Breech

Breech - the position of the fetus in the uterus, in which predlezhit, that is located above the entrance to the small mother's pelvis, pelvic end of the fruit... There are 3-5% of pregnant women. To distinguish breech (flexion type) and leg (extensor type) previa. When pure breech (incomplete) previa to the entrance to the small pelvis mother turned fetal buttocks, his legs bent at the hip joints, knee joints in unfolded and stretched along the body. When mixed breech (full) previa over the entrance to the small mother's pelvis and buttocks are the fruit of the foot, legs bent at the hip and knee joints. At full footswitch previa predlezhat both feet, with incomplete - one stop. Often there is a purely breech presentation, at least - mixed breech and foot.

One of the main causes of breech believe decrease uterine tone and excitability, especially in its lower segment, which leads to its extension. Contribute breech malformations and tumors of the uterus, narrow pelvis, small and polyhydramnios, placenta previa , congenital fetal abnormalities, short umbilical cord.

The diagnosis must be installed no later than at 29 - 30 weeks of pregnancy. It is based mainly on data from ultrasound, which allows to determine not only the presentation, but also the size of the fetus to identify the anomalies of its development, to establish the localization of the placenta, and others. In the case of breech presentation at external research over the entrance to the pelvis is palpated large, irregular round shape , soft consistency, neballotiruyuschaya presenting part of the fetus, which is without clear boundaries becomes fetal trunk (neck and head groove of the fetus is not defined). In the uterine fundus is palpable hard, round, running for part of the fetus - head. Characteristically high standing uterus (at the xiphoid process of the sternum). fetal heart auscultated usually at the level of the navel or above. When vaginal study overtures voluminous soft part of the fruit, with adequate disclosure of the cervix - the ischial tuberosity, anus and pelvis of the fetus. The position of the sacrum clarify the position (the ratio of the fetus back to the right or left side of the uterus) and the kind of fetal position (the ratio of the fetus back to the front or rear wall of the uterus.). When mixed breech during vaginal examination next to the buttocks of the fetus is determined by its feet, with footswitch - just the foot.

Pregnancy. Pregnancy breech occurs in the same way as in the head. In order to transfer breech to head used prophylactic External cephalic version, which is performed only in a hospital, at 35-36 weeks of pregnancy. During surgery, the possible complications: fetal hypoxia , premature detachment of the placenta and others. In some cases, after the turn of the fruit once again takes its original position. It is now used very rarely.

When breech fetus should be hospitalized pregnant gestation 38 - 39 weeks for evaluation and selection of rational tactics of childbirth.

The mechanism for delivery and maintenance. With breech presentation in late pregnancy and early childbirth fetal buttocks usually come in a small basin, so that their transverse dimension (intertrochanteric line) coincides with one of the oblique entrance sizes in a small basin. Promotion of the fetus through the birth canal usually begins after rupture of membranes. There are six aspects of labor mechanism. The first point - internal fetal buttocks turn - starts during the transition of the buttocks of the widest part of the pelvic cavity through a narrow mothers; in the plane of the pelvic outlet buttocks fetal transverse dimension is incorporated into the rate of pelvic, buttock, facing front, fit the pubic arch, facing backward is installed above the coccyx. The second point - a lateral flexion of the lumbar spine of the fetus. This buttock, facing backwards, is shown on the perineum, and followed her out of the pubic symphysis finally born breech facing anteriorly. The third point - the internal rotation of shoulders and torso external version of the fetus - completed the establishment of a coat hanger in the forward rate of the pelvic outlet. At the same time the front shoulder of the fetus fits the pubic arch and the rear mounted above the crotch. The fourth point - a lateral flexion of the cervical-thoracic spine of the fetus, resulting in the shoulder girdle and born fruit handle. The fifth point - internal rotation of fetal head; fetal head enters swept seam connecting the right and left parietal bone, oblique input size in the pelvis (the opposite to that in which were the shoulders); the transition from the wide to the narrow part of the pelvic cavity, it performs an internal rotation, causing the arrow-head seam is in direct output size pelvic and suboccipital fossa - under the pubic symphysis. Sixth point - flexion of the fetal head and its eruption (birth); usually erupt small head size of an oblique, less direct in size (from glabella to the external occipital protuberance).

delivery mechanism with footswitch fetus praevia differs from that described in that the buttocks are not displayed the first of the genital slit, and one or both of his legs.

