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Breech presentation: exercises, breech birth. Should I be afraid of breech presentation of the fetus - what does this feature mean for the baby and the expectant mother?

When a pregnant woman finds out that the baby in her tummy is positioned with her buttocks or legs down, she begins to worry because this is wrong. Breech presentation of the fetus is usually diagnosed by the 32nd week of pregnancy during the next visit to the antenatal clinic. But this position does not always remain until childbirth, because the child is able to change its position. In addition, there are a number of measures thanks to which you can “turn over” the fetus, giving it the correct position.

What is breech presentation of the fetus?

The fetus in a breech position is located head up in the uterus. It turns out that the baby’s pelvis is located from below, and this is not standard for natural childbirth. Such births occur in 3–5% of cases and are pathological, since the baby may be injured or complications may occur. This diagnosis is made after 32 weeks of pregnancy. The baby in the mother’s tummy floats freely and can turn over several times.

Classification of breech presentation of the fetus

Baby in the uterine cavity may have the following location:

Leg - the hips, one or both, are extended, and one leg is located at the exit of the uterus. This arrangement occurs in pregnant women in 10–30% of cases.
Gluteal – the child’s legs are bent at the hip joints and pressed to the tummy. This presentation is observed in 50–70% of women.
Mixed (gluteal-leg) – hips and knees are bent. A similar situation occurs in 5–10% of cases.

Although with this arrangement it is possible to give birth naturally, it is still often shown. If such births occur, they require constant and intensive monitoring by a doctor, because complications may arise.

Causes

Usually, until 31–32 weeks of pregnancy, there is plenty of room in the uterine cavity for fetal movement. As the baby grows, it usually takes a head-down position. Breech presentation of the fetus at 32 weeks of pregnancy occurs in 25% of cases, and closer to childbirth it decreases to three percent. Therefore, if premature birth occurs, there is a high probability of the baby being in an incorrect position.

Breech presentation of the fetus is caused by several factors. The main reasons are uterine excitability and decreased tone. In addition, this situation is facilitated by:

abnormalities of the uterus;
some fetal malformations;
presence of multiple pregnancy;
oligohydramnios or polyhydramnios;
placenta previa.

Signs

Physically, a pregnant woman does not feel this pathology in any way. She is not bothered by discomfort or pain, which may warn of an incorrect position of the baby in the uterus. This situation is determined only during examination. At the same time, the baby’s heartbeat in the navel area can be heard much more clearly.

Such signs are detected during a vaginal examination. For example, in the buttock position, the doctor palpates the inguinal fold, the soft volumetric part, the sacrum and the coccyx. With a mixed foot and buttock position, the child’s feet are determined with a heel tubercle and toes that are located on the same line. To clarify the diagnosis, an ultrasound scan is required.

A baby in the breech position can be born naturally or by caesarean section.

Choosing a method of delivery depends on factors such as:

Childbirth with a pelvic position of the child can be natural if:

pregnancy period is more than 37 weeks;
average fruit weight – 2500 – 3500 g;
the pelvis is of normal size;
the unborn child is a girl
presentation is breech or gluteal-foot.

In all other cases, surgery is required. Sometimes, during a natural birth, the doctor decides to perform a caesarean section, which called emergency. Indications for immediate surgery are:

loss of the baby's arms or legs, as well as the umbilical cord;
placental abruption;
weak labor activity;
fetal hypoxia.

Possible complications

Breech presentation of the fetus does not affect the course of pregnancy at all, but serious complications can arise during childbirth.

Firstly, it may be weak labor. This condition occurs due to the fact that the pelvic end is much smaller in volume than the head and puts less pressure on the uterus, which begins to contract worse.

Secondly, during childbirth, the baby's head may tilt back, and it is difficult for it to come out. There is a high risk of injury to the child.

Thirdly, with a breech presentation, the umbilical cord is usually clamped between the head and the wall of the birth canal. This leads to obstruction of oxygen flow, causing hypoxia in the fetus.

Fourthly, during childbirth, the arms may be thrown back, which can lead to injury.

How to correct abnormal fetal position?

Many pregnant women start to panic very early when they find out that their baby is not positioned correctly in the tummy. Ultrasound at 21 or 22 weeks pregnancy usually already shows what position the fetus has taken and if it is pelvic, then women begin to look for methods that would correct this condition. But it’s too early to think about this. But if an ultrasound at 32 weeks showed an abnormal position of the fetus, then it is recommended to perform special exercises. Thanks to them, in most cases the child takes the head position.

Exercises should be performed from the 32nd week of pregnancy, but only if it proceeds without complications, otherwise you can harm the baby. All classes should begin with a warm-up. The woman should walk at a normal pace for several minutes, after which she should walk on her heels and toes. The arms can be rotated, raised and lowered, and the knees can be raised to the side of the abdomen. Below are simple exercises that are recommended to be performed after 32 weeks of pregnancy if the baby is breech.

Exercise 1

You need to stand up, straighten your back and spread your legs. Your arms should hang freely along your body. Need to stand on your toes, spread your arms to the sides, arch your back and inhale. Then you should exhale and get back to the starting position. This exercise must be performed 4 to 5 times.

Exercise 2

In this case, you will need pillows that will be used to elevate the pelvis. A pregnant woman should lie on the floor and place pillows under her pelvis, which should rise 30–40 cm above shoulder level. Shoulders, knees and pelvis should form a straight line. It is recommended to perform this activity twice a day for five to ten minutes on an empty stomach.

Exercise 3

You should lie on your back, bend your legs and spread them shoulder-width apart. Your feet should rest on the floor. Relaxed arms are extended along the body. Then you need to take a breath, lift your back and pelvis, and when exhaling you need to take the starting position. After this, straighten the legs, take a breath, drawing in the stomach. The muscles of the buttocks and perineum should be tense. When exhaling, return to the starting position. It is recommended to perform this exercise 6 – 7 times.

In addition to physical exercise, walking in the fresh air and proper nutrition can affect the position of the fetus. Pregnant women should sit in chairs with a firm back and a hard seat. If you have to sit on upholstered furniture, you should spread your legs slightly so that your stomach rests freely. You can also buy a fitball to perform special exercises on it that can change the breech presentation of the fetus.

Ultrasound and medications

If such methods do not bring the desired result, then the doctor may offer the pregnant woman an ultrasound procedure and drug intervention. It is recommended to carry it out no earlier than 34 weeks of pregnancy using special medications. This procedure is quite complex, but very effective, after which a woman has the opportunity to give birth naturally.

This procedure has contraindications:

obesity;
entanglement of the fetus with the umbilical cord;
gestosis;
scars on the uterus;
the age of the first-time mother is more than 30 years, etc.

This method is not suitable for everyone during pregnancy, so it is used quite rarely in obstetrics and gynecology.

Thus, you should not panic when you learn that the baby is in a breech position. Before giving birth, he will be able to change his position several more times. From 32 weeks you can perform special exercises, but only in the absence of contraindications. If the baby continues to be in a breech position, the doctor will select the best option for delivery.

