The head is presented above the entrance to the small pelvis. Breech presentation

In the early stages of pregnancy, the baby is still so small that it moves freely in the uterine cavity and can occupy any position there. However, over time, the baby grows and his movements in the uterus become more limited. Thus, by approximately the 28th–30th week of pregnancy, it occupies a certain position - as a rule, longitudinally with the head down. This position of the baby is called cephalic presentation. Normally, a baby is born head first. But sometimes a situation arises when the child’s buttocks or legs are installed above the entrance to the pelvis towards the end of pregnancy. In this case, they speak of breech presentation of the fetus. The incidence of this complication varies between 2.7–5.4 %.

There are several types of breech presentation of the fetus:

purely gluteal (the buttocks of the fetus are installed above the entrance to the small pelvis, with the legs bent at the hip joints, straightened at the knees and extended along the body);
mixed gluteal (buttocks present with one or two legs bent at the hip and knee joints);
leg (full - both legs are presented and incomplete - one leg is presented).

Pure breech presentation is the most common (approximately 65 % of cases).

Often during childbirth, a transition from one type of breech presentation to another may occur. Pure breech presentation is more often observed in primiparous women, mixed breech and leg presentation in multiparous women, which is associated with a decrease in the muscle tone of the uterus and anterior abdominal wall: the fetus has the ability to move more. It has been noted that breech presentation in multiparous women occurs approximately 2 times more often than in primiparous women.

Risk factors

There are a number of factors that can contribute to the occurrence of breech presentation:

narrow pelvis;
abnormal shape of the pelvis (for example, after suffering from rickets in childhood);
malformations of the uterus (saddle-shaped, bicornuate uterus, presence of a septum in the uterus);
uterine fibroids (benign tumors) and tumors of the uterine appendages;
placenta previa (the placenta partially or completely blocks the exit from the uterine cavity). In this and other conditions listed above, the normal position of the fetus is disrupted, the head cannot take the correct position due to the presence of an obstacle and it is more convenient for the child to position his buttocks down;
excessive mobility of the child with polyhydramnios or limited mobility with oligohydramnios, multiple births;
pathological hypertonicity of the lower segment of the uterus and decreased tone of its upper sections. In this case, the fetal head, as the largest and densest part of the body, is pushed away from the entrance to the pelvis and takes a position in the upper part of the uterine cavity. Such disturbances in the contractile activity of the uterus in the third trimester of pregnancy can be caused by dystrophic changes in the myometrium due to inflammatory processes, repeated curettage, multiple pregnancies and complicated childbirth;
malformations of the fetus (for example, hydrocephalus - an excessive increase in cerebrospinal fluid in the cranial cavity, when the enlarged head is too crowded in the lower segment of the uterus and the fetus turns down with the pelvic end).
In addition, it was noted that those patients who were themselves born in a breech presentation often experience a similar situation during their own pregnancy. These facts may indicate a hereditary predisposition to breech presentation. However, this issue requires further study.

Diagnostics

The location of the fetus in the uterus can be determined during a routine external examination by a doctor at the antenatal clinic. With breech presentation, the following signs are determined:

When you feel the abdomen, the fetal head is located in the fundus of the uterus (its upper part) in the form of a dense formation, and the buttocks are located below the entrance to the pelvis (large, irregularly shaped, softer presenting part).

The fetal heartbeat is heard more clearly at the level of the navel and above, in contrast to cephalic presentation, when the heartbeat is heard below the navel.

The nature of fetal presentation is most accurately revealed by ultrasound, during which it is important to establish the type of breech presentation, trace the location of the legs in a breech presentation, determine whether the head is bent or straightened, and what are the features of the location of the umbilical cord. All these data are important in determining further tactics when choosing a method of delivery.

Correction methods

The final pattern of presentation is formed by the 34th–36th week of pregnancy; before this period, the baby can still roll over. Breech presentation of the fetus up to 28 weeks of pregnancy is the norm and does not require any measures to correct the situation - just dynamic observation is enough. Turning of the baby onto its head occurs spontaneously before birth in 70% of multigravidas and in 30% of primigravidas with breech presentation.

