PELVIC PRESENTATIONS

From Big Medical Encyclopedia

PELVIC PRESENTATIONS — the pre-natal provision of a fruit at which its pelvic area predlezhit to an entrance to a basin of mother.

Due to the frequent traumatizing mother and a fruit, high percent of operative measures raised by perinatal incidence and mortality of a fruit at childbirth in pelvic presentation most of obstetricians consider such presentations pathological. However childbirth at Other item quite often proceeds also without complications. Considering it, nek-ry obstetricians consider Other item boundary between normal and pathological presentations.

Frequency of pelvic presentations fluctuates from 2,7 to 5,4%.

Fig. 1. The diagrammatic representation of provision of a fruit at different types of pelvic presentation: and — purely buttock (incomplete) presentation (to an entrance to a small pelvis buttocks are turned, legs are bent in hip joints, are unbent in knee joints and are extended along a trunk); — the mixed (full) buttock presentation (to an entrance to a small pelvis are turned a buttock and a foot of the legs bent in hip and knee joints); in — full foot presentation (to an entrance to a small pelvis both feet are turned); — incomplete foot presentation (to an entrance to a small pelvis one foot is turned).

Other items include buttock (flexion type) and foot (extensive type) presentations. Buttock presentations divide into purely buttock (incomplete) presentations, at to-rykh to an entrance to a basin buttocks are turned, and legs are bent in hip joints, unbent in knee and extended along a trunk (fig. 1, a), and the mixed (full) presentations, at to-rykh to an entrance to a basin predlezhat buttocks together with stupnyam of the legs bent in hip and knee joints (fig. 1, b). Foot presentations subdivide on full, at to-rykh predlezhat both legs (fig. 1, c), incomplete, at to-rykh one leg (fig. 1, d), and knee with presentation of knees of a fruit predlezhit.

Purely buttock presentation (68,2 — 68,0%) meets more often, is more rare — mixed buttock (20,6 — 23,4%) and foot than presentation (11,4 — 13,4%). Purely buttock presentation is more often noted at primapara, mixed buttock and foot presentations — at multipara. According to one researchers, more adverse is purely buttock presentation, at Krom because of an arrangement of legs along a trunk side bending of a fruit decreases that reflects adversely on the mechanism of childbirth. According to others, the most adversely foot presentation, at Krom the volume of the prelying part is much less than subsequent head.

The reasons of Other item are insufficiently clear. One of the main reasons consider decrease in a tone and excitability of a uterus, especially its lower segment that leads to its stretching. Formation of Other item is promoted by malformations and tumors of a uterus (see), hydramnion (see), narrow basin (see), placental presentation (see), and also hydrocephaly (see) and other disturbances of fetation. Other item is often observed at premature births.

The diagnosis of pelvic presentation usually does not cause difficulties, except for cases when there is an expressed muscle tension of a front abdominal wall and the raised tone of a uterus, and also at obesity, twin, an anencephalia of a fruit.

At an outside research (see. Obstetric research ) the prelying part of a fruit (pelvic area) of a soft consistence, does not ballot, has no the expressed spherical outline, passes without special borders into a trunk in view of lack of a cervical and head furrow. In the field of an uterine fundus the firm, round, balloting part of a fruit — a head is palpated. High standing of an uterine fundus attracts attention. Heartbeat of a fruit is usually listened at the level of a navel of mother or above.

At vaginal examonation the soft voluminous part not similar to a head is probed (there are no seams and fontanels). At sufficient disclosure of a neck of uterus it is possible to probe sciatic hillocks of a fruit, a sacrum, an anus, external genitals (it is easier to define at male fruits). At purely buttock presentation the position and its look are established under the provision of a sacrum and the intertrochanteric line (linea intertrochanterica). At the mixed buttock presentation near buttocks define a foot of a fruit. Recognition of foot presentations usually comes easy. At a big patrimonial tumor, the driven edematous buttocks the last can be taken for a head of a fruit, and purely buttock presentation — for front.