About 6% of pregnant women during the next ultrasound hear an alarming conclusion - “breech presentation”. It is obvious to everyone that nature has provided a more natural body position for the baby in the womb - head down. It is easier to move the head forward along the birth canal, to be born into this world; it is the cephalic presentation that does not threaten complications.

But what should those whose kids decide to arrange differently? Is breech presentation always an indication for a cesarean section? Why is it dangerous and is it possible to force a child to change his body position? We will try to answer all these questions as fully as possible in this material.

What it is?

Breech presentation is the abnormal position of the fetus in the uterine cavity, in which it is not the fetal head that faces the exit to the pelvic area, but the butt or lower limbs. The head is located at the bottom of the uterus. The baby is actually sitting.

Breech presentation is a pathological condition of pregnancy; childbirth with it is also considered pathological. There is nothing natural about this position of the fetus. However, about 4-6% of all pregnancies occur with a breech presentation.

For obstetricians, each such case is a real test of professionalism. Caring for pregnancy with a pelvic position of the baby, as well as childbirth with this position of the baby, requires a lot of experience and knowledge from the medical staff.

In modern obstetrics, a woman whose baby is positioned bottom down is increasingly being offered a caesarean section. But you should know that there is an alternative to surgery - natural childbirth. With a breech presentation, the risks of complications during childbirth are higher, but an experienced and well-trained doctor can easily carry out the birth process successfully. The baby will naturally be born feet first.

Kinds

The concept of “breech presentation” is broader than it seems to expectant mothers. It is not enough for an experienced doctor to know where the baby’s head is; he needs to clarify which part of the lower half of the baby’s body is located in relation to the pelvis. Therefore, all breech presentations have a fairly clear and understandable classification.

Gluteal

In this position of the baby, the buttocks are adjacent to the outlet of the small pelvis. A breech presentation may be incomplete, with only the buttocks adjacent to the exit of the uterus, and the legs are bent at the hip joints and extended along the body so that the heels are right next to the baby’s face. Also, a breech presentation can be mixed (combined) or complete, in which the butt fits together with the legs, the baby seems to be squatting.

Incomplete (exclusively breech presentation) occurs in 75% of cases of all breech presentations. Every fifth case refers to complete or combined (mixed) breech presentation.

Foot

This concept refers to the location of the fetal legs towards the exit of the uterus. Foot presentation is much less common than breech presentation. In the full leg position, both legs are adjacent to the exit to the small pelvis, slightly bent at the knees. But such a picture is rather rare. Typically, an incomplete leg presentation is observed, in which one leg is pressed against the outlet of the uterus, and the other is bent at the knee and hip joint and is located significantly higher in level than the first.

There are also such inventive babies who position their knees towards the exit to the small pelvis. This is also a variant of leg presentation - kneeling. With it, the baby does not bend the legs at the hip joint, but bends them at the knee joints, it looks as if the baby is kneeling in the mother’s womb and both knees are pressed to the exit to the small pelvis.

Variants of leg presentation are considered the most dangerous from the point of view of the development of complications during childbirth.

Dangers and Risks

Breech presentation during childbirth is dangerous due to the development of severe complications. The water may pour out prematurely, and along with it, it is possible that the umbilical cord, its parts, and even parts of the fetal body may fall out. Often women develop weakness of labor forces when contractions do not lead to dilatation of the cervix. Often, the birth of a child with the pelvis and legs forward leads to acute hypoxia, the death of the baby, and irreversible changes in his central nervous system.

During the birth process, the baby may throw back his arms and chin. The latter is most dangerous due to the development of disabling birth trauma associated with fractures, displacement of the cervical vertebrae, brain and spinal cord. For the mother, such childbirth is dangerous due to ruptures of the cervix, vagina, and severe bleeding.

For a child, the consequences of breech presentation can be quite unpleasant - congenital hip dislocation, pathologies of the gastrointestinal tract, kidneys and urinary system, injuries, and the development of cerebral palsy.

However, dangers lurk not only during childbirth, but also during pregnancy. In the first half of gestation, breech presentation of the fetus increases the likelihood of miscarriage and hypoxia; the risks of developing early gestosis are also considered increased. In the second half of pregnancy, a woman whose baby is positioned head up is at risk of premature birth, preeclampsia, including severe preeclampsia, and premature placental abruption.

Women with a breech presentation of the fetus have a 60% increased risk of developing fetoplacental insufficiency and subsequent fetal malnutrition. In a state of lack of nutrients, vitamins and oxygen, the baby’s nervous and digestive systems do not develop well and quickly, there are problems with the endocrine system and the functioning of the heart and blood vessels.

From 34-35 weeks of pregnancy, if the baby does not turn over to the head position, the rate of development of the structures of the medulla oblongata slows down, which leads to disruptions in the functioning of the pituitary gland and adrenal cortex. Negative changes in a child who occupies an incorrect position in space also occur in the genital area - swelling and hemorrhages occur, subsequently a girl may develop exhausted ovarian syndrome, and a boy may experience oligozoospermia or azoospermia. Among children with congenital heart defects, there are many who spent the entire nine months with their head up and bottom down.

Among congenital cases of pathologies of the musculoskeletal system, about 40% are due to such a cause as breech presentation of the fetus during pregnancy.

Causes

Doctors and scientists do not fully understand the mechanisms of development of pathology; it is quite difficult to explain why a baby, who by nature is supposed to be head down, takes a different position that is not comfortable for either him or his mother. Therefore, it is not customary to talk about the reasons as such; rather, we are talking about the prerequisites for breech presentation. And they can be very diverse.

Pathologies of the uterus and pelvis

This premise is considered the most common. Tumors, uterine fibroids, a narrow pelvis, as well as the presence of postoperative scars on the uterus can prevent the baby from taking the correct head position. Quite often, the prerequisites are the anatomical features of a particular woman - a bicornuate or saddle-shaped uterus. Increased tone of the uterine muscles also creates a risk that the baby will adopt an incorrect body position.

Women who have given birth many times often experience breech presentation - the uterine muscles are weakened, “stretched”, and cannot provide reliable fixation of the fetus. Women who have previously had many abortions often experience breech presentation and often undergo curettage of the uterine cavity. The baby instinctively tries to take a position in which his head will be in the part of the uterus where spasms occur less frequently. For women who have had several abortions, this section is the fundus of the uterus. Its lower segment is tense.

Fetal pathologies

Quite often, breech babies are born with gross chromosomal abnormalities and developmental defects. So, according to statistics, up to 90% of babies with microcephaly (reduced brain volume), anencephaly (absence of the brain) and hydrocephalus (dropsy of the brain) are located head up in the mother's womb.

Breech presentation is often characteristic of one of the twins, if the pregnancy is multiple, and in this case, the position of the child in the uterus may have nothing to do with any of its pathologies.

Sometimes incorrect body position relative to the outlet to the pelvis is an indirect sign of problems with the vestibular apparatus in a child.

