External obstetric turn. External obstetric rotation in breech presentation of the fetus

Classical obstetric turn fetus "on the leg" - a type of operation that corrects the incorrect position of the fetus; used in the transverse or oblique position of the fetus.

In modern obstetrics, the operation of the classical rotation of the fetus “on the leg” is practically not performed.
CS is considered the optimal method of delivery in the transverse or oblique position of the fetus. transverse and oblique position first fetus may occur in multiple pregnancies.

INDICATIONS FOR TURNING THE FETUS "TO THE LEGS"

The indication is the transverse or oblique position of the fetus. The operation is possible with transverse position the second fetus from twins, but since the operation of extracting the fetus by the pelvic end is shown around the turn, associated with a number of serious complications, then with twins, indications for delivery by CS surgery are currently being expanded, especially in primiparas.

CONTRAINDICATIONS

Launched transverse position of the fetus.
· Risk of uterine rupture.
· Scar on the uterus.
Mismatch between the size of the mother's pelvis and the size of the fetus.

CONDITIONS FOR THE OPERATION

The whole amniotic sac or its opening just before the operation.
Full opening of the uterine os.

PREPARATION FOR OPERATION

Consultation with an anesthesiologist to choose the method of anesthesia.
· Emptying the bladder.
Treatment of the external genitalia and internal surfaces thighs with a disinfectant solution.
Preparation of the obstetrician's hands.

PAIN RELIEF METHODS

To anesthetize the operation of the classic turn on the “leg”, intravenous anesthesia is usually used, which, if necessary, can be enhanced by inhalation anesthesia.

OPERATIONAL TECHNIQUE

The operation of the classic turn on the "leg" is carried out in three stages. The first stage is the introduction of the hand into the uterine cavity, the second stage is the search and capture of the pedicle of the fetus, the third stage is the rotation of the fetus to the “leg”.

The obstetrician inserts into the uterine cavity the hand that he has the best command of, i.e. more often right, although at the first position of the fetus it is advisable to introduce into the uterus left hand, and in the second position of the fetus - right. The hand remaining outside is used to push the labia apart and externally fix the uterus. The inserted hand breaks the fetal bladder and pushes the fetal head up and to the side until the fetus reaches a transverse or oblique position. When the fetal head is sufficiently retracted, the hand is moved towards the small parts of the fetus, trying to find and grab the fetal leg. In a transverse position, it is advisable to use the “long path” to search for the fetal leg: after inserting the hand into the uterine cavity, the side of the fetus is determined, the hand is held to the armpit and back towards the pelvic end and the fetal legs. It is most convenient to grab the leg, which lies closer to the abdominal wall of the woman in labor. At front view the transverse position capture the underlying fetal leg, and in the rear view they try to capture the overlying fetal leg. There are the following differences between the fetal leg and the handle: on the fetal leg, the fingers are smaller and arranged in a row, thumb the legs of the fetus cannot be taken to the side, on the leg of the fetus there is a calcaneal tubercle and ankle.

After the leg is found, it is fixed, while the fetal leg is grasped with a hand, placing the thumb along the tibia. The leg is brought down into the vagina, while the head of the fetus is taken to the bottom of the uterus with the hand located on the abdominal wall of the woman in labor. Only the combined execution of these movements contributes to the transfer of the fetus from the transverse position to the longitudinal one.

The completion of the turn is considered to be the removal of the knee joint of the fetus from the genital gap with a fixed head of the fetus in the bottom of the uterus.

COMPLICATIONS OF TURNING THE FETUS "ON THE LEGS"

Removal of the fetal handle.
uterine rupture.
· Acute fetal asphyxia.
fetal trauma.

FEATURES OF THE POSTOPERATIVE PERIOD

Immediately after the rotation, the fetus is removed by the leg.

INFORMATION FOR THE PATIENT

The classic rotation of the fetus on the “leg” is an operation that is performed during childbirth with the fetus in the wrong position (oblique, transverse). It is currently rarely used. Modern obstetricians with the wrong position of the fetus perform a caesarean section.

It is known that in some pregnant women the fetus is in breech presentation. There are many opinions about what kind of help such women need. And at the same time, there is a single position supported by all the leading obstetricians in the world and voiced by the World Health Organization. We came to a consensus because it was formulated on the basis of qualitative scientific research and not on opinion individual specialists. In this article, I will try to talk about the help that should be offered to a pregnant woman according to international recommendations.

Why obstetricians do not like breech presentation of the fetus?

Births in breech presentation have a greater risk to the health of the fetus.

What is known about the effectiveness of treatment for breech presentation?