From additional methods of a research use an electrocardiography of a fruit (on an ECG a ventricular complex — QRS — a fruit is turned from top to bottom, but not up, as at head presentation), ultrasonic (see. Ultrasonic diagnosis, in obstetrics and gynecology ), is more rare — rentgenol. research. For diagnosis of Other item nek-ry researchers suggest to use an amnioskopiya (see).

After establishment of the diagnosis of Other item at duration of gestation of 29 — 34 weeks and lack of contraindications the complex of the special physical exercises promoting version in head presentation recommend to carry out conducting pregnancy. If after holding 5 — 8 occupations of corrective gymnastics of self-version does not occur, then in the absence of contraindications nek-ry obstetricians recommend to make preventive external version on a head by B. A. Arkhangelsky's technique (see. Obstetric turn). However in a crust, time the number of supporters of external version decreases.

At inefficiency of corrective gymnastics of women with Other item it is necessary to hospitalize at duration of gestation of 38 — 39 weeks for inspection and the choice of tactics of conducting childbirth. At the same time carefully study the obstetric anamnesis, specify duration of gestation, make an outside and internal obstetric research, determine the estimated weight (weight) of a fruit, estimate the sizes of a basin. According to indications make the rentgenopelvimet-riya (see Peljvimetriya) allowing to determine the true sizes of a basin; at the same time the form of an entrance to a small pelvis, the size of a true conjugate, cross diameter of a pelvic cavity and the perednezadny amount of escaping of a basin have special value. Besides, specify character of the prelying part of a fruit, its sizes, reveal nek-ry malformations of a fruit (an anencephalia, hydrocephaly).

The mechanism of childbirth

At buttock presentation at the end of pregnancy and at the beginning of childbirth of a buttock of a fruit usually enter a basin in such a way that their cross sectional dimension matches one of the slanting sizes of an entrance to a basin. Advance of a fruit on a parturient canal begins usually later an izlitiya of amniotic waters (see).

Fig. 2. The diagrammatic representation of some moments of the mechanism of childbirth at buttock presentation: and — side bending of lumbar department of a backbone of a fruit and eruption of buttocks (the second moment); — internal version of a coat hanger (the third moment); in — disengagement (the sixth moment).

At buttock presentations in the mechanism of childbirth distinguish six moments. The first moment — internal version of buttocks — begins upon their transition from a wide part of a cavity of a small pelvis to narrow. The turn is made in such a way that in escaping of a basin of a buttock are located with the cross sectional dimension in a direct size of a basin; the buttock turned kpered approaches under a pubic arch, turned kzad — is established over a tailbone. The second moment — side bending of lumbar department of a backbone of a fruit; at the same time the buttock turned kzad is rolled out over a crotch and after it from under a pubic joint the buttock turned kpered finally is born (fig. 2, a). The third moment — internal version of a coat hanger and external version of a trunk — comes to the end with establishment of a coat hanger in a direct amount of escaping of a small pelvis; at the same time front plechiko a fruit approaches under a pubic arch, and back — is established ahead of a tailbone over a crotch (fig. 2, b). The fourth moment — side bending of cervicothoracic department of a backbone — leads to the birth of a shoulder girdle and handles. The fifth moment — internal version of a head — is characterized by the introduction of a head the slanting size in the slanting size of an entrance to a basin opposite to that, to Krom there went a coat hanger. Upon transition from wide to a narrow part of a basin the head makes internal version, as a result to-rogo an arrow-shaped seam the suboccipital pole — under a pubic joint is established in a direct amount of escaping of a basin, and. The sixth moment — bending of a head — leads to eruption (birth) of a head usually small slanting, more rare the direct size (fig. 2, c).

At foot presentations the mechanism of childbirth differs from described by the fact that from a sexual crack not buttocks, but legs or a leg are shown the first. Emergence of legs from a vulvar ring indicates opening of a bag of waters and the introduction of buttocks in a small pelvis. However it does not mean that the uterine pharynx revealed completely. At full disclosure of a uterine pharynx and the birth of legs to knees of a buttock enter a basin, in a vulvar ring the hip is shown and further process goes the same as at buttock presentation.

The patrimonial tumor at pelvic presentations is located on buttocks or legs.