Amount of amniotic fluid

With polyhydramnios, the fetus has more room for flips, somersaults and somersaults. And this sometimes causes the baby to take an incorrect body position inside the uterine space. With oligohydramnios, the child’s movements, on the contrary, are difficult, and it is difficult to roll over into the correct position.

Umbilical cord and placenta

A short umbilical cord limits the baby’s movements, and a too long one is often combined not only with a breech presentation of the fetus, but also with entanglement around the neck or limbs. The pathological location of the placenta is also a prerequisite for breech presentation - we are talking about placenta previa or its low location.

Heredity

Obstetricians have long noticed that most often breech presentation of a baby develops in pregnant women who themselves were born in a breech presentation or whose mother was in this position throughout her pregnancy.

To be fair, it should be noted that the above premises do not always explain this fact. Sometimes breech presentation is recorded in a baby who does not have any of these prerequisites. Not all cases of breech or oblique breech presentation can be explained, just as it is not always possible to understand why a baby who was positioned head up, just a few hours before birth, suddenly does the impossible and turns over into a cephalic presentation. This happens rarely, but there are plenty of such examples in obstetrics and gynecology.

Diagnostics

Until the third planned screening ultrasound, or more precisely, until 32-34 weeks of pregnancy, the position of the fetus does not play a big diagnostic role, because the baby still has free space inside the uterus to change body position spontaneously. Therefore, breech presentation at an earlier stage is not considered a diagnosis; it is only a statement of fact. The doctor describes the position of the fetus in which it was “caught” during the ultrasound.

After 34 weeks, the chances of a reversal decrease to negligible values. It is at 32-34 weeks that breech presentation already sounds like a diagnosis. The tactics for monitoring a pregnant woman are changing, and the issue of the method of delivery is being decided in advance.

The pelvic position of the baby is first determined by the obstetrician. To do this, he uses the so-called Leopold method. The height of the fundus of the uterus exceeds the norm; palpation with the hands of a physician through the anterior abdominal wall of the expectant mother determines a rounded element, quite mobile, slightly shifted to the right or left of the midline passing through the navel. This is the baby's head. To eliminate mistakes, the obstetrician uses auxiliary methods: the presenting part is palpated in the lower abdomen; if it is the butt, then it is not capable of mobility. The baby's heartbeat is also heard. A tiny heart with a pelvic location usually beats above the mother’s navel, a little to the right or a little to the left of it.

Based on the location of the heartbeat, a woman can determine the presentation of her baby independently, using a phonendoscope. The points and kicks of the baby, which is head up, are felt more painfully and more noticeably in the lower abdomen, almost above the pubis.

With a vaginal examination, the presumptive diagnosis is clarified. Through the anterior vaginal fornix, the doctor determines the softer presenting part. The head, if the fetus is in a cephalic position, is firmer and denser to the touch.

After an examination by a gynecologist, the woman will be offered to undergo an ultrasound examination, which should put everything in its place. An ultrasound will determine not only the position of the baby, but also important nuances for delivery - whether its head is straightened, whether there is an entanglement in the umbilical cord, what is the expected body weight of the baby, whether it has developmental pathologies, where exactly the placenta is located, what is the degree of its maturity.

The angle of extension of the head is of greatest importance. If it is straightened and the child seems to be looking up, then there can be no talk of independent childbirth, because the risks are too great that the baby will receive serious spinal injuries when passing through the genital tract.

When it is established by ultrasound that the baby is lying incorrectly, an ultrasound with Doppler, as well as CTG, must be performed in order to have all the data about possible disturbances in the baby’s condition caused by hypoxia.

Only after the examination is completed, the doctor will be able to give a comprehensive answer about the prospects for further pregnancy management and the desired method of delivery.

Natural fetal inversion

Until 28-30 weeks, absolutely nothing is required from a woman. Doctors take an observant position and strongly recommend that the expectant mother sleep more, rest, eat normally, take vitamins and medications to reduce the tone of the uterus in order to prevent fetal malnutrition and reduce the risks of fetoplacental insufficiency. From the 30th week, the doctor may recommend that the woman do corrective gymnastics.

Exercises according to Dikan, Shuleshova, Grishchenko are aimed at maximally relaxing the muscles of the uterus and pelvis, allowing the child to take the correct position while this is still possible. The effectiveness of gymnastic exercises in combination with breathing exercises is estimated at approximately 75%. In most cases, if gymnastics has helped, the child turns over naturally, without force, within the first week after the start of classes.

Gymnastics for fetal inversion are contraindicated for women with diseases of the cardiovascular system, liver and kidneys. Classes are undesirable for women with scars on the uterus from surgical operations or a history of cesarean section, for expectant mothers with signs of gestosis, the threat of premature birth. If vaginal discharge (watery, bloody) appears that is atypical for the gestation period, gymnastics is contraindicated.

In a natural way, babies can take the head position in 70% of multiparous women and in about a third of pregnant women with their first children. To achieve results, they use not only gymnastics, but also swimming in the pool, as well as psychological influence. According to most obstetricians, the child may well “listen” to his mother’s persuasion and roll over. If he does not do this before 35-36 weeks, then with a 99% probability the baby will remain in a breech position until birth.

You shouldn’t rely on a 1% turnaround already during contractions or shortly before them.

See below for exercises for turning the fetus over.

Obstetric inversion

If gymnastics, swimming, proper breathing and adherence to clinical recommendations up to 35 weeks do not have any effect on the baby, a forced obstetric revolution may be performed. It is also called a coup using the Arkhangelsky method. External revolution is carried out exclusively in a hospital setting. Previously, doctors tried to practice it at 32-34 weeks; now it is considered most reasonable to turn the baby manually at 35-36 or 36-37 weeks.

The woman must have a sufficient amount of amniotic fluid; the revolution takes place under constant ultrasound monitoring. Doctors monitor the baby’s cardiac activity using CTG both before the turn and for some time after it. The essence of the method is a smooth, careful simultaneous movement of the head and buttocks of the fetus clockwise or counterclockwise (depending on the position of the back). It is not always possible to turn the baby; no one can guarantee that Arkhangelsky’s method will give the expected result.

Obstetric inversion is contraindicated for women who are at risk of premature birth, if her pelvis is very narrow, if her age at the time of the first birth is more than 30 years. Doctors will not forcibly turn the baby over if there is not enough mobility, or if the woman has gestosis.

The Arkhangelsky method is not used in cases of multiple pregnancies, in the presence of scars on the uterus, as well as in cases of insufficient amniotic fluid (oligohydramnios) or its excess (polyhydramnios).

If the baby's breech presentation is due to anatomical malformations of the uterus, manual rotation is also not performed. Recently, more and more often, obstetricians are abandoning manual inversion in principle. It is believed that it increases the likelihood of placental abruption, fetal entanglement and asphyxia, and disruption of the integrity of the membranes. Medicine knows of cases where an obstetric revolution resulted in premature birth, uterine rupture and fetal injury.