Complications of labor with breech presentation are more common than at birth in cephalic presentation. Possible delayed rupture of membranes, loss of small parts of the fetus and umbilical cord loops (5 times more frequently than in cephalic presentation), fetal hypoxia , prolonged duration of labor, infection of the uterus and the fetus. In the period of the expulsion of the fetus can occur drawing back of the fetus handles infringement head and fetal hypoxia due to spasmodic contraction of the uterine mouth or turn back posteriorly fruit, perineal tears, uterine body and cervix. When footswitch previa more often than pure breech observed loss of small parts of the fetus and umbilical cord loops, fetal hypoxia .

Labor management tactics depends on the age of the pregnant woman, obstetric history, size of the pelvis, the woman's body ready for childbirth, a condition of membranes, the functional state of the fetus and the size, type of breech, fetal head position (bent, straighten, the degree of extension), and others.

In good condition, the pregnant woman and the fetus, according to the size of the pelvis and the fetus, fetal head bent births are vaginal. Lead generations should obstetrician. In the I stage of labor to prevent early opening membranes woman in labor must comply with bed rest (should lie on that side, the side which faces back of the fetus). When you establish a regular labor, and the opening of the cervix at 3 - 4 cm shows the introduction of anesthetics (promedola) and antispasmodic (shpy etc.) Funds. Immediately after the rupture of membranes is performed vaginal examination to confirm the diagnosis and exclusion of loss of small parts of the fetus and umbilical cord loops. Childbirth should be carried out with monitor observation of the heartbeat of the fetus and uterine activity. For the prevention of fetal hypoxia shown maternity oxygen inhalation, intravenous administration of glucose, ascorbic acid, Sygethin. An important task is the timely diagnosis of anomalies of labor and their treatment. When anomalies of labor activity more frequently than in cephalic presentation fetus, should raise the question of cesarean delivery.

In the II stage of labor prophylactic maternity shown intravenous drip of oxytocin. By the end of the II stage of labor to prevent cervical spasm injected Nospanum. When eruption buttocks spend perineo- or episiotomy, and then in good condition of the fetus begin to provide benefits Tsovyanovu manual. For purely breech it consists in holding the legs of the fetus in the normal position (in the hip flexion and extension of knee joints in) by both hands grasping the fetus so that the thumbs positioned on the hips of the fetus, and the rest on the sacrum. Gradually, as the body of the fetus birth the doctor moves his hands towards the genital slit. With eruption of the shoulder belt of the fetus handles tend to fall themselves. If this does not happen, they are released: without changing hand position, set the shoulder of the fetus belt in the forward rate of the pelvis and reject the body of the fetus posteriorly, with the handle facing front, gets out of the pubic arch, and then the body of the fetus is raised anteriorly, contributing birth handle facing the rear. Simultaneously with the fetal foot drop, then the depth of slit appear sexual chin and mouth of the fetus. If attempts are strong, head of the fetus can be born on their own, while the body should be directed upwards.

In case of delay the birth of her head free special manual techniques. The most common use reception Mauriceau -Levre -Lashapell: in the female genital tract injected arm, fetal body is placed on the forearm, in the mouth the fruit is introduced nail phalanx of the index finger (to prevent extension of the head); index and middle fingers of the other (outer) hand grip shoulder girdle fruit and produce traction in the same direction as the wire axis of the pelvis; when the fetus suboccipital fossa approach under the lower edge of the pubic symphysis, make heads turn around a fixation point in front, while from the genital slit showing chin, forehead and back of the neck of the fetus. Assistant doctor when removing the head exerts a light pressure from the top through the abdominal wall of the pregnant woman.