First, you should not worry about how the fetus is located in the uterus until 36-37 weeks. It is probable that he can take cephalic presentation before this deadline. Gymnastics, which is often offered to pregnant women, turned out to be ineffective (the frequency of fetal rotations in those who perform and do not perform special exercises, is the same). As a method of delivery, a caesarean section is usually offered, but independent childbirth is also possible (this can only be said after an ultrasound on the eve of childbirth and an analysis of the clinical situation by an experienced obstetrician).
Many clinics in the world have completely abandoned independent childbirth in breech presentation, delivering such pregnant women by caesarean section. However, the argument often offered in the Russian Federation that breech birth in boys leads to male infertility is not based on scientific evidence. This story about male infertility is a topic exaggerated in Russian obstetric literature, and it was not heard about outside the USSR.

To avoid caesarean section in all industrialized countries, pregnant women are encouraged to perform an external rotation of the fetus on the head. The obstetrician, by light pressure on the abdomen, rotates the fetus, and it becomes head presentation. This is the safest and most frequently performed procedure in obstetrics, which is practiced throughout the world. The rotation technique differs from previously performed ones, and most importantly, it is carried out under the control of ultrasound and CTG, which means that the obstetrician has good performance about what's going on inside.
There are many speculations about this manipulation that I hear from both patients and medical workers. For many years of practice (I have been performing turns since 2001), I have not observed any complications of this manipulation. Although there is a risk of some complications, and it is negotiated with the pregnant woman before manipulation, the risk of such complications is extremely small. This risk is not comparable to that of a caesarean section or a breech birth.

The most common fear expressed by a pregnant woman is that the fetus can be injured or damaged. It is impossible to injure the fetus during the rotation, it is in a state of hydroweightlessness and is protected by amniotic fluid, and the rotation is carried out with light movements. In the world, such a complication has not been reported, although the manipulation is performed in large numbers.

Time manipulation lasts from a few seconds to several minutes. Although the whole process will take about 2-3 hours, because. ultrasound is preliminarily performed, CTG is recorded before and after the turn is performed. After turning pregnant goes home. We usually ask to visit maternity hospital after 1-2 days. If the rotation is successful, then the woman will have a normal birth.

In about 30-40% of cases, the turn fails. How longer term pregnancy, the more failures. Most often, the failure lies in the fact that in the process of examining a pregnant woman before turning, there are contraindications to its implementation. Less often, the rotation is carried out, but it is not possible to rotate the fetus. For those who want more scientific information, the World Health Organization Reproductive Health Library can be consulted. Fortunately, in 2008 her resume was translated into Russian.

Before certain period the baby in the womb is in constant motion and can change its position several times. Head presentation is considered the most favorable for childbirth, when the fetus is located vertically with its head down. In this case, childbirth takes place without complications.

In about 5% of cases, the fetus is in a breech presentation, in which it is head up. If the birth goes naturally, the legs and pelvis are born first, and the head is born last. Pathological is the longitudinal-transverse position, in which childbirth cannot occur on its own.

To avoid negative consequences a pregnant woman may be advised to have a caesarean section. But also surgical intervention many mothers-to-be are regarded as highly undesirable. As Alternative option in breech presentation, an external obstetric turn, once proposed by Arkhangelsky, can be used.

Reasons for the formation of presentation

All the reasons that can provoke an incorrect position can be divided into two groups. The first is caused by the characteristics or pathologies of the mother. These include:

• abnormalities in the structure of the uterus;
• volume disturbance amniotic fluid(oligohydramnios or polyhydramnios);
• entanglement with the umbilical cord, which prevents the child from turning his head down;
• pregnancy with twins (triplets);
• uterine fibroma large sizes, which creates mechanical obstacles to the normal position;
• malformations and anomalies in the structure of the mother's pelvic bones;
• anomalies in the development of the placenta;
• a slight break between pregnancies, especially if there was a caesarean section in the previous one;
• decrease in uterine tone - more common in multiple births or in those who have undergone multiple abortions, curettage, caesarean section or other operations on the uterus;
• hereditary factor.

Breech presentation presents certain risks for the baby. Mortality during childbirth in this case is 9 times higher than with the usual head presentation. 80% of pregnancies with this indicator end in a caesarean section. During natural childbirth, the woman in labor increases the risk of rupture of the internal genital organs, and the child may develop asphyxia, hypoxia, and hematomas may appear. Childbirth is often complicated by weakness labor activity.

Until the 36th week, the fetus can change its position. If the mother had a breech presentation before this period, this does not mean that it will continue until the very birth. In this case, they take a wait-and-see attitude. After the 36th week, the chances of natural improvement conditions are minimal. In this case, medical attention is needed.

Misposition Diagnosis

Presentation is determined no earlier than the 22nd week of gestation. The phenomenon is more common in multiparous women. The course of pregnancy with pelvic or transverse presentation does not have any specific features.