Considering that there may be no effect, but there may be side “effects,” many obstetricians continue observational tactics until 37-38 weeks of pregnancy, after which they routinely hospitalize the expectant mother in the maternity hospital and choose a method of delivery.

Caesarean section or natural birth?

This is the main question that torments a pregnant woman and haunts her attending physician. This is what needs to be resolved before the 38th week of pregnancy. The opinion that giving birth with a breech presentation will have to be done exclusively through a cesarean section is erroneous. A baby who sits in the uterus with his head up can be born in different ways:

natural childbirth that began spontaneously;
natural birth, stimulated in the PDR, a little earlier or a little later than this date;
planned caesarean section.

To choose the appropriate delivery tactics, doctors use a special childbirth safety scale. If the total score exceeds 16, it is considered that a woman can give birth independently with a breech presentation. Points are awarded as follows:

gestational age – 37-38 weeks – 0 points;
pregnancy period more than 41 weeks – 0 points;
gestational age 40-41 weeks – 1 point;
gestational age 38-39 weeks – 2 points;
large fruit (from 4 kilograms) – 0 points;
fetal weight 3500 -3900 grams – 1 point;
baby weight from 2500 to 3400 grams – 2 points;
foot presentation – 0 points;
combined (mixed) presentation – 1 point;
gluteal – 2 points;
strongly extended fetal head – 0 points;
moderately extended head – 1 point;
bent head – 2 points;
immature cervix – 0 points;
insufficiently mature cervix – 1 point;
mature cervix – 2 points.

Also, from 0 to 12 points are given for the size of the pelvis - the wider it is, the more points the woman will receive. And only the sum of points shows whether you can take a risk and give birth on your own, or whether it is better to trust the experience and qualifications of the surgical team and give birth by cesarean section.

It should be noted that the statements of many pregnant women that they will not give consent to the operation, which are often heard on women’s forums dedicated to issues of pregnancy and childbirth, do not have much significance. Caesarean section, if the score is less than 16, is carried out for medical reasons and only when there is a high risk of injuring the child during natural birth.

The decision to have a planned caesarean section for a breech presentation should always be a balanced one.

If a woman feels that she was sent for surgery simply because the doctor does not want to “mess around” with problematic pathological childbirth, she needs to contact the head of the antenatal clinic and ask to appoint a medical expert commission, which will once again calculate the risk scores and give its conclusion.

For a woman for whom a decision has been made about a possible natural birth, it is important to go to the maternity hospital in a timely manner. You can't wait for contractions to start at home. Even the very initial, first stage of the birth process should take place under the constant supervision of a qualified doctor.

At this stage, it is important to prevent premature rupture of the membranes, rupture of water, especially rapid rupture of water, because along with the water, loops of the umbilical cord and even parts of the baby’s body can fall out.

As soon as contractions become regular and the cervix dilates 3-4 centimeters, the woman is given antispasmodic drugs and painkillers to prevent labor from going into labor too quickly. At this stage, a CTG device is connected, the entire process of childbirth will be accompanied by constant monitoring of the state of the fetal cardiac activity. To prevent hypoxia, a woman is administered chimes, cocarboxylase, sigetin and haloscorbine in injection solutions.

As soon as the water breaks, the doctor will carefully assess the baby’s condition using CTG, and will also conduct an intravaginal examination to check for prolapse of the umbilical cord loops or parts of the baby’s body. If the loops fall out, they will try to put them back in, but if this fails at this stage, the woman will be rushed to the operating room for a caesarean section.

By the way, about 30% of natural births with breech presentation end in caesarean section. And both the woman herself and her relatives should be mentally prepared for it.

No one can predict the course of labor if the baby walks with his legs or butt forward.

In the second stage of labor, if all goes well, the woman is given oxytocin, stimulating contraction and faster dilatation of the cervix. Once it is open enough to allow the baby's buttocks through, the medical team performs an episiotomy - a surgical incision of the perineum and the back wall of the vagina. This will help protect the woman from spontaneous ruptures and make it easier for the baby to pass through.

It is considered a favorable sign if the birth of the head occurs no later than 5 minutes after the birth of the baby’s body. During the birth of a baby, an obstetrician can use different techniques. In one case, the buttocks are supported manually without attempts to stretch them or somehow speed up the process; in the other, the baby is carefully removed by one or both legs, by the groin fold. There are many options in the third stage of labor, it all depends on how the birth proceeds and how the baby will be born.

Delay or inattentive attitude of staff towards such a woman in labor can lead to acute hypoxia, fetal death, and severe injuries that will forever make the child disabled.

That is why a woman who is about to give birth in a breech position should approach the choice of a maternity facility and doctor with great responsibility, and once again weigh all the risks.

Postpartum period

The postpartum period after such births is not much different from the same period during non-pathological births. A woman should not be afraid that she will spend longer in bed or will not be able to care for her newborn. If no complications arise, no bleeding occurs, then from the delivery room the new mother is transferred to a ward where she can rest, and the child is sent to the children's department, where he will receive special treatment.

All babies who were born with their legs or butt first, even if there were no visible complications during childbirth, are monitored more closely by neurologists, because some of the consequences of pathological childbirth can be quite long-term. It is possible that such a baby will be brought in for feeding later than other children; often after birth, babies with the lower body forward require resuscitation support.

Memo for mothers

Pregnancy with a breech presentation has its own characteristics, and a woman needs to remember that:

A prenatal bandage, if the baby is positioned head up, can only be worn until the 30th week of pregnancy. If the baby then continues to have an incorrect body position in space, the bandage cannot be worn.

Before or shortly before childbirth, the belly of pregnant women drops - the head of the fetus, during cephalic presentation, is pressed against the outlet to the pelvis. With breech presentation, abdominal prolapse does not occur until childbirth.

Obstetricians' interest in the issue of breech presentation of the fetus is growing every day, which is understandable. Not so long ago, breech birth was classified as physiological, but today the opinion of doctors has changed dramatically and breech birth is considered a pathology. Firstly, this is explained by the high risk of perinatal complications and death of children in breech presentation, and, secondly, it is associated with a high percentage (up to 6) of serious congenital malformations. In addition, breech presentation of the fetus does not exclude consequences for the woman.

Breech presentation: how to understand the term

Not all expectant mothers understand what breech presentation of the fetus means. In general, it's simple. The baby in the uterus should normally be positioned longitudinally (that is, along the uterine axis), and the largest part, that is, the head, should be present at the entrance.

They speak of breech presentation when the unborn child lies in the uterus correctly, that is, longitudinally, but the pelvic end (buttocks) or legs are at the entrance. Breech presentation is not so rare, occurring in 3–5% of births.