Conducting childbirth

Tactics of conducting childbirth at Other item depends on age of the woman, the obstetric anamnesis, readiness of a maternal organism for childbirth, the sizes of a basin, a condition of a bag of waters, functional state and the sizes of a fruit, type of pelvic presentation and other moments. For the solution of a question of the choice of a method of delivery (in natural patrimonial ways or by Cesarean section) use the predictive index offered in 1967. Fade also Andros (G. I. Zatuchni, G. J. Andros). At the same time consider the result of pregnancies in the past, the term of the real pregnancy, estimated weight (weight) of a fruit, existence of pelvic presentation in the anamnesis, disclosure of a neck of uterus, the location of the prelying part of a fruit.

At good shape of the pregnant woman and a fruit, the normal sizes of a basin and the average sizes of a fruit childbirth should be conducted in natural patrimonial ways. The first period of childbirth (the period of disclosure) at Other item differs from that at head presentation in the fact that the head goes the last. As a result patrimonial ways extend insufficiently and remain low-prepared for childbirth that can lead to a number of complications: to a zaprokidyvaniye of handles, a delay of a head with the subsequent hypoxia of a fruit, pressing of an umbilical cord, formation of a rear view and a delay of a head a chin over a pubic symphysis and asphyxia of the newborn (see Asphyxia of a fruit and the newborn). It should be noted big frequency untimely of lithium of amniotic waters (see. Premature bursting of waters), loss of small parts of a fruit and loops of an umbilical cord, hypoxia of a fruit, long course of childbirth, infection of a fruit.

For the purpose of prevention of early opening of a bag of waters the woman in labor shall observe a bed rest. Childbirth at Other item should be conducted with monitor observation (see) of heartbeat of a fruit. At the established regular patrimonial activity and opening of a neck of uterus on 3 — 4 cm for the purpose of a labor pain relief and regulation of patrimonial activity intramuscular administration of anesthetics (Promedolum) and spasmolytic (Nospanum, aprophene) means, and also use of an electroanalgesia is shown by impulse currents (see the Labour pain relief).

Apply Nikolaev's method to prevention of a hypoxia of a fruit (see Childbirth), and also intravenously enter 2 ml of 1% of solution of Sygethinum, 0,05 g of cocarboxylase, inside give 0,5 g of Galascorbinum. Later from - a lity of amniotic waters at once make vaginal examonation for specification of the diagnosis and an exception of loss of small parts of a fruit and loops of an umbilical cord. At disturbances of patrimonial activity more often than at head presentation, delivery by Cesarean section is shown (see).

In the second period of childbirth (the period of exile) with the preventive purpose enter intravenously kapelno oxytocin, and by the end of the second period for the prevention of a spasm of a neck of uterus — antispasmodics (Nospanum, a papaverine a hydrochloride). At eruption of buttocks produce pudendalny anesthesia, then — perineo-or Epi-ziotomiyu (see the Perineotomy). In the period of exile at pelvic presentations noticeable acceleration of serdtsebiyeniye of a fruit is quite often observed.

At emergence in a sexual crack of an umbilical ring for a fruit there comes extremely dangerous moment since the head, entering a basin, inevitably squeezes an umbilical cord, and the fruit is threatened by asphyxia. Danger increases at the time of the birth of a head. The umbilical cord can be pressed no more than 3 — 5 min. At a prelum of an umbilical cord more than 10 min. the fruit usually perishes. At this time there can come also premature placental detachment (see).

At good shape of a fruit usually render a manual grant across Tsovyanov (see below), and if necessary — a classical manual grant or extraction of a fruit for the pelvic end. At a classical manual grant promote the birth of a shoulder girdle and head. At extraction of a fruit for the pelvic end all moments of breech labors artificially are reproduced, and the fruit is removed after emergence of the prelying part from a sexual crack.

A manual grant across Tsovyanov. At purely buttock presentation the essence of a grant is in supporting normal position of legs of a fruit (bending in coxofemoral and extension in knee joints).