Diagnosis of pathology is not difficult. During an external examination, attention is paid to the discrepancy between the height of the fundus of the uterus and the circumference of the abdomen, the presence of large parts of the fetus in the lateral sections, listening to the heartbeat in the navel.

The most informative diagnostic method is this. With its help, they not only establish the wrong position, but also determine the location of the placenta, the approximate weight of the unborn child, the amount of amniotic fluid, the presence of tumors or nodes in the body of the uterus, disorders prenatal development.

When is an external obstetric turn performed?

If an abnormal position of the fetus was found on the ultrasound, there are a number of measures that can transfer it to the head presentation without medical intervention. Pregnant women are recommended to perform special gymnastics, fitball exercises, swimming or water aerobics. Complete physical activity stimulates the child to take a favorable position for childbirth.

Among the recommended exercises, one can single out being in the knee-elbow position for 15 minutes several times a day and quick flips from side to side at intervals of 10 minutes. However, as practice shows, such exercises are not very effective.

Contraindications to corrective gymnastics should be taken into account - a threat premature birth, low attachment placenta, narrow pelvis, increased arterial pressure.

Corrective gymnastics for pelvic presentation of the fetus

If the presentation by the 34-35th week has remained unchanged, one of the ways out in this situation is the use of an external obstetric turn. This technique known for a long time, but for many years it was used quite rarely, because, not wanting to take risks, many doctors preferred to perform a caesarean section. Modern equipment has made it possible to control and monitor the condition of the mother and fetus during the rotation, which has caused doctors to increasingly return to this method and refuse to undergo surgery.

External obstetric rotation should be carried out by a doctor in a hospital.

The procedure can be carried out only if the following conditions are met:

• one fruit weighing no more than 3700 g;
• integrity amniotic sac;
• normal amount of amniotic fluid;
• lack of increased or decreased tone of the uterus;
• the size of the woman's pelvis is normal;
• a satisfactory condition of the woman and the absence of anomalies of intrauterine development of the fetus.

The procedure is carried out only if the operating room is equipped with ultrasound equipment and if it is possible to provide an emergency medical care in case of unforeseen circumstances.

Contraindications

External obstetric rotation is not performed if the anamnesis was diagnosed habitual miscarriage pregnancy and premature birth. Symptoms late toxicosis such as high blood pressure, disorders heart rate, swelling as a result of poor kidney function, are also a contraindication.

Other contraindications include:

• pregnancy with twins, triplets;
• fetus weighing over 4 kg;
• cord entanglement;
• violation of the integrity of the fetal bladder and leakage of water;
• the presence of large uterine fibroids or multiple myoma nodes;
• expressed;
• risk of bleeding and placental abruption;
• previous births by caesarean section;
• previous operations on the uterus.

Relative contraindications include excess weight pregnant.

Approximately 15% of women have rhesus negative blood. Before carrying out the manipulation, the presence or absence in the blood is taken into account. anti-rhesus antibodies. Obstetric rotation is not possible in the presence of antibodies, which usually occurs with repeated pregnancies. If antibodies are not present, negative Rh factor is not a contraindication.

How is the procedure carried out?

The rotation procedure takes place in several stages:

1. Hospitalization of a woman at the 35-36th week of pregnancy and full informing the expectant mother about the upcoming manipulation, her moral preparation.
2. Conducting ultrasound and CTG to assess the condition of the pregnant woman, determine the location of the placenta, assess readiness female body for the upcoming birth.
3. General preparation for the procedure, including bowel and bladder emptying.
4. Carrying out - the introduction of tocolytics, drugs that inhibit the contractile activity of the uterus.
5. Conducting external obstetric rotation.
6. Control ultrasound and CTG to assess the condition of the fetus and prevent complications.

The probability of maintaining head presentation until delivery is about 60-70%. If the turn is made for more late term, the effectiveness of the procedure is reduced.

How painful is the manipulation?

During it, the pregnant woman experiences some discomfort, which is still not a reason for the introduction of anesthesia. Multiparous people tolerate obstetric rotation more easily. AT individual cases epidural anesthesia is indicated.

The patient should lie on her back on the couch, and the doctor should take a position next to her, facing her. One hand of the doctor is on the pelvic area, and the second - on the head of the fetus. With careful, but rhythmic and persistent movements, the buttocks are displaced towards the back, and the back towards the head. The head is displaced towards the abdominal wall of the fetus.

The obstetrical rotation technique allows its implementation both along and counterclockwise, depending on the position of the fetus. In the transverse position, the fetus is first transferred to the pelvic, and then to the head position.

Control ultrasound allows you to make sure that all procedures were performed correctly. AT without fail monitor the fetal heartbeat and. But often the successful outcome of the turn does not guarantee that the child will keep the head presentation until the very birth. Perhaps his return to the pelvic position.

