior view of the fetal position, cephalic occipital presentation), labor is likely to be faster and easier. By the end of pregnancy, most babies take exactly this position.

In the anterior position, the fetus curls up “comfortably” with its head towards the pelvis. During birth, the baby rounds his back, pointing and pressing his chin to his chest. Childbirth will be easy because:

• The top of the baby's head puts even pressure on the cervix during contractions. This helps it expand and the body to produce the hormones necessary for childbirth.
• During pushing, the baby moves at such an angle that the smallest area of ​​the head appears first. (Try wearing a tight turtleneck without retracting your chin and you will understand the mechanism).
• When the baby hits the lower part of the pelvis, he turns his head slightly so that the widest part of the head is at the widest part of the pelvis. The back of the head slips under the pubic bone. During birth, the baby's face passes through the area between the vagina and the perineum.

What is the posterior view of the fetal position?

The posterior position means that the fetus is also in a cephalic presentation, but the back of its head is directed towards the spine. By the time labor begins, in one case out of 10 the fetus is in this posterior position - back-to-back.

Most deliveries with the fetus in a posterior position are delivered vaginally. But childbirth is more difficult, especially if the baby's chin is pushed up rather than pressed to the chest.

• You may experience back pain as your baby's skull puts pressure on the spine.
• Your water may break early.
• Labor may be difficult and slow, with intermittent contractions.
• You feel the straining even before the cervix is ​​fully dilated.

WITH the right help During childbirth, most babies turn over in the back position and take the front position. When a baby hits the lower part of the pelvis, he has to roll almost 180 degrees (half a circle) to get into the best position.

It may take quite a while for a long time, or the baby may decide that he is not going to roll over at all. The latter means that he will be born facing you. To do this you will need forceps or a vacuum extractor.

Why are some kids in the back position?

The fetus may be in a posterior position due to the type and shape of your pelvis. Most women have a pelvis that is narrow and oval (anthropoid pelvis) or wide and heart-shaped (male female pelvis), rather than a round pelvis.

If your pelvis is oval or heart-shaped rather than round, then your baby will most likely take a posterior position, a position back to back in the widest part of the pelvis.

This happens because in this position it is easier for the fetus to position its head.

If you sit for a long time in a comfortable chair watching TV, or working at a computer, your pelvis is tilted back. This causes the back of the baby’s head and his spine (the heaviest part of the body) to overweight and roll the fetus onto his back. Thus, the fetus takes its posterior position.

If you spend a lot of time upright, the baby will most likely take an anterior position because the pelvis is tilted forward.

How to help your child take a forward position?

Try tilting your pelvis forward rather than backward when you sit. Make sure your knees are always lower than your hips. This is the optimal position for the fetus as it encourages the fetus to move into an anterior position.

Also, try the following steps:

• Check that your favorite chair or place on the sofa does not cause your pelvis to sag or your knees to rise. If this happens, try to take a position on all fours.
• Wash the floor! When you're on all fours, the back of your baby's head points toward the front of your belly.
• If you have a sedentary job, make sure to move more and take regular breaks.
• To raise your pelvis, place a pillow on your car seat.
• Watch TV while sitting on an exercise ball or leaning forward on it. If you sit on it, make sure your hips are higher than your knees.

Don't worry about the correct position of the fetus during sleep. When you are in a horizontal position, there is no vertical pressure on the baby. However, the side position rather than the back position is the best option for sleep in the last stages of pregnancy.

Can you help your baby get into the right position for birth?

The most proven way to help your baby take the correct prenatal position is to take the position on all fours twice a day for 10 minutes.

You should also remain upright or leaning forward longer than you would normally.

However, your correct positioning does not always result in the correct position of the fetus, so the result of its posterior position may be the shape of your pelvis, regardless of your efforts.

How to improve fetal position immediately before birth?

If the fetus is in a posterior position during labor, you can still adopt rotation-stimulating positions and movements to help your baby and relieve pain.

It often happens that already during childbirth, the fetus turns from the posterior position to the anterior position before the attempts themselves.

You may experience some minor pain for a few days before giving birth. It may go away, but will be a sign that the baby is trying to roll over to a forward position.

One of the best positions is on all fours. In this position, the fetus moves away from the spine of your spine, helping to relieve back pain and, even more desirable, rotates.

Get plenty of rest at night.

Vary your daily routine, starting with walking and moving around, ending with a pose on all fours or a kneeling-chest-to-the-floor position - resting your knees on the floor, head, shoulders and chest on a pillow or mattress, and your pelvis in the air.