When footswitch previa manual allowance Tsovyanovu boils down to in order to prevent the birth of the fetus legs to full disclosure of uterine throat. To do this, cover the gap mothers sexually sterile diaper, the palmar surface of the right hand, attached to the genital slit, prevent premature birth legs. After a full disclosure of uterine throat (as evidenced by the strong bulging of the perineum, gaping anus, frequent and severe attempts, state border of the ring 6 - 7.5 cm above the upper edge of the pubic symphysis) opposition does not have the legs and feet are born after the buttocks and torso the fetus does not meet difficulties due to the good preparedness of the birth canal. After the birth of the body to the lower corners of the blades fruit carefully maintained by the hips, so that it does not hang down.

In case of delayed expulsion of the fetus classic manual manual used. The first stage includes its techniques used after the birth of the fetus to the navel and promoting the birth of the fetus to the lower angle of the blades: fruit grab with both hands in the hips, torso translate directly pelvic outlet size and reduced to the appearance of the genital slit in the lower angle of the blades. The second step is to release the handles of the fetus. Each pen free hand of the same name (right handle - right hand, left - left). First release the handle facing backwards. Both legs of the fetus and the capture of the tibia is removed up to the side opposite the back of the fetus. In the vagina (on the back of the fetus) introduced two fingers of the other hand and sliding on the back, then on the back of the fetus, reach the elbow. Then output the fetal handle so that it slid across the face and breast of the fetus ( "umyvatelnoe" movement), with the first showing of the vagina elbow, forearm and then. The body of the fetus is rotated by 180 ° so that the remaining handle facing backwards, after which it was withdrawn in such manner as the first. There are other ways to release the handles, eg reception Muller: fetal body is pulled down until from under the pubic arch anterior shoulder, and then the corresponding knob; then pick up the body of the fetus as long as the cuts in the rear shoulder and the handle is born. The third stage - the liberation of the fetal head (often by receiving Maurice Levre -Lashapell).

In the III stage of labor uterine bleeding prophylaxis is carried out by intravenous drip metilergometrina or oxytocin. Postpartum usually proceeds normally. However, more often than at birth in cephalic presentation, there are infectious puerperal disease .

Often breech there is a need of labor induction at the whole sac or preterm rupture of membranes.

The indications for caesarean section routinely breech are burdened obstetric history, age nulliparous older than 30 years, anatomically narrow pelvis, large fruit straightened head of the fetus, post-term pregnancy , previa cord loop, placenta previa , postoperative scar on the uterus, vices development and tumors of the uterus, chronic fetal hypoxia , extragenital diseases pregnant (eg, circulatory disorders, severe pathology of the organ of vision), and others.

Emergency cesarean section is indicated for preterm rupture of membranes in the absence of readiness pregnant for childbirth (especially when combined with other disorders), as well as anomalies of labor activity is not curable, prolapse of the umbilical cord loops, acute fetal hypoxia and other complications, if there are no conditions for fast delivery vaginally.

The extraction (extraction) of the fetus for pelvic end is carried out at the end of the need for urgent delivery (eg, heart disorder mothers, fetal hypoxia) in the absence of conditions for caesarean section, as well as stillbirth. Performed under general anesthesia in the operating room. The conditions for the operation are complete opening of the uterine mouth, match the size of the pelvis mother and fetus head, opening membranes. During surgery artificially reproduce all the stages of childbirth. The fruit is removed by manual methods or special tools for inguinal fold of either one or both legs.

Forecast. Maternal mortality breech fetus is not greater than that at the cephalic presentation. Often observed asphyxia newborn, intracranial hemorrhage, spinal cord injuries, malformations, fractures and abdominal hemorrhage in them, damage to the cervical spine and brachial plexus, fractures and dislocations of the extremities (particularly frequent dislocation of the hip joint). Later in children can occur cerebral paresis, epilepsy , hydrocephalus , mental retardation.

Prevention of complications for mother and fetus include early diagnosis of breech presentation, timely hospitalization pregnant with breech preserved fruit, choice of rational method of delivery, the monitor control in labor, the correct execution of obstetric benefits in childbirth, timely solution to the caesarean section.