Management of labor in the transverse position of the fetus

The transverse position of the fetus occurs in about 0.3-0.5% of all births, moreover, in multiparous children 5 times more often than in primiparous. In 1/4 of women with a transverse position of the fetus, labor occurs prematurely. With a full-term pregnancy, spontaneous delivery is impossible and threatens the life of both the fetus and, often, the mother, for whom this pathology is one of the most common causes of birth injury. The reasons contributing to the formation of the transverse position of the fetus are varied: an arched uterus ( uterus arcuatus ), inferiority of the muscles of the uterus or a violation of its tone, an abundance of amniotic fluid and, as a result, excessive fetal mobility, prematurity , twins, malformations of the fetus, narrow pelvis, placenta previa , uterine tumors. Sometimes in the process of childbirth, a spontaneous correction of the transverse hollow is observed , that is, the fetus occupies a longitudinal position and subsequently the natural termination of childbirth is observed. Premature, especially dead, the fetus can spontaneously be born by the mechanism of self – reversal . However, most often with the transverse position of the fetus, the course of labor almost from the very beginning assumes a pathological character and requires timely intervention by the obstetrician. Especially often (in 20%) there is an early discharge of amniotic fluid. At the same time, the fetal pen often falls out (in 1/5 of all cases); quite often also the umbilical cord falls out. With the loss of the umbilical cord, stillbirth reaches 50%, and with the simultaneous loss of the handle and umbilical cord – even more. 

Pa handle lowers and “hammers” into the pelvic entrance shoulder; prerequisites are created for the formation of a running lateral position. The mechanism of its occurrence is as follows: the opening of the pharynx after the discharge of water is slow or completely stopped, the water continues to flow out, contractions intensify, with each contractions the uterus more and more tightly covers the fetus, the shoulder is more and more “driven” into the pelvic entrance, the dropped handle swells; pauses between contractions are reduced, and the uterus comes into a state of totanic contraction. This condition threatens the fetus with death due to a deep violation of the uterine and placental circulation with the subsequent development of intrauterine asphyxiation, and the mother with rupture of the uterus and severe infection. In such an obstetric situation, a big mistake on the part of the doctor would be an attempt to perform a turning operation, which in such cases is absolutely contraindicated, since it can lead to a violent rupture of the uterus. For proper management of labor in the transverse position of the fetus, it is necessary, firstly, to establish the correct diagnosis in a timely manner and, secondly, to prevent the appearance of a neglected transverse position. Typically, a diagnosis is presented but presents difficulties : the pregnant woman’s stomach is pulled out in a transverse dimension; the height of the bottom of the uterus corresponds to the gestational age, the bottom of the uterus is missing a large part (head or buttocks); above the bosom, the precursor part is also not defined, and the hand, upon palpation, freely penetrates the entrance to the pelvis, which is not filled with any precursor part. The head or buttocks are palpated in the right or left half of the uterus at the level of the navel. The heartbeat is heard at the same level also on the right or left. The position is set by the location of the head: the first position when the head is on the left, the second on the right. Most often, the back of the fetus is facing anteriorly and somewhat downward – the front view; flight – small parts are determined in front, and the back is facing the spine – rear view. In the outgoing waters, if the uterus tightly covers the fetus, and the abdominal walls are also tense, it can be difficult, and sometimes impossible, to obtain all the required data with an external examination. In this case, you can determine the position of the fetus by the dropped handle. 

First of all, you should find out which pen fell out. It is necessary to mentally “say hello” to the fetus by the hand; if the right hand of the obstetrician and the handle of the fetus meet one another correctly, as during a handshake, the dropped handle is the right; if the left hand of the obstetrician is suitable for a handshake, the left handle fell out. You can also navigate by turning the dropped handle with your palm forward (up): if the thumb of the handle is turned to the right – the right handle, and vice versa. The position of the fetus can be accurately judged only after vaginal examination: lifting two examining fingers along the handle, they reach the axilla of the fetus: if it closes to the left, the first position; to the right is the second position. If at the same time the scapula is facing posteriorly, it is a rear view, anteriorly it is a front view. If the shoulder blade is difficult to reach, you can navigate along the ribs. Sometimes with vaginal examination it is difficult to distinguish between the handle and the leg. But the toes of the legs are short, small, the thumb is closely pressed to the other fingers; the fingers of the handle are longer, of unequal size, between the thumb and forefinger a large gap. The main distinguishing feature of the legs is the calcaneal tuber. Vaginal examination with a whole fetal bladder must be done extremely carefully so as not to burst the bladder. If this study is used when the transverse position of the fetus is neglected, the degree of mobility (or complete immobility) of the fetus should also be determined, since the accuracy of further delivery management tactics depends on the accuracy and proper assessment of all these data. The study and determination of the degree of fetal mobility when running lateral position requires extreme caution, as the slightest violence during palpation can lead to uterine rupture. 