What measures should be taken to reduce the risk of pelvic position recurrence?

To fix the position of the child favorable for childbirth, a special bandage is used. It is a ribbon 10 cm wide, which is fixed at the level of the navel. Such fixation excludes the return of the fetus to the transverse or pelvic position. The bandage must be worn for 2 weeks, that is, almost until the very birth.

Is external obstetric rotation dangerous?

There is an opinion that it is prohibited due to heightened danger for the fetus.

Indeed, turning has certain risks, but caesarean section and even natural childbirth at pelvic position no less dangerous.

It is almost impossible to injure a child, since it is reliably protected by amniotic fluid. The procedure lasts only a few minutes, and in total the woman spends medical institution about three hours (taking into account the time of preliminary and control ultrasound and preparation).

As a rule, a second visit to the doctor is scheduled after 1-2 days in order to assess the success of the rotation. If everything went well, expect a natural birth. Otherwise, the patient is preparing for a caesarean section.

The failure rate is about 30%. As a rule, they are associated with the contraindications indicated above. If the turn could not be carried out, the patient must be provided with complete rest in order to prevent damage to the fetal bladder and not provoke.

Sometimes manipulation can provoke premature birth. This is not critical, since the rotation is carried out no earlier than the 35th week, when the fetus is already quite viable.

Possible Complications

External obstetric rotation is carried out only in a specialized institution, so the risk of complications is no more than 1%. In some cases, the following negative consequences are possible:

• premature detachment of the placenta;
• fetal distress;
• premature rupture of the fetal bladder;
• the appearance of heavy bleeding;
• uterine rupture;
• infectious complications in the postpartum period.

Bleeding and severe cramping pains, aggravated by palpation, testify to premature detachment of the placenta. With a small loss of blood, no signs of hypoxia in the fetus and a satisfactory condition of the pregnant woman, a decision is made to maintain gestation. If the detachment progresses, an urgent caesarean section is necessary to prevent hypoxia (lack of oxygen) of the fetus. Insufficient oxygen supply leads to the development of neurological problems and the child's lag in physical and mental development.

fetal distress ( intrauterine asphyxia) also has a detrimental effect on the condition of the child. Due to the lack of oxygen, hemorrhage occurs in the brain, heart, liver, kidneys. main feature asphyxia of a newborn is a respiratory disorder that negatively affects the baby's cardiac activity and the functioning of its nervous system.

In the future, children who have had birth asphyxia develop hyperexcitability syndrome, hydrocephalus, a tendency to convulsions and other neurological problems.

Uterine rupture is a very rare occurrence, in most cases occurs in the presence of scars left over from a previous caesarean section or surgery. To eliminate the gaps, the organ is sutured, followed by the appointment of antibiotics and drugs that prevent thrombosis.

To agree to an external obstetric turn or rely on, the woman herself decides after weighing all the pros and cons, as well as after consulting a doctor. Even if there are certain risks during the procedure, one should not forget that natural childbirth is always preferable to surgical intervention.

Obstetric turn (versio obstetrica) aims to change wrong position fruit on the longitudinal. In breech presentation, the rotation is performed on the head. Currently, obstetric rotation is extremely rare due to low efficiency (the fetus often returns to its original position) and the risk of complications.

With external obstetric rotation, only external techniques are used through the abdominal wall without any influence from the vagina. The external-internal rotation of the fetus involves the action of two hands, of which one is inserted into the uterine cavity, the second contributes to the rotation from the outside. In most cases, a turn is made on the pedicle of the fetus. In multiparous, with an overstretched uterus, the oblique and transverse position of the fetus is sometimes easier to translate into a breech presentation.

Variants of the classic obstetric turn:
- turn on the leg;
- turn on legs;
- rotation on the buttocks;
- turn on the head.

The effectiveness of the rotation is low, after it is carried out, the fetus often returns to the breech presentation.

In connection with the introduction of ultrasound and β-agonists into practice, interest in external obstetric cephalic rotation has revived. Ultrasound makes it possible to follow the movement of the fetus, and the introduction of β-agonists helps to relax the myometrium.

Indications for use:
Obstetric rotation of the fetus is performed when the fetus is in the wrong position: transverse or oblique. In breech presentation, the rotation is performed on the head. Incorrect positions of the fetus occur with a frequency of 0.2-0.4%. Breech presentation occurs in 3-5% of pregnancies. You can talk about the position of the fetus from 22 weeks of pregnancy, especially in the case of threatening preterm birth. The incorrect position may be temporary, especially in oblique position of the fetus and in multiparous women.

With the onset of labor, the position of the child may spontaneously improve. Therefore, it is more correct to talk about the wrong position in the development of labor activity.