Classification

According to the domestic classification, the following types of breech presentations are distinguished:

Gluteal or flexor
- purely gluteal - when the buttocks are adjacent to the entrance, and the legs are bent at the hip joints, but extended along the body of the fetus and press the arms to the chest, and the head is also pressed to the chest;
- mixed gluteal – when the buttocks and foot (one or both) are adjacent to the entrance;
Leg or extensor
- incomplete leg - when only one leg is adjacent to the entrance (and nothing else);
- full leg – respectively, both legs are adjacent;
- knee - the fetus seems to be on its knees, it is quite rare, and during the birth process it turns into a leg position.

Most often, pure breech presentations are observed (up to 68% of all breech presentations), mixed breech presentation in 25%, and foot presentation in 13%. During childbirth, it is possible to transition from one type of breech presentation to another. Complete leg is diagnosed in 5 - 10%, and incomplete leg is observed in 25 - 35% of births.

Expectant mothers should not immediately become upset because the baby is lying incorrectly. A lot of fetuses that are presented at the pelvic end by the end of pregnancy turn over and are presented at the head.

Such spontaneous rotation is more often observed with the presentation of the buttocks, and in multiparous women this happens 2 times more often than in first-born women. And, what’s good is that if the child turned over on his own, then his reverse “somersault” is unlikely.

Etiology

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

Maternal factors

This group includes factors depending on the state of the mother’s body:

Uterine malformations- due to improper development of the uterus, the fetus takes on a pathological position or presentation. This may be a saddle or bicornuate uterus, a septum in the uterine cavity, a hypoplastic uterus and others
Tumor-like formations in the uterus— various tumors (usually myomatous nodes) often prevent the fetus from turning around correctly and taking the necessary cephalic presentation. Uterine polyps (fibrous) and adenomyosis cannot be excluded
Increased or decreased uterine tone
Scars on the uterus
Overdistension of the uterus- in this case, polyhydramnios or a large number of births in history may affect
Narrowing of the pelvis - a significantly narrowed pelvis (3rd - 4th degree) or a curved and irregularly shaped pelvis also impedes the physiological position of the baby in the uterus
Pelvic tumors
Compounded gynecological and/or obstetric history- numerous abortions and curettages, childbirth with complications, inflammation of the uterus and cervix and other pathologies.

Fruit factors

Etiological factors associated with the fetus include:

Low fetal weight or prematurity- in 20% of cases leads to breech presentation due to excessive fetal mobility
Multiple pregnancy - pregnancy with more than one fetus is often (13%) complicated by incorrect position and presentation of either one or both babies
Congenital malformations- this subgroup includes defects of the central nervous system (dropsy of the brain, anencephaly, tumors and hernias of the brain), defects of the urinary system (Potter's syndrome), anomalies of the cardiovascular and musculoskeletal systems (hip dislocation, myotonic dystrophy). Chromosome pathologies and multiple intrauterine developmental defects also play a role.

Placental factors

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

Placenta previa- prevents the larger part of the fetus (head) from being located at the entrance to the pelvis
Short umbilical cord- limits fetal mobility
Excess or lack of amniotic fluid- promotes either increased activity of the baby or reduces his mobility
Fetoplacental insufficiency— leads to intrauterine growth retardation of the fetus and its malnutrition, which increases its motor activity
Umbilical cord entanglement- prevents the fetus from developing correctly in the uterus.

Case Study

Late in the evening, a woman was admitted to the maternity ward with contractions. A vaginal examination revealed an opening of the uterine pharynx up to 5 cm, in which the fetal legs could be clearly felt. After diagnosis: Pregnancy 38 weeks. The first period of 5 term births. Leg presentation. It was decided to immediately end the birth by caesarean section. It must be said that the woman was not young, about 40 years old, she had given birth 5 times (4 children were waiting for her mother at home), and she was not registered. I've never even had an ultrasound. After cutting the uterus and removing the fetus, it turned out that he had no brain (anencephaly). The child died immediately. The operation was completed by suturing the uterus and ligating the fallopian tubes, that is, sterilization.

I would like to note that such carelessness of my mother could have ended badly. Natural childbirth is much safer (in many cases) for a woman than operative delivery. In this case, the postoperative period proceeded without complications, and the “unnecessary” caesarean section was justified by sterilization. What if the birth was the first? What if something happened after or during the operation? Therefore, I give this example for expectant mothers as science. You should never disregard your own health (don’t see a doctor, don’t get tested, and don’t attend an ultrasound).

Course of pregnancy

The final diagnosis of breech presentation is made at 36 weeks, when the fetus is firmly in position in the uterus, although spontaneous rotation is not excluded. Pregnancy with a breech presentation of the fetus is much more likely to have complications than with a cephalic presentation. The main complications are:

threat of miscarriage or premature birth;
gestosis;
placental insufficiency.

All of these complications lead to oxygen starvation of the fetus, and, accordingly, to its developmental delay (hypotrophy and low weight), abnormal amount of amniotic fluid (low or polyhydramnios), and entanglement of the umbilical cord. In addition, breech presentation is often accompanied by placenta previa, unstable fetal position and prenatal rupture of water.

Also, such presentation affects the development of the fetus and the functions of the fetoplacental system:

Maturation of the medulla oblongata

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

Adrenal glands

The function of the adrenal glands, as well as the hypothalamic-pituitary system, is depleted, which significantly reduces the adaptive and protective reactions of the fetus during childbirth and after.

Sex gonads (testes and ovaries)

There is poor circulation and tissue swelling, mature cells of the sex gonads partially die, which subsequently affects reproductive function (hypogonadism, oligo- and azoospermia) and leads to infertility.

Congenital malformations

When presented with the pelvic end, congenital defects occur 3 times more often, in contrast to cephalic presentation. Primarily, defects of the central nervous system and heart, as well as anomalies of the digestive tract and musculoskeletal system.

Disturbance of uteroplacental blood flow

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

Pregnancy management

Considering the high risk of complications in pregnant women with breech presentation, preventive measures are prescribed to improve uteroplacental blood flow, prevent the threat of miscarriage and fetal hypoxia. Presentation with the pelvic end at 21 weeks is considered physiological, and the position of the fetus with its head down occurs by 22–24 weeks. Pregnant women are recommended to have a balanced diet (to prevent fetal hypo- or hypertrophy), as well as a gentle regimen (full sleep, rest).

Special gymnastics

Exercises for breech presentation of the fetus are recommended to begin at 28 weeks. But performing special gymnastics has a number of contraindications:

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

Methods according to Dikan, according to Grishchenko and Shuleshova, as well as according to Fomicheva or Bryukhina are used. The simplest gymnastics are Dikan exercises. The pregnant woman lies first on one side or the other, turning over every 10 minutes. In one session, you need to make 3–4 turns, and perform the gymnastics itself three times a day. After the fetus is in a cephalic position, the abdomen is secured with a bandage.

External rotation of the fetus

If there is no effect from gymnastic exercises at 36 weeks, external rotation of the fetus is recommended. Manipulation is not performed in the following situations:

existing scar on the uterus;
planned cesarean section (other indications available);
uterine defects;
deviations on CTG;
premature release of water;
fetal defects;
small amount of water;
refusal of a pregnant woman;
pregnancy with more than one fetus;
placenta previa;
oxygen starvation of the fetus;
unstable position of the fetus.