Along with this, an insufficiently careful assessment of the degree of neglect of the transverse position and all the attendant circumstances (a long anhydrous period, the condition of the fetus, the degree of mobility of it, the appearance of the dropped handle, signs of infection in the mother) can lead to erroneous decisions. So, the fetus can die when it was still possible to make a turn (of course, with proper precautions); on the other hand, a turning operation may be undertaken when it is already contraindicated, which leads to rupture of the uterus. Once again, we cite the symptoms of a neglected lateral position: a) the discharge of water a few hours ago and the “hammering” of a shoulder; b) lack of fetal mobility in the uterus; c) overstretching of the lower segment of the uterus and the presence of a contraction ring (“ retraction ” ring) in the form of an oblique groove reaching the navel level and above, which indicates the complete impossibility of further stretching of the uterus; d) fetal death due to a deep disturbance, and then the termination of placental circulation as a result of prolapse of the umbilical cord, tetanic state of the uterus, placental abruption. The only preventive measure that can be used to prevent severe complications in the lateral position of the fetus is an external rotation of the fetus onto the head. The general rules for this operation are the same as for pelvic sentences. However, with the transverse position of the fetus, unsuccessful results are observed more often. 

This is due to the fact that in these cases either the shape of the uterus is incorrect, or the tone of its muscles is significantly impaired. As a result of this, even after a successful rotation, the fetus often again occupies a transverse position. Nevertheless, a pregnant woman with a transverse position of the fetus should be hospitalized at the 34-36th week of pregnancy, and after appropriate preparation, an external preventive turn is performed. After surgery, the fetus should be fixed in a longitudinal position using bandaged semi-rigid ridges, and the pregnant woman must be left in the hospital until delivery . Currently, the method of correcting incorrect positions by applying a complex of gymnastic exercises (I. I. Grishchenko and A. E. Shuleshov ) is widely used . Contraindications to rotation , placenta previa, insufficient fetal mobility, nephropathy, febrile postpartum period after previous births, history of cesarean section, uterine fibroids. With an external rotation of the fetus, it is necessary to avoid the formation of extensor previa of the head. To do this, in the rear view, you need to move the head in the first position clockwise, l in the second – counterclockwise. The same can be done with the front view, but only in those cases when the back is facing forward. If the back is facing not only anteriorly, but also to the crib , displacement of the head and rotation of the fetus must be done in a long way – pa 270 °, that is, in the first position – counterclockwise, and in the second – clockwise. The rotation of the fetus is carried out with both hands: one palm is placed on the head, the other on the pelvic end. The fetus is moved simultaneously with both hands, and the pressure on the head and pelvic end is produced in the opposite direction; thereby the movement of these parts takes place in one direction. The pressure exerted by the hands of the obstetrician should be smooth, rhythmic, continuous, without jerking and the strength of the impact is exactly the same for both hands. 

If a preventive turn was not made in a timely manner with the transverse position of the fetus, childbirth is recommended to the bone , adhering to the following basic rules (according to L. Yu. Lurie). 1. Childbirth has just begun, the fetal bladder is intact; the cervix is ​​not smoothed and passes (or does not pass) the finger. Put the woman in labor in bed, prohibit sudden movements, make every effort to ensure that the fetal bladder is kept intact for as long as possible. With good fetal mobility and the absence of contraindications, try to observe the maximum caution to make an external turn on the head. If the rotation fails, enter the colpeirinter in order to preserve the waters until they are fully opened. 2. The waters withdrew in the absence of contractions and a small neck opening. It is necessary to proceed with the delivery by Caesarean section. If there are no conditions for a cesarean section and it is not possible to transport a woman in childbirth to a hospital, you can use a metrerider to save water and give birth . After ron; denia of the metreurter (full opening), make a turn followed by extraction of the fetus. 3. The waters are intact or recently (2-4 hours ago) have departed; the fetus is mobile; full opening of the cervix. Immediately under anesthesia, make an internal rotation of the fetus on the leg and immediately remove it. 4. The waters departed davpo ; full opening of the cervix. With an immovable fetus – a fruit- destroying operation even with a living fetus. The rotation of the fetus in this situation often causes uterine rupture and pedigree damage to neighboring organs. After the operation, a manual examination of the uterus is necessary to make sure that there is no rupture of the uterus. In the transverse position of the fetus, one should not resort to turning but Wraxton – Hicks , perform a cesarean section in whole waters and incomplete opening of the cervix, undertake a vaginal cesarean section, cut off the fallen out handle. The combination of the transverse position of the fetus with placenta previa or with a narrow pelvis with a live fetus and significant bleeding, but without obvious infection in the uterus, of course, serves as an indication for caesarean section.

Leave a Reply

Your email address will not be published. Required fields are marked *