The reasons leading to the incorrect position of the fetus are varied.
The following factors are of primary importance:
- decreased tone of the myometrium, flabbiness of the anterior abdominal wall, which is especially typical for multiparous women;
- anomalies of development and tumors of the uterus;
- anomalies in the development of the fetus (tumors of the neck, sacrococcygeal teratoma, hydrocephalus);
- excessive or severely limited fetal mobility;
- polyhydramnios or oligohydramnios;
- placenta previa;
- anomalies of the pelvic bones (narrowing of the size, structural features, malformations, tumors, traumatic injuries);
- multiple pregnancy.

Diagnosis of malposition of the fetus
The transverse and oblique position of the fetus in most cases is diagnosed without much difficulty.

A preliminary diagnosis of malposition of the fetus is established at 30 weeks of gestation, the final diagnosis is at 37-38 weeks.

Signs of abnormal fetal position include:
- shape of the uterus - elongated in the transverse direction;
- an increase in the circumference of the abdomen with a relatively low standing height of the fundus of the uterus;
- when using Leopold's techniques, there is no large part of the fetus in the bottom of the uterus, which is found in the lateral parts of the uterus;
- the fetal heartbeat is best heard in the navel;
- the position of the fetus is determined by the head: in the first position, the head is determined on the left, in the second - on the right;
- the type of fetus is determined by the back: the back is facing forward - front view, the back is backward - rear.

A vaginal examination made during pregnancy or at the beginning of labor with a whole membranes confirms the absence of the presenting part. After the outflow of amniotic fluid with sufficient opening of the cervix (45 cm), you can determine the shoulder, shoulder blade, spinous processes of the vertebrae, inguinal fold.

Ultrasound is the most informative diagnostic method that allows you to determine not only the incorrect position, but also the estimated body weight of the fetus, the position of the head, the location of the placenta, the amount of amniotic fluid, cord entanglement, the presence of anomalies in the development of the uterus, fetus, and its tumor.

The course and tactics of pregnancy
Pregnancy with the wrong position of the fetus passes without any special deviations from the norm. There is an increased risk of premature rupture of amniotic fluid, especially in the third trimester. The greatest risk is birth in a transverse position, which is pathological. Spontaneous delivery through the natural birth canal with a viable fetus in this case is impossible. If childbirth begins at home or there is not enough observation of the woman in labor, then complications can begin already in the first period. In the transverse position of the fetus, there is no division of amniotic fluid into anterior and posterior, therefore untimely outpouring amniotic fluid. This complication may be accompanied by prolapse of the loops of the umbilical cord or the handle of the fetus. Deprived of amniotic fluid, the uterus tightly fits the fetus, a neglected transverse position of the fetus is formed. The only way delivery in the transverse position of the fetus, regardless of the gestational age, is a caesarean section.

Correction of the incorrect position of the fetus
When diagnosing an incorrect position of the fetus after 30 weeks, corrective gymnastics is initially possible. Contraindications for implementation gymnastic exercises are the threat of premature birth, placenta previa, low attachment of the placenta, anatomically narrow pelvis II-III degree and other conditions.

Recommend a position on the side opposite the position of the fetus, knee-elbow position 15 minutes 2-3 times a day. Methods exercise were proposed by I.I. Grishchenko, A.E. Shuleshova and I.F. Dikan.

Correction of the incorrect position of the fetus by external obstetric rotation is possible from 32 weeks of gestation and should be performed only in an obstetric hospital, since emergency abdominal delivery is indicated in case of complications.

In most cases, with expectant management of pregnancy, fetuses that had an incorrect position are located longitudinally to the onset of labor. Only less than 20% of fetuses that were transverse before 37 weeks' gestation remain in this position at the onset of labor. Thus, waiting for the term of labor reduces the number of unnecessary attempts at external rotation. If the oblique or transverse position of the fetus is maintained by the time of delivery, an attempt can be made to externally rotate the fetus to the head during full-term pregnancy or with the onset of labor. After successful correction of the position of the fetus, induction of labor is possible. The external rotation of the fetus on the head in the case of a full-term pregnancy leads to an increase in the number physiological childbirth in head presentation. After a successful external cephalic rotation, reverse spontaneous rotations are less common.

Before the operation, the purpose and essence of the manipulation being performed are explained to the pregnant woman, and informed consent is issued for its implementation. Conditions for external obstetric rotation:
- satisfactory condition of the pregnant woman and the fetus, the absence of developmental anomalies;
- the presence of one fetus;
- estimated fetal body weight - normal uterine tone;
- normal arrangement placenta;
- sufficient mobility of the fetus in the uterus;
- a sufficient amount of amniotic fluid, a whole fetal bladder;
- normal sizes pelvis
- having an experienced qualified specialist who owns the technique of turning;
- the possibility of conducting an ultrasound assessment of the position and condition of the fetus before and after the rotation;
- readiness of the operating room to provide emergency assistance in case of complications.