Lean forward during contractions and try swinging on a fitness ball.

Eat and drink regularly to maintain strength and hydration in your body.

Try to remain calm and positive.

During the birth itself, try to vary your positions and movements, and use the following methods, depending on what is most comfortable for you:

• Take a pose on all fours or kneeling-chest-to-the-floor - resting your knees on the floor, head, shoulders and chest on a pillow or mattress, and your pelvis in the air.
• Lean forward during contractions using a ball, pillow, partner, or bed.
• Ask your partner to massage your back.
• Rock your pelvis during contractions to help your baby roll over. The fitness ball is great for swaying your pelvis.
• Perform a lunge, either standing on one leg, kneeling while lying in bed. The side that is most comfortable for lunging will likely be the side that gives the child more room to turn.
• Lie down in a way that encourages your baby to turn into the correct position.

• Move or walk around occasionally. Don't sit or lie back for long periods of time.
• Try not to rush the epidural as it increases the likelihood that the fetus will remain in a posterior position. With an epidural, you are less likely to give birth on your own.

During the nine months of carrying a baby, a pregnant woman often hears about fetal presentation. Obstetricians and gynecologists talk about it during examinations, specialists ultrasound diagnostics. We will talk about how it happens and what it affects in this material.

What it is?

During pregnancy, the baby repeatedly changes its position in the womb. In the first and second trimester, the baby has enough free space in the uterus to roll over, somersault and take a wide variety of positions. The presentation of the fetus at these stages is stated only as a fact and nothing more; this information has no diagnostic value. But in the third trimester everything changes.

The baby has little room to maneuver, by the 35th week of pregnancy a permanent location in the uterus is established and a revolution becomes very unlikely. In the final third of the gestation period, it is very important what position the baby is in - correct or incorrect. The choice of delivery tactics and the likely risk of complications for both the mother and her baby depend on this.

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When talking about presentation, it is important to understand what exactly we are talking about. Let's try to understand the terminology. Fetal presentation is the relationship of a large part of the fetus to the exit from the uterine cavity into the pelvic area. The baby can be turned towards the exit either with the head or buttocks, or in an oblique position across the uterus.

The position of the fetus is the ratio of the location of the longitudinal axis of the baby’s body to the similar axis of the uterine cavity. The baby can be positioned longitudinally, transversely or obliquely. The longitudinal position is considered the norm. The position of the fetus is the relationship of its back to one of the walls of the uterus - left or right. The type of position is the ratio of the back to the posterior or anterior wall of the uterus. Articulation is the relationship of a baby's arms, legs, and head in relation to its own body.

All these parameters determine the baby’s posture, and it must be taken into account when deciding which way a woman will give birth - natural, natural with stimulation, or by caesarean section. A deviation from the norm in any of the listed parameters can influence this decision, but presentation is usually decisive.

Kinds

Depending on which part of the body is closest (adjacent) to the exit from the uterus to the pelvis (and this is the beginning of the baby’s journey at birth), there are several types of presentation:

Pelvic

In approximately 4-6% of pregnant women, the baby is positioned towards the exit with its butt or legs. A complete breech presentation is a position in the uterus in which the baby is aimed towards the exit with the buttocks. It is also called gluteal. A foot presentation is considered to be one in which the baby’s legs, one or both, “look” toward the exit. A mixed (combined or incomplete) breech presentation is considered to be a position in which both the buttocks and legs are adjacent to the outlet.

There is also a knee presentation, in which the baby's legs bent at the knee joints are adjacent to the exit.

Breech presentation is considered a pathology. It can be very dangerous for both mother and child. The most common is breech presentation; with it, the prognosis is more favorable than with foot presentation, especially with knee presentation.

The reasons why a baby is in a breech position can be different, and not all of them are obvious and understandable to doctors and scientists. It is believed that children whose mothers suffer from pathologies and anomalies in the structure of the uterus, appendages, and ovaries are most often positioned head up and bottom down. Women who have undergone many abortions and surgical curettages of the uterine cavity, women with scars on the uterus, who often give birth a lot are also at risk.

The cause of breech presentation may be a chromosomal disorder in the child himself, as well as abnormalities in the structure of his central nervous system - absence of a brain, microcephaly or hydrocephalus, disruption of the structure and functions of the vestibular apparatus, congenital malformations of the musculoskeletal system. Of the twins, one baby can also take a sitting position, and it is dangerous if this baby lies first towards the exit.

Oligohydramnios and polyhydramnios, a short umbilical cord, entanglement that prevents the baby from turning, low placenta previa - all these are additional risk factors.