After the birth of a buttock, the turned kpereda, the obstetrician covers thumbs of a hip of a fruit (other fingers are in area of a sacrum). In process of the birth of a trunk of a fruit the doctor carefully presses legs of a fruit to its abdominal wall, gradually advancing hands to a sexual crack of mother that prevents loss of legs of a fruit, and also a zaprokidyvaniye for a head of the handles pressed to a thorax of a stupnyama of the legs extended along a trunk. The fruit gradually is born to an umbilical ring, and then and to a bottom corner of shovels. Except forward, the fruit makes rotary motion, and a coat hanger passes into the direct size of an exit of a basin. Front plechiko suits the first under a pubic arch. For simplification of the birth of the front handle from under a pubic arch it is recommended to direct buttocks several kzada (from top to bottom), to the corresponding hip of the woman in labor (at the first position — to left). For the birth of the back handle a fruit raise up (kpered). Removal of the subsequent head usually does not represent difficulties; for this purpose it is enough to direct buttocks of a fruit of a kpereda (up). Usually after the birth of a shoulder girdle from a sexual crack the chin is shown, and the head is born independently. If the birth of a head does not occur, she is usually brought manual receptions (abroad — on the way Brakh-ta, in our country — on Moriso's way — Levre — LaChapelle — see below).

Fig. 3. The diagrammatic representation of a manual grant across Tsovyanov at foot presentation: the palm of the obstetrician pressed to the sexual crack covered with a sterile diaper counteracts the premature birth of legs.

At foot presentation the manual grant across Tsovyanov comes down to allowing the birth of legs of a fruit before full disclosure of a uterine pharynx. For this purpose, having covered a sexual crack of the woman in labor with a sterile diaper, the palmar surface of the right hand laid to a sexual crack counteract the premature birth of legs (fig. 3). During each attempt the fruit as if «squats» in a parturient canal. In this regard buttocks put pressure upon the channel of a neck of uterus and promote its disclosure. At the same time the mixed buttock presentation is formed. Counteraction to the born legs should be rendered until there comes full disclosure of a uterine pharynx. After full disclosure of a uterine pharynx of counteraction to legs do not render any more, and the buttocks born after legs and a trunk of a fruit do not meet difficulties thanks to good readiness of patrimonial ways. After the birth of a trunk to bottom corners of shovels the manual grant is rendered, as at buttock presentation. Tsri carrying out this method it is necessary to monitor heartbeat of a fruit, height of standing of the contraction ring, a condition of the lower segment of a uterus carefully. At loss of legs and incomplete disclosure of a uterine pharynx also start rendering a manual grant across Tsovyanov.

Fig. 4. The diagrammatic representation of provision of obstetrical hands at a classical manual grant at pelvic presentation: and — capture of a fruit in hips (the first stage); — the provision of obstetrical hands at version on 180 ° (the second stage); in — the provision of obstetrical hands at release of the back handle (the second stage); — release of a head in the way of Moriso — Levre — LaChapelle (the third stage).

Classical manual grant — a complex of the actions directed to the birth of a shoulder girdle and head. The fruit independently is born to an umbilical ring. After the birth of a fruit to a navel it is necessary to examine an umbilical cord (a pulsation, a tension). The strong tension should be weakened; if it does not work well, it is necessary to cross an umbilical cord and to hurry with the end of childbirth. By the time of the birth of a fruit to a navel everything shall be prepared for rendering a manual grant. If to begin release of handles earlier, then it is difficult for doctor to reach fingers the handle of a fruit; if to pull too strongly for the pelvic end, handles can be thrown back for a head. Distinguish three stages in rendering a classical manual grant. The first stage — from a navel to a bottom corner of a shovel. The fruit is taken both hands in hips (fig. 4, a), and a trunk transfer to the direct amount of escaping of a basin and reduce to emergence in a sexual crack of a bottom corner of a shovel.

The second stage — release of handles — is made by the following rules: the obstetrician releases each handle the hand of the same name (the right handle — the right hand, left — left), the first always release the back handle (more space in a sacral hollow), the second front handle should be translated previously in back for what the trunk is turned on 180 °, without doing tractions so that the back passed under a pubic joint (fig. 4, b).

