Management of the II period in breech presentation

In the second stage of labor, it is necessary to use intravenous drip oxytocin, starting with 8 drops/min, increasing every 5-10 minutes to 12-16 drops, but not more than 40 drops per minute. At the end of the second stage of labor, to prevent spastic contraction of the uterine os, simultaneously with uterine contraction agents, antispasmodics should be administered intramuscularly (1.5% ganglerone solution - 2 ml, no-shpa - 2-4 ml of standard solution or 0.1 % atropine sulfate solution - 1 ml). Experience shows that when labor is enhanced by oxytocin in the expulsion period, indications for extraction arise extremely rarely, as well as the previously observed complication - throwing back of the arms.

The most favorable for the fetus method of labor management is N. A. Tsovyanov (abroad by the Bracht method). Without describing this method, as well as the classic manual aid, which are described in detail in special manuals, we recommend using the method of releasing the shoulders and handles according to Müller in our modification:

The first option is used from the moment of birth of the lower angle of the anterior scapula, when the obstetrician, without changing the position of the hands, pulls the child's body strongly downwards, as a result of which the anterior shoulder of the fetus fits under the symphysis. The anterior arm is born spontaneously, or it can be easily removed. Then the body is tilted upward (anteriorly), due to which the posterior shoulder with the posterior arm is released.

The second option: the fetus's body is tilted forward (upward), and the II and III fingers of the obstetrician's right hand (with the fetus in the 1st position) or left hand (with the 2nd position) are successively passed along the shoulder, elbow bend and forearm of the back arm. The latter is released with a normal "washing" movement and brought out. As soon as the back arm is brought out, the fetus's body is moved downward (backward) with the same "outer" hand; with a "washing" movement, the front arm is brought out from under the pubis with the same "inner" hand. Thus, the release and removal of the fetus's arms in breech presentation can be performed without external rotation around the longitudinal axis of the pelvis by 180. There is also no need for the surgeon to alternately insert the hands into the vagina. It is also important that manual assistance is performed with one “inner” hand, i.e. the obstetrician should not change hands when releasing the “front” and “back” arms of the fetus.

With regard to the 4th moment - the birth of the subsequent head in case of various kinds of difficulties - it can be brought out in one of many ways, while the most physiological and convenient and the least dangerous for both the mother and the fetus must be recognized as the Morisot-Levre method (described in detail in textbooks on operative obstetrics). With this method of bringing out the head, traction must be done with the "inner" hand in the direction of the axis of the birth canal obliquely forward (upward). At the moment of bringing out the head of the fetus, it is necessary to apply gentle pressure with the hand on the head from the side of the mother's abdomen.

We recommend that you pay attention to the new method of bending the subsequent head during the birth of a fetus in breech presentation according to Myers.

As is known, one of the important moments in the management of labor in the breech presentation of the fetus is the prevention of extension of the subsequent head. At present, the most widely used method is the Morisot (1664) - Smellie-Wait (1906) and the application of Piper forceps (abroad) both in vaginal and abdominal delivery.

A new modification of fetal head flexion during labor in breech presentation: after the arms appear, the fetal body is placed on the palm of the obstetrician's left hand, as in the classical method. The index and middle fingers of this hand are placed on the fetal upper jaw on either side of the nose. The palm of the obstetrician's right hand is at the level of the fetal shoulder girdle, the index and middle fingers are inserted as deeply as possible along the spine, which allows the occipital protuberance to be reached in premature fetuses. During pushing, the combined movement of the obstetrician's fingers allows the necessary degree of fetal head flexion to be achieved.

In case of difficulties with the birth of the head, the following method is recommended. After turning the body of the fetus with its back to the mother's left thigh and the birth of the front arm (in the 1st position), the fetus should be turned not towards the womb, as recommended by N. A. Tsovyanov, but towards the opposite thigh of the mother in labor, towards her groin (to the right one in the 1st position), and then towards the womb. Thanks to this turn, following the birth of the back (in this case, the right) arm, the head itself turns to the straight size and is born without difficulties.

In case of foot (complete or incomplete) presentation, the colpeiris operation is advisable - insertion of a rubber balloon - colpeirinter, filled with sterile isotonic sodium chloride solutions into the vagina. The most physiological should be considered the use of the colpeiris operation of variable capacity, i.e. by the type of communicating vessels (according to the Sobestiansky-Starovoitov method). In this case, the compensation reservoir should be placed 100 cm above the level of the mother's bed.

The colpeiris operation is indicated only in the case of conservative management of labor, the presence of an intact amniotic sac, small fetal size and sufficient labor activity, and is contraindicated in the case of prolapse of the umbilical cord loop.

Abroad, three methods are used to deliver the fetus's body:

1. Total fetal extraction by the pelvic end, in which one and then both lower limbs are grasped and used literally to extract the fetus from the uterus, is the most dangerous method (!) of normal childbirth in breech presentation.
2. Spontaneous delivery of the entire fetus, without the use of manual techniques, is the second most dangerous method.
3. Artificial labor, in which the fetus is born spontaneously up to the navel level, and then it is extracted. This is the least dangerous (!) method of childbirth.

Thus, the following factors predispose to damage to the fetus during childbirth in breech presentation:

• increased risk of umbilical cord prolapse;
• compression of the umbilical cord in the first stage of labor;
• increased risk of premature placental abruption;
• infringement of the fetal head in the cervix of the uterus;
• damage to the fetus's head and neck during rapid passage through the birth canal;
• damage to the head and neck of the fetus as a result of the chosen method of delivery;
• Throwing the fetus' arms back behind its head, which can occur frequently, increases the risk of nerve damage.

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