If you experience difficulty in turning, the operation should be stopped. Contraindications for external obstetric rotation
- aggravated obstetric and gynecological history (recurrent miscarriage, perinatal losses, history of infertility, etc.);
- extragenital diseases (arterial hypertension, severe cardiovascular disease, kidney disease, etc.);
- multiple pregnancy;
- outpouring of amniotic fluid;
- anomaly of the location of the placenta;
- large fruit, entanglement of the umbilical cord of the neck and trunk of the fetus;
- fetal distress;
- complications of pregnancy (preeclampsia, the threat of premature birth, polyhydramnios, oligohydramnios, bleeding, placental abruption, fetal hypoxia);
- changes in the birth canal (narrowing of the pelvis and exostoses, tumors and cicatricial deformities of the cervix and vagina);
- the presence of a scar on the uterus;
- uterine fibroids of large sizes, multiple, with low localization of nodes, tumors of the appendages.

Technique for external obstetric rotation
Before the operation, an ultrasound is necessarily performed, in which the condition of the fetus, its size, the location of the placenta, the umbilical cord are assessed, if necessary, dopplerometry is performed, and possible contraindications are determined.

The readiness of the female body for childbirth is also assessed. Preparation for surgery consists in emptying the intestines and bladder. The operation, especially in multiparous women, can be done without anesthesia. However, perhaps 30 minutes before the operation, the introduction of 1 ml of a 1% solution of promedol. 20 minutes before the start of the rotation on the head with a breech presentation of the fetus or its incorrect position, intravenous drip administration of β-adrenergic agonists is started, which is continued during the rotation. With oblique positions of the fetus, it is necessary to lay the woman in labor on the side towards which the presenting part is deviated. For example, in the first position, the woman is laid on her left side. In this position, the bottom of the uterus, together with the buttocks of the fetus, deviates to the left, and the head in the opposite direction, towards the entrance to the small pelvis.

The operation of external obstetric rotation is carried out under the control of ultrasound and continuous cardiotocographic monitoring. The pregnant woman is laid on a hard couch on her back, her legs are slightly bent and drawn to her stomach. At the time of the operation, the presence of an anesthesiologist and a neonatologist is necessary due to the risk of complications and the occurrence of indications for an emergency caesarean section.

Technique of turning on the head with a breech presentation of the fetus
The doctor is sitting right side(face to face pregnant) on the edge of the couch. The operation is performed with two hands. One hand is located at the pelvic end, the second - on the head.

At the first position of the fetus, the pelvic end is retracted to the left, at the second position - to the right. Systematically, carefully and gradually, the pelvic end of the fetus is displaced towards the back, the back towards the head, and the head towards the entrance to the pelvis.

With a palm with spread fingers, they cover the head of the fetus, advance it so that the back of the head not only passes over the plane of the entrance to the small pelvis, but also moves somewhat further from the central point of the pubic articulation. This position of the nape allows the head to be inserted into the mother's pelvis in a bent position during childbirth. With the second hand, the buttocks are transferred to the bottom of the uterus. All these manipulations should be done persistently, but extremely carefully. After a successful turn in 80% of cases, births occur in the head presentation, the rest remain in the breech presentation.

After external rotation surgery, the possibility of recurrence is not ruled out, so it is necessary to fix longitudinal position fetus. To this end, Arkhangelsky proposed a special bandage in the form of a tape 10 cm wide, which is fixed on the pregnant woman's abdomen at the level of the navel or slightly below it; this contributes to an increase in the vertical and a decrease in the horizontal diameter of the uterus. The bandage should not be removed for 1-2 weeks to exclude the possibility of the fetus moving into a transverse position. Keeping the longitudinal position of the fetus after external rotation to the head can be done using two rollers rolled from sheets placed on both sides of the fetus, followed by bandaging the abdomen.

Technique of external rotation in the transverse and oblique position of the fetus
As a rule, in the transverse and oblique position of the fetus, a turn is performed on the head. Pregnant emptied bladder and lay her on a hard couch on her back with her legs bent at the knees. The obstetrician places his hands on the head and pelvic end, shifts the head to the entrance to the pelvis, and the pelvic end to the bottom of the uterus. If the back of the fetus is facing the entrance to the pelvis, then first a breech presentation is created (so as not to lead to an extensor presentation of the head), and then the fetus is transferred to the head presentation by turning the torso of the fetus by 270 °. Wiegand's external rotation involves simultaneous action on the head and buttocks, guided solely by the ease of movement, without taking into account the position of the fetus, the latter is gradually transferred to a longitudinal position. The transfer of the fetus from the transverse to the oblique position is performed using separate hand movements, resembling finger strikes on the back of the head.