For release of the back handle one hand take legs of a fruit from an ankle joint and lift them forward and aside, opposite to a back of a fruit (fig. 4, c). Enter two fingers into a vagina (on a back of a fruit, is closer to a sacral hollow) (index and average) the corresponding hand and, sliding on a back, and then on a shoulder of a fruit reach an elbow bend. Then fingers the obstetrician shifts the handle so that it slid on a face and a breast of a fruit, i.e. made the «umyvatelny» movement; from a vagina the elbow, and then a forearm and a brush is shown in the beginning.

Then remove the front handle, previously having transferred it to back. There are also other ways of release of handles. So, according to Müller handles shall be born independently. At the same time it is recommended to delay a trunk of a fruit down until from under a pubic arch does not seem front plechiko and then the corresponding handle does not approach under a pubic joint and will come to light. After that the trunk is vigorously raised up until from under a crotch it is cut through back plechiko and the back handle will be born.

The third stage — shall undergo release of a head, edge through a parturient canal in a condition of bending (the small slanting size) that is reached by means of various receptions. The best of them is Moriso's way — Levre — Lasha-pell (fig. 4, d), at Krom is entered into a genital tract that hand, edges released the second handle. The trunk of a fruit is stacked on a forearm. Enter a nail phalanx of an index finger of a hand into a mouth of a fruit, on a cut there is a fruit. The finger entered into a mouth is not the attracting force but only supports bending of a head. Other (outside) hand take kryuchkoobrazno the fingers bent index and average plechiko a fruit. Support by an internal hand a head in a condition of bending that promotes the correct rotation and transition of a head from cross sectional dimension of an entrance to a basin in the slanting size of a cavity of a small pelvis, and then and in the direct amount of escaping of a basin. An outside hand make tractions. The direction of tractions shall match a wire axis of a basin, during the finding of a head in an entrance to a basin the direction of tractions goes kzad (on socks of the obstetrician), to pelvic cavities — from top to bottom (on knees of the sitting obstetrician). When the suboccipital pole approaches under bottom edge of a pubic symphysis, do turn of a head around a point of fixing of a kpereda, and from a sexual crack the chin, a forehead and a nape are shown. The assistant at extraction of a head puts careful pressure upon it from above through an abdominal wall.

Fig. 5. The diagrammatic representation of some stages of extraction (extraction) of a fruit at different types of pelvic presentation: and — traction of a fruit for a leg at the mixed buttock presentation; — traction of a fruit after eruption of buttocks at the mixed buttock presentation; in — extraction of a fruit a pakhovy bend at purely buttock presentation.

Extraction (extraction) of a fruit the pelvic end is, as a rule, made by means of manual receptions. There are ways of extraction of a fruit a leg (legs) and for a pakhovy bend. Indications to extraction of a fruit the pelvic end is the serious illness of the woman in labor demanding the urgent end of childbirth (heart diseases, an eclampsia, etc.), the begun hypoxia of a fruit and a state after classical podalic version (see. Obstetric turn). In a crust, time extraction of a fruit the pelvic end is carried out or at a dead fruit, or in the absence of conditions for Cesarean section. Extraction is made under anesthetic on condition of full disclosure of a neck of uterus, compliance of the sizes of a head of a fruit and a basin of the woman in labor and opening of a bag of waters. Extraction of a fruit at the mixed buttock presentation consists of four moments: extraction of a fruit to the level of a navel, extraction of a fruit to a bottom corner of shovels, release of handles, release of the subsequent head. Ahead the lying leg is taken a hand. Make traction for a leg (kzada) from top to bottom and turn a leg the flexion party forward (fig. 5, a), at the same time the fruit turns a back of a kpereda. At eruption of buttocks the index finger of the hand of the same name is entered into a pakhovy bend. The ileal bone of a fruit turned forward represents a point of fixing. The obstetrician takes a front hip of a fruit both hands, vigorously raises its kpered, and the back rump is gradually rolled out over a crotch outside. The second (back) leg should not be released — it drops out. After eruption of buttocks the obstetrician puts thumbs of both hands along a sacrum of a fruit (fig. 5, b), covering other fingers of his hip. Tractions become more horizontally (from top to bottom), and the fruit is taken to a navel. Extraction of a fruit to a bottom corner of shovels, release of handles and a head is conducted, as during the rendering a manual grant.