If, during pregnancy over 28–30 weeks, the doctor reveals a breech presentation during examination and it is confirmed at the third screening ultrasound of the fetus (at 32–34 weeks of pregnancy), the pregnant woman is recommended to carry out a set of gymnastic exercises to help turn the fetus onto its head. The essence of all these exercises comes down to creating discomfort in the child in a certain position, after which he strives to take a convenient and comfortable position by turning over.

There are several methods of such exercises:

Methodology of Grishchenko I. I. and Shuleshova A. E.

Exercises are performed before meals 4-5 times a day. It is necessary to lie on the side opposite to the position of the fetus (that is, opposite to the position of the child’s back). Bend your legs at the knees and hip joints. You should spend about 5 minutes in this position, and then straighten your upper leg and, while inhaling, press it to your stomach; while exhaling, straighten your leg, bending slightly forward. These movements must be repeated slowly for 10 minutes. Then you should lie down for 10 minutes without moving on your back, and then take the knee-elbow position for 5-10 minutes. Thus, the child is subject to additional pressure that creates inconvenience, and he tends to turn around in order to get into more comfortable conditions.

Dikan's technique I. F.

Exercises are performed 3–4 times a day. It is necessary to alternately lie on your right and left sides for 10 minutes. You need to change position 4-5 times during the exercise. This technique is well suited for pregnant women with increased uterine tone, since in the lateral position, uteroplacental blood flow improves, the muscles of the uterus relax, and the baby has room to move and the ability to roll over.

"Bridge". You need to lie down on a flat sofa or bed, or on the floor, place a pillow under your lower back so that your pelvis is 20–30 cm higher than your head. You should remain in this position for 10–15 minutes. Performed 2 times a day before meals. During this exercise, the baby's head strongly presses against the fundus of the uterus, creating significant discomfort for the baby, and he tends to turn.

It should be remembered that for all these exercises there are certain contraindications, which include:

a scar on the uterus (after a cesarean section in a previous birth or other operations on the uterus);
placenta previa;
threat of premature birth;
oligohydramnios;
polyhydramnios;
multiple births;
gestosis (toxicosis of the second half of pregnancy, manifested by edema, increased blood pressure, and the presence of protein in the urine);
uterine tumors;
severe maternal concomitant diseases (for example, heart defects, arterial hypertension, diabetes mellitus).

According to various authors, the effectiveness of these exercises is about 75%.

To the hospital before giving birth

Upon reaching 38–39 weeks, all pregnant women with breech presentation are advised to undergo prenatal hospitalization in a hospital. An in-depth examination of the pregnant woman is carried out there:

Ultrasound to determine the type of presentation (pure breech, mixed breech or leg), the degree of extension of the head (normally the fetal head is bent and the chin is pressed to the chest, extension of the head can complicate its birth), the size of the fetus;
according to indications (for example, if a large fetus is expected) - X-ray pelviometry (accurate determination of the size of the pelvis using computed tomography or magnetic resonance imaging);
assessing the condition of the fetus using cardiotocography - studying the fetal heartbeat and uterine tone, conducting a non-stress test (studying the reaction of the fetal cardiovascular system in response to its movements: with physical activity, the heart rate increases);
assessment of a woman’s body’s readiness for childbirth.

Based on the examination results, the prognosis of labor and the choice of obstetric tactics for its management are determined. During the examination, pregnant women are divided into 3 groups according to the risk level of upcoming birth for the fetus.

TO Group I Pregnant women are classified as high risk:

estimated fetal weight more than 3600 g – large fetus;
narrowing of the pelvis;
chronic hypoxia (lack of oxygen) of the fetus;
extragenital (not related to pregnancy) diseases affecting the condition of the fetus and labor, for example arterial hypertension, diabetes mellitus, renal failure;
primigravidas over 30 years of age.

These pregnant women usually undergo a elective cesarean section.

In II group includes pregnant women who may develop complications during childbirth (for example, with a low placenta, entanglement of the umbilical cord, rapid labor in the past). Childbirth in this group must take place under mandatory intensive monitoring of the state of labor and the fetal heartbeat. If complications arise during childbirth, a caesarean section is performed.