When performing these techniques, the fetus, after turning, is in the anterior view. With this technique, the fetus, while maintaining the correct articulation and shape of the ovoid, remains in a flexion position, which is most favorable for its rotation in the uterine cavity. The disadvantages of external rotation of the fetus in expectant pregnancy management is the possibility of premature rupture of the membranes and the onset of labor before the planned attempt to implement this procedure. The risk of complications during external rotation is reduced, since the procedure takes place directly in the delivery room with continuous monitoring of the fetal condition.

Complications during external obstetric rotation
Most frequent complications when conducting an external obstetric turn are: premature detachment normally located placenta, fetal distress, uterine rupture. In the case of careful and skilled execution of the external rotation of the fetus on the head, the frequency of complications does not exceed 1%. If complications develop, an emergency caesarean section is indicated.

External-internal rotation of the fetus
The classic obstetric combined external-internal rotation of the fetus is aimed at changing the incorrect position of the fetus to a longitudinal one. Combined turn, as a rule, is made on a leg. The classic combined (external-internal) rotation of the fetus on the leg involves the action of two hands, of which one is inserted into the uterine cavity, the second contributes to the rotation from the outside.

Types of classic obstetric turn:
- external-internal classic (combined) - with full opening of the cervix;
- external-internal (combined) - with incomplete opening of the cervix of the uterus - according to Braxton Hicks.

Over the past 5 years, there have been no studies regarding the implementation of the obstetric turn and the evaluation of its effectiveness.

This is an operation with the help of which it is possible to change the position of the fetus, which is unfavorable for the course of childbirth, to a favorable one, and always only longitudinal. There are the following methods of obstetric rotation: external rotation to the head, less often to the pelvic end; internal rotation with full opening of the uterine os - a classic, or timely, rotation.

The external rotation of the fetus is performed by the doctor only by external methods through without any influence from the vagina. Indications: transverse and oblique positions of the fetus, pelvic presentation of the fetus. Conditions for carrying out: good fetal mobility (with receded waters, rotation is not shown); normal pelvic dimensions (true conjugate not less than 8 cm); lack of indications for the rapid completion of labor (, premature detachment, etc.).

Technics. External rotation, especially in multiparous, can be done without anesthesia. With oblique positions of the fetus, it is sometimes enough to lay the woman in labor on the side to which the presenting part is deviated. For example, with the left oblique position of the fetus (head to the left), the woman is laid on her left side. In this position, the bottom of the uterus, together with the buttocks of the fetus, deviates to the left, and the head in the opposite direction, to the entrance to.

With a clearly expressed transverse position of the fetus, special external techniques are required for rotation. 30 minutes before the operation, a woman in labor is injected subcutaneously with 1 ml of a 1% solution (for some relaxation of the uterine muscles so that further manipulations do not cause unnecessary disturbance). The woman in labor lies on the couch (preferably on a hard one) on her back, with her legs slightly bent and drawn to her stomach. The obstetrician sitting on the side on the edge of the couch puts both hands on the woman in labor so that one of his hands lies on the head, grabbing it from above, and the other on the pelvic end of the fetus, covering its lower buttock (Fig. 1). Grasping in this way, with one hand they press on the head of the fetus towards the entrance to the pelvis, and with the other they push the pelvic end up, to the bottom of the uterus. All these manipulations are done persistently, but extremely carefully, only during a pause, at the moment of complete relaxation of the uterus; when a fight occurs, the obstetrician's hand remains in place, holding the fetus in its position.

Rice. one. External rotation to the head in the transverse position of the fetus (anterior view).
Rice. 2. General rules external prophylactic rotation (along the arrows) in breech presentations: displacement of the buttocks towards the back, back towards the head, head towards the entrance to the pelvis.
Rice. 3. The overlying leg is captured (posterior view of the transverse position).

An external rotation to the head in breech presentation, the so-called prophylactic rotation, is done at the 34-36th week in a hospital by a doctor. General rules for a preventive turn - see fig. 2. After turning, it is necessary to systematically monitor the pregnant woman. If the cephalic presentation is again replaced by the breech one, the rotation is immediately repeated.

To prevent breech presentation and correct it in the head, it is proposed following method. A pregnant woman (in terms of 29 to 40 weeks) is prescribed classes: lying on a bed (couch), she should alternately turn to one side or the other, remaining on each of them for 10 minutes. Exercises are repeated 3-4 times (on average, each lesson takes 60-80 minutes.), The exercise is carried out 3 times a day before meals. After several classes (usually in the first 7 days), the fetus turns onto the head. After establishing the head, in order to prevent recurrence of breech presentation, the pregnant woman is recommended to lie on her side, corresponding to the position of the fetus, and on her back, and also to wear a fixative. A pregnant woman should visit a doctor at least once a week. In case of relapse, additional classes are carried out.