Headlines

Head presentation is considered correct, intended as ideal for a child by nature itself. With it, the baby’s head is adjacent to the opening to the woman’s pelvis. Depending on the position and type of position of the child, several types of cephalic presentation are distinguished. If the baby is turned to the exit with the back of his head, then this is an occipital cephalic presentation. The back of the head will be the first to appear. If the baby is positioned towards the exit in profile, this is an anterior parietal or temporal presentation.

In this position, childbirth is usually a little more difficult, because this size is wider and it is a little more difficult for the head to move along the woman’s genital tract in this position.

Frontal presentation is the most dangerous. With it, the baby “pushes” his way with his forehead. If the baby’s face is turned towards the exit, this means that the presentation is called facial, and it is the baby’s facial structures that will be born first. The occipital version of the cephalic presentation is considered safe for the mother and fetus during childbirth. The remaining types are extension variants of cephalic presentation; it is quite difficult to consider them normal. When passing through the birth canal, for example, with facial presentation, there is a possibility of injury to the cervical vertebrae.

Also, cephalic presentation may be low. They talk about it at the “finish line”, when the stomach “sinks”, the baby presses its head against the opening of the small pelvis or partially exits into it too early. Normally, this process occurs during the last month before birth. If the head drops earlier, pregnancy and presentation are also considered pathological.

Up to 95% of all babies are usually in cephalic presentation by 32-33 weeks of pregnancy.

Frontal presentation

Head presentation

Transverse

Both the oblique and transverse position of the baby’s body in the uterus, characterized by the absence of the presenting part as such, are considered pathological. This presentation is rare; only 0.5-0.8% of all pregnancies occur with this complication. The reasons why the baby may be positioned across the uterus or at an acute angle to the opening of the pelvis are also quite difficult to systematize. They do not always lend themselves to a reasonable and logical explanation.

Oblique presentation

Transverse

Most often, the transverse position of the fetus is characteristic of women whose pregnancy occurs against the background of polyhydramnios or oligohydramnios. In the first case, the baby has too much space to move; in the second, his motor capabilities are significantly limited. Often, women who have given birth suffer from overstretched ligaments and muscles of the uterus, which do not have sufficient elasticity to fix the position of the fetus even during long periods of pregnancy; the child continues to change body position.

Often the fetus is positioned transversely in women with uterine fibroids, because the nodes prevent the baby from positioning normally. In women with a clinically narrow pelvis, the baby often cannot fix itself in the correct position.

Polyhydramnios

Diagnostics

Before 30-32 weeks, diagnosing fetal presentation does not make sense. But at this time, an obstetrician-gynecologist can draw conclusions about which part of the body the baby is adjacent to the exit from the uterus during a routine external examination. Usually, if the baby is not positioned correctly in the mother’s womb, the height of the fundus of the uterus exceeds the norm (with a pelvic presentation) or lags behind the norm (with a transverse presentation).

When the baby is positioned transversely, the belly looks asymmetrical, like a rugby ball. You can easily determine this position yourself by simply standing upright in front of a mirror.

If the baby's heartbeat is incorrectly positioned, it can be heard in the area of ​​the mother's navel. On palpation in the lower part of the uterus, a dense round head is not detected. With a breech presentation, it is felt in the area of ​​the fundus of the uterus, with a transverse presentation - in the right or left side.

The doctor also uses a vaginal examination to clarify the information. An indisputable confirmation of the diagnosis is an ultrasound scan (ultrasound). It determines not only the exact position, position, presentation, posture, but also the weight of the fetus, height and other parameters necessary for a more careful choice of the method of delivery.

Possible complications

No one is immune from complications during childbirth and while carrying a child, even if the baby is positioned correctly at first glance. However, breech and transverse presentations are considered the most dangerous.

The main danger of breech presentation of the fetus lies in the likelihood of premature birth. This happens in about 30% of pregnancies, in which the baby is located in the mother's stomach with its head up. Very often, such women experience premature rupture of amniotic fluid; it is rapid in nature; along with the water, parts of the baby’s body often fall out—legs, arms, umbilical cord loops. All these complications can lead to serious injury, which can make the baby disabled from birth.

At the beginning of labor, women with breech presentation often develop weakness of labor forces, contractions do not bring the desired result - the cervix does not open or opens very slowly. During childbirth, there is a risk of throwing back the baby's head or arms, injuries to the cervical spine, brain and spinal cord, placental abruption, and the onset of acute hypoxia, which can lead to the death of the child or total disruption of the functioning of his nervous system.