TO III group pregnant women are classified as low risk. Their birth is carried out with usual supervision. This includes women under 30 years of age without serious chronic diseases, an estimated fetal weight of up to 3600 g, normal pelvic dimensions and satisfactory fetal condition according to CTG and Doppler measurements (a method for studying utero-fetal-placental blood flow).

Indications for surgery

The absolute indications for performing a planned caesarean section are:

extragenital diseases that require the exclusion of attempts (for example, heart defects, including operated ones, threatening retinal detachment, etc.);
severe disturbance of fat metabolism (obesity of the 2nd degree and higher);
pregnancy after IVF;
post-term pregnancy (pregnancy 42 weeks or more);
malformations of the internal genital organs;
narrowing of the pelvis;
scar on the uterus;
estimated fetal weight less than 2000 g or more than 3600 g;
placenta previa (situations when the placenta partially or completely covers the internal os of the cervix);
cicatricial changes in the cervix;
multiple pregnancy (breech presentation of the first fetus located closer to the entrance to the pelvis). In other cases, cesarean section is performed according to a combination of indications (for example, the age of the expectant mother is over 30 years, complications during pregnancy, chronic fetal hypoxia).
The caesarean section rate for breech presentation is 80 % or more.

How will the birth go?

The main difference between birth in a breech presentation through the natural birth canal and birth in a cephalic presentation is as follows. The largest part of the fetus - the head - during childbirth in the cephalic presentation, is the first to overcome all the narrow parts of the bony pelvis, being configured by soft sutures and fontanelles. If there is a discrepancy between the sizes of the head and the bony pelvis, then the child simply cannot be born on its own and an emergency caesarean section is performed. If the head has successfully passed all the narrow parts of the pelvis and was born, then the remaining parts of the baby are born without much effort. With a breech presentation, the narrow sections of the pelvis are the first to overcome the baby’s buttocks, which happens quite easily, but when it comes to the head, a discrepancy may arise, which will be critical, and surgical intervention will be required.

During childbirth with breech presentation, the following complications may develop:

Premature rupture of amniotic fluid (rupture of the membranes before the opening of the cervix by 5–6 cm is considered premature, since until this moment the amniotic sac is involved in the process of dilatation). This occurs due to the strong pressure of small parts of the fetus on the lower pole of the amniotic sac.
The loss of small parts of the fetus and the umbilical cord occurs with premature rupture of the membranes and rupture of amniotic fluid due to the lack of tight contact between the pelvic end of the fetus and the lower segment of the uterus.
Primary weakness of labor occurs at the beginning of labor due to premature rupture of amniotic fluid and insufficient pressure of the pelvic end of the fetus, which is softer than the head, on the cervix.
Secondary weakness of labor develops during labor due to the fact that the woman in labor becomes fatigued with prolonged labor. It manifests itself as weak contractions, during which the opening of the cervix slows down or stops.
As the fetal head passes through the birth canal, the umbilical cord may become tightly pressed against the walls of the pelvis. If it lasts more than 5–7 minutes, then fetal death may occur (as oxygen-carrying blood stops flowing to the fetus and severe hypoxia occurs).
The throwing back of the arms and the extension of the head in the second stage of labor occurs reflexively at the birth of the body.
Aspiration of amniotic fluid is the entry of water into the baby’s respiratory tract when trying to take a breath when his head is still in the birth canal and has not been born.
Injuries to the birth canal and fetal injuries (traumatic brain injury with cerebral hemorrhages) occur when the birth of the fetal head and shoulders is difficult.

Management of childbirth

In the first stage of labor, constant monitoring of the condition of the fetus (CTG recording) and contractile activity of the uterus is necessary. Timely pain relief during labor and the administration of antispasmodic drugs are carried out in order to accelerate the dilatation of the cervix. Timely diagnosis of possible complications, their correction and determination of further labor management tactics are important.

