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Management of the II period in breech presentation

 
, medical expert
Last reviewed: 19.10.2021
 
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In the II stage of labor, intravenous administration of oxytocin should be done by dropping, starting at 8 drops / min, increasing every 12 to 16 drops, but not exceeding 40 drops per minute. At the end of the II period of labor to prevent spastic contraction of the uterine pharynx simultaneously with uterine contracting agents, intramuscular injection of spasmolytics (gangleron solution 1.5% - 2 ml, no-spawning - 2-4 ml of standard solution or atropine sulfate solution 0.1 % 1 ml). Experience shows that with the intensification of labor activity with oxytocin in the period of expulsion, indications for extraction are extremely rare, as well as the previously observed complication-the tilting of the handles.

The most favorable for the fetus is delivery by method of N. A. Tsovyanov (abroad by the Braht method). Without describing this method, as well as the classical manual manual, which are detailed in the special manuals, we recommend the use of the Müller's method of releasing the shoulders and pens in our modification:

The first option is applied from the moment of the birth of the lower angle of the anterior scapula, when the obstetrician, without changing the position of the hands, pulls the trunk of the child downwards, so that the frontal shoulde fits under the symphysis. The front handle is born in this case spontaneously, or it can be easily removed. Then the trunk is deflected upwards (anteriorly), so that the rear shoulders with the rear handle are released.

The second option: the trunk of the fetus is deflected anteriorly (upward), and the second and third fingers of the right hand of the obstetrician (at the 1st position of the fetus) or the left arm (at the 2nd position) are held sequentially along the shoulder, the elbow and the forearm of the back handle. The latter is released by the usual "wash" movement and taken out. As soon as the rear handle is withdrawn, the trunk of the fetus is taken down (back) by the same "external" arm; "Wash" movement of the same "inner" hand from under the bosom of the front handle. Thus, the release and removal of fetal handles in pelvic presentation can be performed without an external rotation around the longitudinal axis of the pelvis at 180. There is also no need for sequential insertion of the surgeon's hands into the vagina. It is also important that the handbook is produced with one "inner" hand, that is, the obstetrician should not change his hand when releasing the "front" and "back" fetus handles.

With regard to the fourth moment - the birth of the subsequent head with various kinds of difficulties - it can be inferred in one of a variety of ways, while the most physiological and convenient and least dangerous for both the mother and the fetus is the Moriso-Levre method (described in detail in the textbooks on operative obstetrics). With this method of removing the head of traction, it is necessary to make an "inward" arm in the direction of the axis of the birth canal anteriorly (upward). At the time of removal of the fetal head, gentle pressure should be applied with the hand on the head from the side of the maternity belly.

We recommend to pay attention to the new technique of flexing the subsequent head at birth of the fetus in the pelvic presentation on Myers.

As is known, one of the important moments in the management of labor in the pelvic presentation of the fetus is the prevention of extension of the subsequent head. At the present time, the most widely used method is Moriso (1664) - Smelly-Veit (1906) and the application of forceps Piper (abroad), both with vaginal delivery and with abdominal delivery.

A new modification of the frontal head flexion when conducting labor in the pelvic presentation of the fetus: after the appearance of the handles, the trunk of the fetus is placed on the palm of the left hand of the obstetrician, as in the classical method. The index and middle fingers of this hand are placed on the upper jaw of the fetus on either side of the nose. The palm of the right hand of the obstetrician is at the level of the shoulder girdle of the fetus, the index and middle fingers are inserted as deep as possible along the spine, which allows the preterm fetuses to reach the occiput. During the attempt, the combined movement of the fingers of the obstetrician makes it possible to produce the necessary degree of flexion of the fetal head.

If there is difficulty in the birth of the head, the following method is recommended. After turning the body of the fetus with your back to the mother's left thigh and the birth of the anterior handle (at 1 position), you should rotate the fetus not to the bosom, as recommended by NA Tsovyanov, but to the opposite thigh of the parturient woman, to her groin (to the right one at position 1) and then to the bosom. Due to this turn, after the born back (in this case, the right) handle the head itself turns into a straight size and is born without any difficulties.

In the case of leg (full or incomplete) presentation, it is advisable to perform colpeiris surgery - the introduction into the vagina of a rubber balloon - colpeyrinter filled with sterile isotonic sodium chloride solutions. The most physiological should be considered the application of colpeiris operation of variable capacity, i.e. By the type of communicating vessels (according to the method of Sobestiansky-Starovoitova). In this case, the compensation tank should be placed 100 cm above the bed level of the parturient child.

The operation of colpeirisis is indicated only in the conservative management of labor, the presence of a whole fetal bladder, small fetal size and sufficient labor and is contraindicated in the prolapse of the umbilical cord.

Abroad for the birth of the fetus body, three methods are used:

  1. The total extraction of the fetus at the pelvic end, in which one, and then both lower limbs, are captured and used literally to extract the fetus from the uterus, is the most dangerous way (!) Of normal births with breech presentation.
  2. Spontaneous birth of the fetus entirely, without the use of manual techniques - the second most dangerous method.
  3. Artificial birth, in which the fetus is born spontaneously to the level of the navel, and then produce its extraction. This is the least dangerous (!) Way of delivery.

Thus, the following factors predispose to damage to the fetus during labor during pelvic presentation:

  • increased probability of umbilical cord prolapse;
  • compression of the umbilical cord in the first stage of labor;
  • increased probability of premature placental abruption;
  • infringement of the fetal head in the throat of the uterus;
  • damage to the head and neck of the fetus during rapid passage through the birth canal;
  • damage to the head and neck of the fetus as a result of the chosen method of conducting labor;
  • tipping the fetus's handles by the head, which can be observed frequently, increases the likelihood of nerve damage.

trusted-source[1], [2], [3], [4], [5], [6], [7], [8], [9]

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