Fetal inversion during breech presentation must be monitored by ultrasound and CTG; the procedure itself is carried out “under the cover” of tocolytics (ginipral, partusisten), and after the manipulation a non-stress test is performed and the ultrasound is repeated.

Complications of the procedure include:

fetal hypoxia;
placental abruption;
uterine rupture;
fetal brachial plexus injury.

Hospitalization of a pregnant woman

A woman is hospitalized with a breech presentation of the fetus at 38–39 weeks. In the hospital, additional examination of the pregnant woman is carried out:

clarification of obstetric history;
clarification of extragenital pathology;
ultrasound examination (clarification of presentation, fetal size and degree of head extension);
X-ray of the pelvis;
amnioscopy;
assess the readiness of the pregnant woman’s body for labor and the condition of the fetus.

Then they decide on the method of delivery. Caesarean section for a breech fetus is routinely prescribed for the following indications:

fetal weight is less than 2 and more than 3.5 kg;
narrowed pelvis, regardless of the degree of narrowing;
curvature of the pelvis;
excessive extension of the head;
delayed fetal development;
history of fetal death or birth trauma;
post-maturity;
placenta previa;
breech presentation of the first baby with multiple births;
scar on the uterus;
foot presentation;
“old” primigravida (more than 30);
pregnancy after in vitro fertilization;
extragenital pathology requiring exclusion of the second stage of labor.

Diagnostics

Diagnosing breech presentation is not difficult. For this purpose, external and internal examination is used, as well as additional research methods.

External inspection

For this purpose, Leopold's techniques are used (determining the position and presentation of the child) and measuring the abdomen:

Fundus height

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

Leopold's techniques

When palpating the abdomen, it is clearly determined that the dense and rounded part (the head) is located in the fundus of the uterus, and the buttocks (large, soft, irregularly shaped and non-balling, that is, the stationary part) is located at the entrance to the pelvis.

Fetal heartbeat

With cephalic presentation, the heartbeat can be clearly heard on the right or left, but below the navel. When the pelvic end is presented, the heartbeat is heard at or above the navel.

Vaginal examination

This method is the most informative when carried out during childbirth:

in case of presentation of the buttocks, the soft part and the gap between the buttocks, as well as the sacrum and genitals are palpated;
if the presentation is purely gluteal, the inguinal fold is easily determined;
in the case of a mixed breech presentation, the foot is felt next to the buttocks;
with the foot, the legs of the fetus are determined, and in the case of a prolapsed leg, its main difference from a fallen handle is the sign that it is possible to “say hello” to the handle.

Additional Methods

Fetal ultrasound

The presentation of the fetus is specified, as well as its weight, the presence or absence of congenital defects and umbilical cord entanglement, and the degree of extension of the head.

CTG and ECG of the fetus

Allows you to assess the condition of the baby, hypoxia, entanglement or compression of the umbilical cord loops.

Course of labor

Childbirth with a breech presentation of the fetus usually occurs with complications. Perinatal mortality during such births increases significantly compared to births in cephalic presentation (four to five times).

Complications during labor:

Premature rupture of water

Since the pelvic end, compared to the head, does not completely fill the pelvic cavity, which leads to insufficient relaxation of the cervix, resulting in the passage of water, and often, prolapse of the umbilical cord. The umbilical cord is compressed by the pelvic end and the wall of the cervix or vaginal wall, which disrupts fetoplacental blood flow and leads to fetal hypoxia. If the compression continues for a significant period of time, the child’s brain may be damaged or die.

Weakness of generic forces

Weakness of contractions occurs as a result of untimely release of water, as well as insufficient pressing of the pelvic end to the entrance to the pelvis, which does not stimulate the opening of the cervix. Weak contractions, in turn, lead to protracted labor and cause oxygen deficiency in the fetus.

Complications during the expulsion period:

Difficult birth of the head

This complication often leads to asphyxia or fetal death. Difficulties in the birth of the head are determined by three factors. Firstly, the pelvic end of the baby is significantly smaller than the head, so the birth of the buttocks occurs quickly and without difficulty, but the head “gets stuck”. In the case of premature birth, the pelvic end may be born with incomplete dilatation of the cervix, and subsequent cervical spasm aggravates the situation during the birth of the head. Secondly, difficulties in the birth of the head can be caused by its hyperextension. And, thirdly, difficult birth of the head may be associated with the throwing back of the fetal arms. This is observed more often during premature birth, when the body is born too quickly, and the arms “do not have time.”

Damage to soft tissues of the birth canal

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

Management of childbirth

The management of labor in the case of breech presentation has a significant difference compared to childbirth in the cephalic presentation.

Managing the period of contractions

Bed rest

If during a normal birth a woman in labor is strongly recommended to behave actively (walk) in the first period, then in the case of a breech presentation the woman is supposed to lie down, and it is better to raise the foot end of the bed. This tactic prevents premature or early rupture of water. It is recommended to lie on the side where the baby's back is facing, which stimulates uterine contractions and prevents weak contractions.

After the water breaks

As soon as the waters have broken, it is necessary to conduct a vaginal examination to rule out prolapse of the legs or umbilical cord loop. If the presentation is purely breech, you can try to tuck in the dropped loops. This method is not used for leg presentation. If the loop does not tuck or the legs are present, an emergency caesarean section is performed.

Monitoring

The first stage of labor should be carried out under the control of CTG, in extreme cases, auscultation of the fetus should be carried out every half hour (for childbirth in the cephalic presentation, every hour). You should also monitor the contractile activity of the uterus and keep a partogram (graph of the opening of the uterine pharynx).

Prevention of fetal hypoxia

Timely provision of medicinal sleep-rest (at the beginning of the first period) and the introduction of the Nikolaev triad every 3 hours.

Anesthesia

Antispasmodics

Timely administration of antispasmodics (no-spa, papaverine) begins with the opening of the cervix by 4 cm and is repeated every 3 to 4 hours, which prevents its spasm.

Conducting the second period

Oxytocin

At the end of the period of contractions and the beginning of the second period, oxytocin is administered intravenously, which prevents weakness of contractions and pushing and maintains the baby’s correct positioning. With the onset of pushing, atropine is administered intravenously against the background of oxytocin administration to prevent cervical spasm.

Monitoring

Monitoring of the fetal heartbeat and contractions (CTG) continues.

Episiotomy

As soon as the buttocks emerge from the genital slit (eruption of the buttocks), a dissection of the perineum is performed - an episiotomy.

Manual manual

Depending on the situation, during the eruption of the buttocks or the birth of the legs, one or another manual aid is provided (according to Tsovyanov 1 or 2, extraction of the fetus by the pelvic end, the Moriso-Levre-Lashepelle maneuver).