During contractions, a pregnant woman is recommended to rest in bed; a vertical position is unacceptable, as premature rupture of water and loss of umbilical cord loops are possible. This is due to the size of the presenting part, which is smaller than the head and does not press tightly against the entrance to the pelvis.

A doctor delivers a breech birth, as opposed to a physiological birth, which is performed by a midwife under the supervision of a doctor. In the second stage of labor (during pushing), it is desirable to monitor cardiotocography, while during normal labor, sometimes simply listening to the fetal heartbeat between pushes with an obstetric stethoscope is sufficient. OXYTOCIN (a drug that increases contractile activity of the uterus) is injected intravenously to prevent weakness in pushing. Dissection of the perineum (episiotomy) is mandatory to speed up the passage of the head after the pelvic end and reduce the duration of compression of the umbilical cord by the head. Depending on the type of breech presentation, after eruption of the presenting part, special obstetric care is provided (actions performed by an obstetrician-gynecologist). The most common is the Tsovyanov manual - it is used for pure breech presentation. It is based on the preservation of the normal position of the fetus (the legs are kept in a bent position, pressed to the body until they are fully born), which prevents the development of such serious complications as throwing back the arms and straightening the head. Next, a classic manual aid is performed for breech presentations (releasing the shoulder girdle and fetal head).

In mixed breech presentation, support is provided from the moment the lower corners of the shoulder blades emerge from the genital slit; it is aimed at freeing the fetal shoulder girdle and facilitating the birth of the head.

The birth tumor (swelling of the soft tissues of the presenting part) with breech presentation is located on the buttocks, with leg presentation - on the child’s legs, which from this become swollen and blue-purple. Often the birth tumor moves from the buttocks to the external genitalia of the fetus, which looks like swelling of the scrotum or labia.

The need for a cesarean section during natural childbirth may arise in the following cases:

when umbilical cord loops or small parts of the fetus fall out;
when the condition of the fetus worsens due to increasing hypoxia;
in case of uncorrectable weakness of labor within 2–3 hours or in case of ineffective labor stimulation during this time during prenatal rupture of waters;
with premature detachment of a normally located placenta.

In conclusion, it should be said that no matter where your baby is located and no matter how he is born, the most important thing is that he is born healthy. And don’t be upset if doctors recommend a cesarean section. When you are close to your child, you will forget all your doubts and just enjoy happy motherhood! But if the doctor talks about the possibility of a natural birth and sees no indication for a cesarean section, you should not be afraid of a natural birth. The main thing is a positive attitude, confidence that everything will go well, and careful implementation of all the doctor’s recommendations during childbirth.

Harbingers of childbirth

Already from the ninth month, the body is reconstructed from a state of “preserving pregnancy” to a state of preparation for childbirth. The last month of pregnancy gives you a whole range of new sensations indicating the approach of childbirth. All these sensations are called “harbingers” of childbirth. They can appear 2-4 weeks before birth, or maybe a few hours before it. Some women may not experience any discomfort, but this does not mean that their body is not preparing for the birth of a child, since these sensations are individual for each woman.

Reasons and mechanisms for preparing the body for childbirth

1. Aging of the placenta

Placental hormones play a major role in the development of labor. From the 36th week of pregnancy, the placenta begins to change the amount of hormones produced: estrogen levels increase and progesterone levels decrease. Since progesterone inhibited the contractile activity of the uterus during pregnancy, a decrease in its level in the blood of the expectant mother leads to increased contractions of the uterus.
Estrogens activate the synthesis of contractile proteins of the uterus, thereby increasing the sensitivity of uterine muscle cells to irritation. Thus, without causing contractions of the uterine muscle, estrogens seem to increase its sensitivity to substances that cause contraction. An increase in estrogen levels leads to an increase in the content of prostaglandins in the uterus. They stimulate the secretion of oxytocin in the pituitary gland in the mother and fetus, cause the destruction of progesterone, and also directly trigger labor by causing contraction of the uterine muscle.

2. Generic dominant

It is believed that a normal course of labor is possible only when a “generic dominant” is formed in the pregnant woman’s brain. 1.5-2 weeks before birth, there is a significant increase in the electrical activity of the areas of the brain responsible for labor, which also increases the production of oxytocin, the main hormone of labor, in the pituitary gland.