Extraction of a fruit at purely buttock presentation presents considerable difficulties, especially at a vkolachivaniye of buttocks in a basin, a cut happens at weakness of patrimonial activity or owing to discrepancy of the sizes of a fruit and a basin of mother. Therefore at weakness of patrimonial activity, a large fruit, lack of advance of a fruit it is necessary to make Cesarean section. At a vkolachivaniye of buttocks in a basin extremely adverse situation since delivery in patrimonial ways becomes difficult and traumatic for mother and a fruit is created, and time for delivery by Cesarean section is missed. Extraction of a fruit at the buttocks driven in a basin — one of the most difficult operations in obstetrics. At high standing and mobility of buttocks purely buttock presentation is transferred in incomplete foot by bringing down of a leg, and then begin to take a fruit.

The first moment of operation — extraction of a fruit a pakhovy bend to an umbilical ring — is made by an index finger, to-ry enter into a pakhovy bend (fig. 5, c). Traction is made by kzad kryuchkoobrazno a curved finger during an attempt. For strengthening of tractions it is recommended to clasp the hand making operation, other hand in a wrist. The front buttock is taken to bottom edge pubic' a symphysis, and the ileal bone of a fruit becomes a point of fixing. Then enter a finger of the second hand into a back pakhovy bend and remove a back buttock.

Then the obstetrician puts both thumbs along a sacrum of a fruit, clasping with other fingers of his hip, and takes a fruit to an umbilical ring. The following three stages of extraction are conducted also, as at a manual grant. In case of death of a fruit at purely buttock presentation extraction can be made for a pakhovy bend by means of tools (a hook, a loop). Use of obstetric nippers for extraction of a fruit the pelvic end is undesirable in connection with high percent of complications.

Difficulties and complications during the rendering a classical manual grant and extraction of a fruit the pelvic end

Zaprokidyvaniye of handles arises owing to discrepancy of the sizes of a fruit and a basin of the woman in labor, and also at excessively bystry extraction of a fruit. G. G. Genter suggested to distinguish three degrees of a zaprokidyvaniye of handles: ahead of a face, on each side heads and a zaprokidyvaniye on a nape. To improve situation of the thrown-back handles happens very difficult, especially at their zaprokidyvaniye for a nape. At a zaprokidyvaniye of one handle from a back of a fruit enter 2 — 4 fingers into a vagina (or all brush) and try to remove the thrown-back handle. If the lying handle is thrown back ahead, in the regular way release the back handle, do turn of a trunk on 180 ° aside, opposite to the direction of turn in normal conditions (under a pubic symphysis not the back, and a breast of a fruit approaches). If the back handle is thrown back, the fruit is turned in the direction, the return to the occurred zaprokidyvaniye (a back under a pubic symphysis). If for a nape both handles are thrown back, situation becomes critical. For release of handles it is necessary to untwist «the twisted plait». If untwisting of a fruit does not work well, it is necessary to take a head together with the thrown-back handles that usually leads to infringement of a head. Nevertheless repeated attempts to release the thrown-back handles are not reasonable in connection with loss of time and a possibility of death of a fruit from a hypoxia.

For release of handles at formation of a rear view of pelvic presentation it is necessary to transfer a head to the direct or slanting size of a small pelvis, at the same time it is necessary to consider in what party the turn is easier made. After turn of a head and a trunk removal of handles does not meet difficulties. The turn of a head from a basin, slanting in the direct size, with turn of a nape of a kpereda is made by the combined pressure upon a head of fingers of two hands entered into a vagina, and fingers of one hand are located on a temporal bone, and another — behind an ear of a fruit on the opposite side. If such turn does not work well, start release of handles in a rear view. For this purpose recommend two ways: release of handles from a breast and release of handles a so-called false hand. At the last reception the fruit is taken for legs and lift kpered to an abdominal wall of mother. The hand opposite to the released handle, enter into a vagina from a back to a shoulder girdle of a fruit, and then lower a trunk of a fruit from top to bottom; four fingers of an internal hand release a shoulder, trying to advance it together with a palm of a fruit by a face. If after release of the first handle it is not possible to turn a fruit a back forward, then the second handle is released the same obra-time.