For a woman in labor, the pelvic position of the fetus is dangerous due to severe ruptures of the perineum, uterus, massive bleeding, and pelvic injuries.

Quite often, breech presentation is combined with umbilical cord entanglement, fetal hypoxia, and placental pathologies. Babies in breech presentation often have lower body weight, they are hypotrophic, have metabolic disorders, suffer from congenital heart defects, pathologies of the gastrointestinal tract, and kidneys. By the 34th week of pregnancy, if the baby does not take the correct position, the rate of development of some structures of the child’s brain slows down and is disrupted.

If the baby is positioned in a cephalic presentation with the back of the head facing the exit longitudinally, no complications should arise either during pregnancy or during childbirth. Other variants of cephalic presentation can cause difficulties during childbirth, because it will be more difficult for the head to move along the birth canal, its extension will not occur towards the mother’s sacrum, which can lead to hypoxia and weakness of labor forces. In this case, if there are concerns for the child’s life, doctors use forceps. In itself, it raises many questions, because the number of birth injuries received by children after the application of obstetric forceps is very large.

Umbilical cord entanglement

Forceps delivery

The most unfavorable prognosis is for frontal presentation. It increases the likelihood of uterine and cervical ruptures, the appearance of fistulas, and the death of the baby. Almost all types of cephalic presentation can be allowed for natural birth, except frontal. Low cephalic presentation is fraught with premature birth, and this is its main danger.

This birth will not necessarily be complicated or difficult, but the baby’s nervous system may not have time to mature to independent life outside the mother’s belly, just as sometimes his lungs do not have time to mature.

The danger of transverse presentation is that natural childbirth can hardly be achieved without severe abnormalities. If you can somehow try to correct the oblique position of the baby already during the birth process, if it is still closer to the head position, then the complete transverse position is practically not subject to correction.

The consequences of such childbirth can be severe injury to the baby’s musculoskeletal system, his limbs, hip area, spine, as well as the brain and spinal cord. These injuries are rarely of the nature of a dislocation or fracture; usually these are more serious lesions that essentially make the child disabled.

Often children in transverse presentation experience chronic hypoxia during pregnancy; prolonged oxygen starvation leads to irreversible changes in the nervous system and the development of sensory organs - vision, hearing.

Which way to give birth?

This issue is usually resolved at 35-36 weeks of pregnancy. It is by this time, according to doctors, that any unstable position of the fetus in the mother’s womb becomes stable and permanent. Of course, there are isolated cases when an already large fetus literally a few hours before birth changes the incorrect position of the body to the correct one, but counting on such an outcome is at least naive. Although it is recommended that both the pregnant woman and her doctors believe in the best.

The choice of delivery tactics is influenced by many factors. The doctor takes into account the size of the expectant mother’s pelvis - if the fetal head, according to ultrasound, is larger than the size of the pelvis, then with a high degree of probability the woman will be offered a planned caesarean section for any fetal presentation. If the fetus is large, then this is the reason for prescribing a planned cesarean section for breech and transverse presentation, and sometimes for cephalic presentation, it all depends on what weight ultrasound specialists “predict” for the baby.

An immature cervix may also be a reason for prescribing a cesarean section, regardless of presentation. In addition, doctors try not to take risks and perform surgery on women who become pregnant as a result of IVF - their birth can present a lot of unpleasant surprises.

With a breech presentation, natural childbirth is possible if the fetus is not large, the birth canal is wide enough, and the size of the pelvis allows the baby’s bottom and then his head to pass through unhindered. Natural childbirth allowed to women with complete breech presentation, and also sometimes with mixed presentation. If the child is low weight, has signs of hypoxia, or is entangled, they will not be allowed to give birth.

In case of foot presentation or its knee version, the optimal method of delivery is considered to be a cesarean section. It will help avoid birth injuries in the child and bleeding in the mother.

With frontal cephalic presentation, doctors also try to prescribe a cesarean section so as not to risk the life and health of the baby. If one of the two babies is in the wrong position during a multiple pregnancy, a caesarean section is also recommended, especially if the baby who will be born first is sitting or lying across the uterus. For transverse and oblique presentations, they most often try to prescribe a planned caesarean section. Natural childbirth is very dangerous.

A planned caesarean section is usually performed at 38-39 weeks of pregnancy, without waiting for the onset of spontaneous labor. Central importance in choosing a method is assigned to individual characteristics female body, on the anatomical features of her baby. There is no universal risk assessment system. There can be so many nuances that only an experienced doctor can take them into account.