3. Fruit maturity

In addition, due to the high growth rate of the fetus and the decrease in amniotic fluid, the uterus grasps it more and more tightly. In response to stress, the fetal adrenal glands begin to secrete large amounts of cortisol, the stress hormone. Fetal cortisol also promotes the production of prostaglandins in the mother. There is evidence that after the maturation of the hypothalamic-pituitary-adrenal system of the fetus during full-term pregnancy, the adrenal glands begin to produce cortisol, which stimulates the production of prostaglandins, and not stress triggers this process.
Labor will begin as soon as the required amount of prostaglandins and oxytocin accumulates in the pregnant woman’s body. In the meantime, estrogens will make the tissues of the birth canal more elastic and pliable: the cervix, vagina and perineum.

Anatomy of readiness for childbirth

Towards the end of pregnancy, the fetal head descends to the entrance to the small pelvis and presses tightly against the bony ring of the pelvis, so the fetus prepares for birth. It occupies a characteristic position: the baby’s torso is bent, the head is pressed to the chest, the arms are crossed on the chest, and the legs are bent at the knee and hip joints and pressed to the tummy. The position that the baby occupies at 35-36 weeks does not change anymore. In this position, the baby will move along the birth canal during childbirth.
In the case of the pelvic position of the fetus, the lowering of the presenting part (mainly the buttocks of the fetus) does not occur, since due to its large size and softness, the child’s butt cannot be inserted into the bone ring of the mother’s pelvis.

Towards the end of pregnancy, a woman’s body produces the hormone relaxin, which relaxes all ligaments and muscles, preparing them for childbirth. The lower segment of the uterus becomes softer and stretches before childbirth. In the first pregnancy, this occurs several weeks before birth, and in subsequent pregnancies, just before birth.

"Raturation" of the cervix
The cervix (a muscular formation with circularly arranged muscle fibers), under the influence of estrogens and prostaglandins, shortens, softens, and takes a middle position along the axis of the birth canal before childbirth. This process is called "ripening" of the cervix and is the first harbinger of labor.

This harbinger of labor is more noticeable to the obstetrician during examination than to the woman herself. The maturity of the cervix is an important criterion for the body’s readiness for childbirth. Ripening in the prenatal period, the cervix opens slightly, which facilitates its further opening during childbirth... In a healthy woman with good hormonal levels, the cervix is mature by the time of delivery, which means it is ready for the onset of labor. If a woman, for some reason, has a reduced formation of prostaglandins, then the cervix is not mature enough at the time of birth and may require medicinal preparation (introduction of artificial prostaglandins). Signs of cervical maturity appear during full-term pregnancy, starting at 38 weeks.

True harbingers of childbirth

Precursors of childbirth are usually called external manifestations of those changes in her body that are actually noticeable for the expectant mother, which are direct preparation for the onset of labor. 2-3 weeks before birth the following appear:

"Prolapse" of the abdomen
About 2-3 weeks before giving birth, a woman feels that her stomach has dropped. This is due to the fact that the fetal head is pressed tightly against the entrance to the pelvis. At the same time, the height of the uterine fundus, which increases by 1 cm weekly and by the 37th week is about 37-40 cm (if there is only one baby in the uterus), decreases by 2-3 cm in a few hours. In multiparous women, this rarely happens before the onset of labor . The expectant mother notes that the shape of the abdomen is changing - it becomes flat, sloping at the top. A palm can now easily fit between the chest and stomach. As a result of moving the child, pressure is removed from the diaphragm (the partition that separates the chest cavity from the abdominal cavity) and stomach, it becomes easier to breathe, shortness of breath disappears due to the fact that there is more room for the lungs, heartburn goes away, since the descending fundus of the uterus no longer puts so much pressure on the stomach. But painful sensations may appear in the lower abdomen and legs, because now the baby is putting pressure on the muscles, ligaments and nerve endings.