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

Case Study

A young primigravida woman was admitted to the maternity hospital with complaints of contractions. I was not registered with the antenatal clinic (our women do not like to see a doctor). The mother was approximately 32 weeks pregnant. Palpation of the abdomen revealed that she was pregnant with twins (2 heads and both in the fundus of the uterus) and 2 heartbeats above the navel. A vaginal examination revealed a cervical opening of 8 cm, no amniotic sac, legs were present, one immediately fell out. A woman complains of pushing. It's too late to do a caesarean section. I immediately took it to the birth table. It must be said that during the pushing, the woman in labor behaved rather inappropriately. She screamed, tried to run away from the table and reached for her crotch with her hands while I tried to remove the first baby. The birth of the legs and torso went more or less normally, but the head, of course, was “stuck.” Having placed the child on the left hand as a rider and inserted a finger into the mouth, I grabbed the child’s neck with the fingers of my right hand like a fork (Morisot-Levre-Lachepel maneuver), trying to remove the head. The process took about 3 – 5 minutes, I no longer expected the birth of a live baby. But he was born alive, albeit in severe asphyxia. The second child also “walked” with his legs. But with his birth, things went faster, since “the path was paved,” although difficulties also arose with removing the head. The succession period is without features. A neonatologist and an anesthesiologist were present at the birth and immediately provided resuscitation to the children. After being discharged from the maternity hospital, the woman was transferred to the children's department for further nursing of the babies. In conclusion, I would like to say that I saw her and the children about a year after birth, and talked with the mother. The children are said to be normal, developing and growing well.

Consequences

Breech birth often results in complications in the form of birth injuries and has consequences for children:

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

Breech presentation is the position of the baby in the uterus with the buttocks or legs down. It is considered a certain deviation from the normal course of pregnancy and childbirth. Most often this may be due to the following reasons:

Repeated births
Polyhydramnios
Uterine abnormalities
Fetal malformations
Low position or placenta previa

There is a point of view that the formation of breech presentation depends on the maturity of the vestibular apparatus of the fetus, so it is more often detected in a short period of pregnancy.

How and when can a diagnosis be made?

Up to 30 weeks of pregnancy, breech presentation is detected in 33-35% of cases. During this period, the fetus turns freely in the uterus. By 33-34 weeks, the fetus begins to occupy a more definite position, and in full-term pregnancy, the frequency of this type of presentation is only 3-4%.

As a rule, starting from 28 weeks of pregnancy, a diagnosis of breech presentation can be made during a doctor's examination and ultrasound examination.

When and how can you help your baby turn into a cephalic presentation?

There are techniques that increase the likelihood of such a turn, which usually occurs at 28-32 weeks. You can start using them after 32-34 weeks of pregnancy, after consulting with your doctor. It is more effective to use two or more techniques simultaneously.

Special exercises

Turns. This is the simplest and most commonly recommended set of exercises. Lying on the couch, turn from side to side 3-4 times every 10 minutes. Do it 3 times a day. Fetal rotation usually occurs within the first week.

Using gravity

The intended effect of these exercises is that gravity pushes and rotates the fetal head against the fundus of the uterus, and the baby turns into a cephalic presentation.

Pelvic tilt. Performed on an empty stomach. You need to lie with your back on an inclined surface, raising your pelvis 20-30 cm above your head. In the absence of a special exercise machine, you can use pillows placed on the floor in front of a low sofa.

Stay in this position for at least 5 minutes, but no more than 15 minutes. Do this exercise 2 times a day for 10 minutes for 2-3 weeks, starting at 32 weeks. Research shows that this method is effective in 88-96% of cases.

Knee-elbow position. An alternative to the previous exercise. Stand on your knees and elbows, at this time your pelvis is located above your head. Stay in this position for 15-20 minutes several times a day. Yoga. The classic "shoulder stand" pose is used.

Pool. The effectiveness of diving while performing handstands has been reported. The last two approaches look quite exotic and require almost professional training.

Unconventional methods of treatment

For successful fetal rotation with good results, the following can be used: acupuncture/acupressure (Bladder 67), homeopathy (Pulsatilla), aromatherapy (Bougainvillea). When using these methods, the help of a specialist is required.

Alternative techniques

Although there is no scientific evidence of the effectiveness of these methods, their use does not cause harm and even allows you to devote more time to your unborn child.

Suggestion. Use the power of suggestion, tell the child that he must turn around. You can ask to talk to your partner's child.

Visualization. During deep relaxation, visualize the baby turning. Try to imagine not the process of turning, but the child who has already turned.

Light. Placing a source of light or music directly above the womb encourages the fetus to turn toward the light or sound. Place a flashlight near the perineum so that the child can turn towards the light.

Music. Place the player's headphones with pleasant music under the clothes in the lower abdomen, this will encourage the child to move towards the music. This technique can be quite effective.

Water. There is evidence that when swimming or simply being in the pool, the fetus turns. If you are careful, visiting the pool does not pose any particular problems.

How to keep a baby in cephalic presentation after a successful rotation?

Tailor's pose. Helps move the head deeper into the pelvic cavity. Sit on the floor, touch the soles of your feet to each other. Press your knees as close to the floor as possible, and pull your feet towards you. Practice this pose for 10-20 minutes 2 times a day until labor occurs.

36-37 weeks - consider external rotation.

If there is enough amniotic fluid at 36-37 weeks, your obstetrician-gynecologist may suggest an external rotation.

In the hands of an experienced doctor, this technique is successful in 65-70% of cases. It is performed in a maternity hospital with monitor and ultrasound monitoring of the condition of the fetus and the administration of drugs that relax the uterus. The greatest risk with external rotation is the possibility of placental abruption, however, thanks to ultrasound guidance, this is rare.

Is your unborn baby still in a breech position?

You have exhausted all options, and the baby is still in the breech position. Even in this case, you can give birth to him yourself. Up to half of births with this type of presentation pass through the natural birth canal. When deciding whether to deliver a breech fetus spontaneously, several criteria are usually considered, although there are differing opinions on their precise definition. A successful breech birth is more likely if the following are present:

Fetus in pure breech presentation (straightened legs raised up)
You have already had one or more vaginal births
The fetus is not rated as excessively large
No pelvic or uterine abnormalities

In some cases, with a breech presentation, a caesarean section may be preferable. Your doctor will help you determine the best option.

Literature:

Obstetrics. Ed. Savelyeva G.M. - M.: Medicine, 2000.
Prenatal

The situation when a pregnant woman has a baby in a breech position in her last stages is considered rare - out of 100 pregnant women there are about 5 women with this deviation. This explains the fact that many pregnant women do not know how breech presentation of the fetus, the incorrect position of the baby’s head in the uterus, can threaten the child and the pregnant woman herself during childbirth, what pathologies arise in the baby if the birth is not carried out skillfully and competently. In other cases, the pelvic position of the fetus is an indication for cesarean section, as the safest method of childbirth.

What is breech presentation of the fetus?