Difficulties at release of a head are observed at its extension, space discrepancy between a head of a fruit and a basin of the woman in labor, formation of a rear view. So, extension of a head is observed at the wrong carrying out reception of Moriso — Levre — La-shaiyell when the trunk of a fruit is raised by kpered before fixing of a suboccipital pole at bottom edge of a pubic arch. At establishment of the reason of extension of a head it is necessary to make its bending. For this purpose the obstetrician enters a nail phalanx index (or an average) a finger into a mouth, and the assistant at the same time presses on a head from above.

At space discrepancy between a head of a fruit and a basin of the woman in labor doctors sometimes make a mistake, throwing a trunk of a fruit astride the hand and aiming to advance a head the direct size through the direct size of an entrance to a basin. The head can pass through an entrance to a basin only if its direct size matches cross sectional dimension of a basin. Therefore the head is transferred the direct size to cross sectional dimension of an entrance to a basin, then make its easy bending and translated in slanting, and then in the direct size of a basin and taken.

Fig. 6. The diagrammatic representation of formation of a rear view of presentation (the nape of a fruit is turned to a back of mother) at release of a head of a fruit at childbirth in pelvic presentation (a) and the obstetric method used in this case: and — the head is unbent, the chin is late under a pubic symphysis; — the obstetrician enters an index finger into a mouth of a fruit, aiming to make bending of a head.

In case of formation of a rear view of presentation (the nape of a fruit is turned to a back of mother, fig. 6, a) it is possible to apply reception, at Krom enter a tip of an index or long finger into a mouth of a fruit, make bending of a head and bring it out of a pubic joint by traction of a kzada of a chin and the person before formation of a point of fixing under a pubic joint, the trunk of a fruit is sharply rejected by kpered and remove a head over a crotch (fig. 6, b). If this reception does not work well, then, holding a finger in a mouth, quickly raise a trunk (for legs) kpered and remove a head. In this case a point of fixing is the nose bridge or a malar; over a crotch the nape is rolled out, and then, during the lowering of legs — the person.

Extraction of a fruit the pelvic end at incomplete disclosure of a uterine pharynx leads often to heavy complications, one of to-rykh the convulsive reduction of a uterine pharynx depending on many factors is (untimely introduction of antispasmodics at the end of the second period of childbirth, incorrectly chosen method of anesthesia and errors in technology of operation). At a spasm of a neck of uterus the woman in labor should give a deep anesthesia and after that to release a head. Also the section of a uterine pharynx is admissible if its edges are thinned.

Operation of extraction of a fruit the pelvic end often leads to injuries at mother — to ruptures of a vulva, vagina, crotch, neck of uterus, damages of a pubic symphysis and a sacroiliac joint (see Childbirth, patrimonial traumatism), and also to an injury of a fruit — to fractures of a hip, shoulder, clavicle, dislocations of extremities, damages grudino - a clavicular and mastoidal muscle, an intracranial injury (see. Birth trauma).

In some cases (at a perenashiva-niya of pregnancy, the immunoconflict, etc.) at pelvic presentations there is a need of a rodovoz-buzhdeniye in the presence of the whole bag of waters or at premature izlitiya of amniotic waters. At the whole bag of waters usually within 3 days (at «unripe» or insufficiently «mature» neck of uterus — within 5 days and more) create a hormonal background. After achievement of «maturity» of a neck of uterus start initiation of patrimonial activity. The most effective method of initiation of patrimonial activity at the whole bag of waters is intravenous drop administration of oxytocin (in cultivation of 5 PIECES reparathat on 500 ml of isotonic solution of sodium chloride or a 5%r-r of glucose) during all childbed, including an early puerperal period (10 — 15 min.), F2a prostaglandin in a dose of 5 mg, and also the combined introduction of oxytocin (2,5 PIECES) and F2a prostaglandin (2,5 mg).