Frequent urination
After the fetal head is displaced and pressed against the entrance to the pelvis, the uterus begins to press on the bladder with even greater force. Added to this is a physiological increase in urine output to thicken the blood before childbirth, and the toilet in the last days of pregnancy should always be within direct reach.

Loosening the "stool"
Childbirth hormones affect a woman’s intestines, leading to a decrease in the tone of its wall and causing loosening of the “stool”. Some women may experience mild abdominal cramps and diarrhea. There is a feeling of pressure in the rectum and pelvic area (there may be a false urge to defecate).

Reducing body weight
Before the onset of labor, some women lose weight from 1 to 2 kg, mainly due to the body's release of excess fluid in the form of urine. The additional volume of fluid that was previously used to produce amniotic fluid and increase the volume of blood circulating in the body of the mother and child is no longer needed - excess water is eliminated from the body. The usefulness of this harbinger lies in the fact that as a result of a decrease in the liquid part of the blood, the blood thickens, its coagulability increases, which helps reduce blood loss during childbirth.

Removal of the mucus plug
As the cervix ripens, its canal begins to open slightly. During pregnancy, thick cervical mucus in the form of a plug prevents harmful microorganisms from entering the uterus, and by the time of birth it thins out. The thinning of mucus is facilitated by estrogens, the level of which increases towards childbirth. All this leads to the fact that a lump of colorless, yellowish, or blood-stained mucus is pushed out of the cervical canal. More often, the mucus plug is released gradually, in parts, leaving brownish marks on the underwear for 1-3 days. Much less often, it leaves entirely at once, then it is light or dark brown discharge in the amount of about 1-2 tablespoons. The removal of the mucus plug is an equally significant criterion for the body’s readiness for childbirth; this usually occurs 1-3 days before birth (rarely 5 days). Every woman has a question: is this amniotic fluid? After all, both of these discharges are liquid, and at first observation they seem to be similar.
The water, unlike the mucus plug, is clear, warm and constantly leaking, but may be yellowish or greenish. In order to decide, you can use a simple cough. When you cough, the water will flow more strongly, but the amount of mucus plug will not change. You can also put a gasket, which will get completely wet after a while when the water drains.

Harbingers - sensations

Change in appetite
Appetite may change just before giving birth. More often it decreases. This is due to the influence of changed hormonal levels on the muscular lining of the gastrointestinal tract and its enzymatic activity. The body is preparing to spend energy on childbirth, and not on digesting food.
It is advisable to take food 5-6 times a day, the last meal should be no later than 2-3 hours before bedtime. Meat and fish dishes should be consumed in the first half of the day, dairy - in the second. You should give up meat and fish broths, replacing them with vegetable and milk soups; rich broths require high activity of intestinal enzymes. Explain why.

"Training" contractions
“Training contractions mostly appear 2-3 weeks before birth. They are also called “false” contractions, or Braxton-Higgs contractions. O. The purpose of precursor contractions is to prepare the muscles of the uterus and birth canal, and specifically to promote ripening of the cervix. In order for a muscle to successfully complete a marathon during childbirth, it needs training during pregnancy. It is thanks to these trainings that a pregnant woman, in response to the movement of the fetus or physical activity, periodically feels tension in the abdomen, as if it is “cramping”, the abdomen becomes harder to the touch than usual, and a pulling sensation may occur in the lower abdomen or lower back.
Premonitory contractions are irregular, begin long before birth, come 4-6 times a day, but no more than 2 hours in a row, last a few seconds, rarely up to a minute, their intensity weakens over time or does not change, stops when the body position changes and after massage, warm bath.
True contractions are regular, begin with the onset of labor, and their frequency and intensity increases over time.
If these sensations are not very pleasant and tiresome, you can lie on your side and wait until they pass.

Change in fetal activity
After the head drops, the child presses his head tightly against the bony rim of the small pelvis, as a result of which he cannot turn, but can only move his arms and legs, and his motor activity decreases. The movements of the fetus become more like swaying, it may either calm down a little or move more actively. Fixing the head prevents the baby from turning over and facilitates the beginning of the birth process.