During the entire pregnancy, the embryo changes its position in the uterus several times. Gynecologists consider these movements to be a normal process until the last period of pregnancy, when, in most cases, the fetus takes a head-down position, which is considered the correct presentation for natural childbirth. The fetal head is the most voluminous part of the body, therefore, during normal childbirth, when the head has passed through the perineum, the rest of the body follows it inertly, without causing problems during obstetrics.

The situation when, after the 30th week of pregnancy, an anatomical breech or leg presentation of the fetus is recorded by an obstetrician, can greatly complicate childbirth. The baby's legs or buttocks are born first, which do not take up much volume, and only then the head is born, the passage of which through the birth canal may cause difficulties, fraught with the threat of serious pathologies in the newborn baby.

Causes

If the fetus is in a breech position in the last stages of pregnancy, then there are many reasons for this condition. Factors influencing abnormal presentation of the fetus are divided into three main groups:

Dependent on the mother, or maternal. These include: a narrow pelvis, which prevents the child from taking the correct position with the head towards the pelvic floor, a history of fibroids or fibroids, ovarian tumors, hypoplasia, pathological abnormalities in the structure of the uterus.
Caused by abnormalities in the development of the fetus, or fruit. These include: polyhydramnios, entanglement of the umbilical cord around the embryo, its length being too short, hypoxia, hydro-, anen- and microcephaly of the fetus, twins or triplets according to ultrasound results.
Placental, when the breech presentation of the child is facilitated by low placenta previa and high tone of the lower parts of the uterus, caused by various operations, scars, and frequent curettage of the uterine cavity. The fetus tries to take the upper position when its head is not pressed by the spasming muscles of the uterus.

Classification

There are several types of abnormal presentation of the fetus in the mother’s pelvic ring:

Fully breech presentation of the fetus, when the buttocks of the fetus are lowered down, and the legs are bent and pressed with the arms to the tummy.
Foot presentation, when the fetus has one or two feet in the pelvic ring. Sometimes the fetal knees end up there.
Mixed presentation. In this case, the buttocks and one foot are located on the pelvic ring, the second leg is straightened.

Why is it dangerous?

The condition with a breech presentation recorded by obstetricians is dangerous due to the risk of early termination of pregnancy, which interferes with the normal formation of the central nervous system and endocrine systems of the fetus. In the last stages of gestation, the medulla oblongata of the fetus is formed, and the pelvic position of the fetus can lead to disruption of this process, causing cerebral edema in the newborn baby. Developmental defects may also be recorded, including heart failure, abnormal development of bones, muscles, central nervous system, and genital organs.

Does the stomach drop during breech presentation?

One of the most important signs that the fetus is in a breech presentation is that the pregnant woman’s belly in the last stages does not fall, but is in an elevated state. The belly is pulled down by the head, which after 30-32 weeks descends to the pelvic ring. If the head is located on the upper segments of the uterus, and below are the buttocks, feet or knees of the fetus, then the abdomen will not move down.

Diagnostics

A stable breech presentation is recorded by gynecologists starting from the 32nd week of gestation during a routine gynecological examination of the pregnant woman. At the bottom of the uterus, a large head can be felt, the heartbeat is felt opposite the navel, and at the entrance of the womb you can feel the sacrum, spine, soft, irregularly shaped parts of the child’s body, in which the buttocks, heels, feet and toes can be guessed. Based on the visual examination data, the gynecologist or obstetrician records the abnormal position of the embryo.

A pregnant woman is prescribed the following additional procedures to confirm the diagnosis of pathological presentation: examination of the child using three-dimensional ultrasound, which gives a three-dimensional picture of the position of the embryo in the uterus, Dopplerography and cardiotocography, which allow assessing the health of the internal organs of the fetus that has become malpresented.

Management of pregnancy with breech presentation of the fetus

The difference between observing a woman with a fixed breech or leg presentation of the fetus from standard pregnancy management is attempts to correct the pelvic position of the fetus. The following methods are used for this:

The woman is prescribed special gymnastics, in which she must turn from one side to the other and lift the pelvis above head level from a lying position. Exercises have contraindications: exercises cannot be done with scars on the uterus, low placenta previa, or preeclampsia.
If gymnastics does not help, then doctors can hospitalize the patient and attempt external rotation in a hospital setting. If the external rotation is incorrect, it can cause rupture of the placenta, membranes, rupture of amniotic fluid and premature birth.

Childbirth

To determine how childbirth will proceed with a breech presentation of the fetus, the pregnant woman is admitted to the hospital at 33 weeks of gestation. The decision on the method of delivery is made based on an assessment of the general condition of the patient, the position of the baby in the womb, the presence of a history of diseases that can negatively affect the intrauterine development of the baby, the age, blood pressure of the pregnant woman, the number of previous pregnancies of the expectant mother, her willingness to follow orders obstetrician

Biomechanism of labor in breech presentation

The pelvic position of the fetus determines other obstetric methods of natural childbirth than the cephalic position. Since the buttocks are considered the largest part of the baby’s body after the head, the baby will be born according to the following algorithm:

The buttock that is closest to the birth canal is born first. It descends into the small pelvis, where the buttock is inverted and shifted onto the finger, as a result of which it extends end forward, emerging from the birth canal.
Then the baby's pelvic region is fixed at the end of the pubic arch, the baby's spine is strongly curved, and the second buttock is born.
If the baby's legs are bent at the knees, then they are born at the same time as the buttocks. With the legs positioned along the body, the obstetrician waits for the next contractions of the woman in labor to pull the legs out of the birth canal.
The baby's torso passes through the birth canal easily if the birth of the baby's buttocks and legs has passed without complications before this stage.
The baby's shoulders are born one at a time, with a fixed fixation point. At the same time, the handles are released.
Then the head is born, passing with its sharp end forward in a transverse dimension. From the moment the baby is born to the shoulders until the head is removed, no more than 10 minutes should pass, because the head compresses the umbilical cord and the baby begins to suffocate from lack of oxygen.

Indications for caesarean section for breech presentation of the fetus

Doctors prescribe an operative method of obstetrics under the following circumstances:

if the mother is a first-time mother, over 35 years old;
narrow pelvis;
a history of inflammatory and tumor diseases of the genital organs, scars on the wall and cervix;
numerous abortions, childbirth and constant miscarriage;
the weight of the embryo is more than 3500 grams or its hypoxia;
conflict of Rh factors of mother and baby.

Possible complications during childbirth

A pregnant woman who insists on independent childbirth with a pelvic position of the child should know that there are the following serious complications with this method of birth:

rupture of the placenta, early discharge of amniotic fluid, prolapse of the umbilical cord, fraught with the fact that the child may suffocate;
throwing back handles;
trauma to the baby's spine and head, leading to cerebral hemorrhages;
water entering the baby's lungs while the head is still in the birth canal.

Consequences for the child

If a natural birth is performed incorrectly in a pelvic position of the baby, the consequences for him will be the most serious, including the presence of serious pathologies at birth and death. Therefore, doctors recommend cesarean section as the safest method of childbirth, in which the child has a high probability of being born healthy and without developmental disabilities.