If introduction of oxytocin and prostaglandin during 5 — 6 hours does not give effect, carry out repeated initiation of patrimonial activity or raise a question of delivery by Cesarean section.

At premature izlitiya of amniotic waters (see. Premature bursting of waters ), irrespective of readiness of an organism for childbirth, 3 — 4 times create the «accelerated» hormonal background by intramuscular administration of solution of folliculin (estrone), oestradiol of Dipropionas or hexestrol with ether (0,5 — 1 ml) each 2 — 3 hours. Then in the presence a «mature» neck of uterus in 2 — 3 hours after an izlitiya of amniotic waters initiation of patrimonial activity is begun by introduction of oxytocin or F2oc prostaglandin intravenously or inside. Less effective remedies should not be used. If readiness of the pregnant woman for childbirth is absent, especially in the presence of other pathology, or in labor the anomalies of patrimonial activity which are not giving in to treatment and also loss of a loop of an umbilical cord, a hypoxia of a fruit and other complications take place, and there are no conditions for bystry delivery in natural patrimonial ways, delivery by Cesarean section is shown. Due to the danger of traumatizing a fruit at rodorazreshayushchy operations in natural patrimonial ways most of obstetricians consider expedient extension of indications to Cesarean section at pelvic presentation.

In the third (puerperal) period of childbirth carry out prevention of bleeding by drop introduction intravenously metilergometri-on or oxytocin.

The forecast

Perinatal mortality at Other item is on average equal to 80 — 120 ‰. Intra-and a postnatal mortality during the use of a manual grant from 33 to 92 ‰ hesitate, at extraction of a fruit — from 200 to 250 ‰, i.e. almost every fourth child perishes.

The children born in pelvic presentation should be carried to group of high risk since perinatal mortality (see) at this pathology is 3 — 5 times higher, than at childbirth in occipital presentation. For rendering the resuscitation help to newborns presence at the time of delivery not only of the obstetrician and the anesthesiologist, but also the pediatrician (neonatolog) is desirable. At joint survey the condition of the newborn is estimated, special attention is paid to identification of symptoms of an intracranial injury, disturbance of cerebral circulation. In 20 — 22,5% of cases newborns have a dysplasia of hip joints, disturbance nevrol is twice more often observed. status and delay of motor development.

Maternal mortality (see) at Other item it is connected with the same reasons, as at head presentation (see. Childbirth ).

Prevention of complications

Danger to mother and especially for a fruit decreases at early diagnosis of Other item, use of corrective gymnastics for the purpose of correction of pelvic presentation, timely hospitalization (38 — 39 weeks), wide use of modern methods of a research for assessment of a condition of a fruit, a rational method of delivery, cardiomonitor overseeing by a condition of a fruit in labor, use of a manual grant across Tsovyanov and timely Cesarean section.



Bibliography: Grishchenko I. I. and Sh at - l e sh about in and A. E. Prenatal corrections of the wrong provisions and pelvic presentations, Kiev, 1979; D and - sink I. F. Metod of the prevention and corrections of pelvic presentation, Akush. and ginek., No. 5, page 71, 1961; Ilyin I. V. To a discussion about conducting pregnancy and breech labors of a fruit, in the same place, No. I, page 49, 1979; The Multivolume guide to obstetrics and gynecology, under the editorship of JI. S. Persianinova, t. 3, book 1, page 25, M., 1964; Practical obstetrics, under the editorship of A. P. Nikolaev, page 90, etc., Kiev, 1968; The P e r N at x and E. A. Pregnancy and childbirth at pelvic presentations, Akush. and ginek., No. 4, page 52, 1980; Andreyev Zh. S. Sedalishchno to the razhdena, Sofia, 1976; Martius G. Gynakolo-gische Operation en, S. 54, Stuttgart — N. Y., 1980; ZatuchniG. I. a. Andros G. J. Prognostik index for vaginal delivery in breech presentation at term, Amer. J. Obstet. Gynec., v. 98, p. 854, 1967.


E. A. Chernukh.

Яндекс.Метрика