Classic inside twist produces . AT emergency cases if it is impossible to call a doctor, a classic internal turn can be performed. When carrying out an internal obstetric turn, one hand is inserted into the uterus, the other through the abdominal wall of the woman in labor helps the first. A classic internal rotation is shown in the transverse position of the fetus, as well as in presentations dangerous for the mother (for example, frontal) and insertions of the head (for example, posterior parietal). With a classic turn, you can turn the fetus from a transverse position (sometimes longitudinal) to the head and to the leg. Head turn now practical value does not have. Conditions for rotation: full opening of the uterine os, full fetal mobility. A contraindication to internal rotation is the neglected transverse position of the fetus.

Technique of the internal classic turn on the leg in transverse positions. Three stages should be distinguished: 1) the introduction of the hand, 2) the search for and capture of the leg, and 3) the actual rotation of the fetus. In the transverse position of the fetus, it is recommended to insert the arm corresponding to the pelvic end of the fetus, counting the side of the obstetrician.

In the anterior view of the transverse position (back to the front), the underlying fetal pedicle should be captured (when capturing the overlying pedicle, a posterior view can easily be obtained, which is unfavorable for labor management); at rear views transverse position, the overlying leg should be captured (Fig. 3), since it is easier to transfer the rear view to the front. When looking for the fetal leg, two methods are recommended: “short” - the hand is carried directly to the fetal leg and “long” - the hand is advanced along the back of the fetus to the buttocks, then along, to the corresponding leg. Always capture one leg with the whole hand (Fig. 4) or with two fingers (Fig. 5). When looking for the legs with a hand lying on the abdominal wall ("outer" hand), they help the hand inserted into the uterus ("inner" hand). The “outer” hand lies on the pelvic end of the fetus, bringing it down to the entrance to the pelvis towards the “inner” hand.

As soon as the fetal leg is found and captured, it is necessary to immediately transfer the “outer” hand from the pelvic end to the head and push it to the bottom of the uterus (Fig. 6). If this is not done, leave the hand in the same position and press it on the pelvic end, the head may be pinched - a complication that threatens to completely fail the turn.

Rice. 4. The leg is captured with the whole hand. Rice. five. The leg is grasped with two fingers. Rice. 6. The leg is captured by the “inner” hand, the “outer” hand is moved from the pelvic end to the head and pushes it to the bottom of the uterus.

The rules for turning the fetus (turning itself): traction (attraction) is performed outside the fight; traction is done downward, towards (with traction on oneself, and especially upward, the symphysis will interfere); do traction until the knee comes out of the genital gap. When the leg is brought out to the knee and the fetus has taken a longitudinal position, the turn is completed.

Further, if there are no contraindications, childbirth can be left to the forces of the body and carried out in the same way as with incomplete foot presentation. Currently, most obstetricians adhere to a different tactic: in the interests of the fetus, after the turn made, they immediately perform an operation to extract the fetus by the pelvic end (see).

The internal classical rotation of the fetus on the leg with head presentation is done according to the same rules as in the transverse position of the fetus.

Indications: the need to urgently complete childbirth. Into the uterus as deeply as possible (up to the elbow), a hand is inserted corresponding to the small parts of the fetus, counting the side of the obstetrician. When holding the hand into the uterus, you must first push the head to the side and, most importantly, do not forget to timely transfer the "outer" hand from the pelvic end to the head, after the leg is captured. head in these cases is particularly disadvantageous.

With obstetric head-to-pedicle rotation, it is easy to mix the stem with the handle. To avoid this, it is necessary to insert the hand deeper, and then, when grasping the leg, pay attention to the calcaneal tubercle, which serves as a difference between the leg and the handle.

Complications in obstetric rotation and assistance with them. 1. Handle falling out, . The dropped part is not set back, since the filled part usually falls out again. A loop should be placed on the handle that has fallen out so that in the future it cannot tip over the head. 2. Obstetric rotation fails because traction is done incorrectly (toward or up, not down). 3. The obstetric turn is done incorrectly - during the fight, while it must be done outside the fight. 4. Infringement of the head (the “outer” hand was not transferred after grabbing the leg from the pelvic end to the head). First of all, you must carefully try to push the head away. In case of failure, you should reduce the second leg (create more space for yourself in the uterine cavity) and again make an attempt to push the head away. If this fails, it is necessary to perforate the head. 5. Crossing of the legs: the leg resting against the symphysis, crossing with the lowered leg, prevents the fetus from turning. It is necessary to reduce the second leg.