Mood changes
There may be an emotional upsurge, sudden euphoria, causeless sadness, tearfulness, irritability, increased drowsiness, and by the end of pregnancy there is a feeling of fatigue and a desire to bring the hour of labor closer. Sometimes these feelings change quickly throughout the day. Changes in mood are largely associated with neuroendocrine processes occurring in the body of a pregnant woman before childbirth.

Sleep disorders
At this time, it is difficult to find a comfortable position for sleeping, you have to get up often to go to the toilet, “training” contractions at night disturb you much more often, in addition, cramps in the leg muscles may bother you during sleep. All this leads to restless, interrupted sleep.
The manifestation of precursors of labor is very individual and optional. They may appear during the last two to three weeks before childbirth; their presence, as well as absence, is normal and does not require seeing a doctor. It is important to learn to listen to your body’s preparations and not be afraid of changes in well-being associated with prenatal preparation. If you have any doubts, consult a doctor, he will evaluate this or that symptom from a medical point of view.

Lingering harbingers

Sometimes the period of precursors of labor is delayed. Then the normal period of precursors passes into the pathological preparatory (preliminary) period. If normal prenatal contractions of the uterus are painless, often occur at night and lead to ripening of the cervix, then the pathological preliminary period is characterized by painful prenatal contractions that occur not only at night, but also during the day, are irregular and do not develop into labor for a long time. Fatigue and psychological stress accumulate. The duration of the pathological preliminary period can be up to 240 hours, depriving the woman of sleep and peace. In case of severely painful preparatory pain that deprives a woman of rest and sleep, it is better to consult a maternity hospital doctor after 6-7 hours, as this very tires the woman in labor and interferes with the development of normal labor.
The essence of the pathological preliminary period is the increased tone of the uterus, while no changes occur in the cervix. The presenting part of the fetus is not pressed against the pelvic inlet; due to the constant increased tone of the uterus, the fetus suffers oxygen starvation.
The pathological preliminary period is often accompanied by severe disturbances in well-being (sweating, sleep disturbances, pain in the sacrum and lower back, palpitations, shortness of breath, impaired intestinal function, increased and painful fetal movements).
In this case, you need to consult a doctor; sometimes a few hours of full-fledged medicated sleep is enough to restore strength for normal labor. In the absence of treatment, the pathological preliminary period often turns into primary weakness of labor; Fetal hypoxia (lack of oxygen) often occurs, which negatively affects its condition.

The position of the fetus in the uterine cavity in the vast majority of cases (99.5%) is longitudinal and only in 0.5% is transverse or oblique. The longitudinal position of the fetus is spoken of in cases where the length of the fetus coincides with the length of the uterus. With the longitudinal position of the fetus, the uterus has the shape of an ovoid. The fetus, which occupies a longitudinal position, can be turned downwards by the head or pelvic end. That part of the fetus that is closest to the entrance to the pelvis and the first to enter the birth canal is called the presenting part. With longitudinal positions of the fetus, cephalic presentation occurs in 96.5%, pelvic presentation - in 3.5% of cases.

When examined externally, the head is felt in the form of a dense spherical body. To palpate the presenting part, both hands are placed flat on the inferolateral sections of the abdomen and with extended fingertips they try to gradually penetrate the pelvic cavity in order to bring the fingers as close as possible; the latter is successful if the presenting part is absent or located above the plane of the pelvic inlet.

Depending on the position of the head, it is considered mobile, (balloting), pressed or fixed at the entrance to the pelvis (Table 2).

Table 2. Determination of the position of the fetal head in relation to the pelvic planes in occipital presentation

Head location	External research data	Vaginal examination data
The head is balling (or movable) above the entrance to the pelvis	The head moves freely to the sides. The fingers of the examining hands can be easily placed under the head on both sides	It is possible to reach the head with your fingers only if you press it with your outer hand to the entrance to the pelvis. The cape can be felt with outstretched fingers, if it is reachable at all. In addition to the promontory, you can feel the entire internal surface of the small pelvis (the upper edge of the symphysis, innominate lines, the sacrum along its entire length and the pelvic bones)
The head is pressed against the entrance to the pelvis or has limited mobility	The head is deprived of freedom of movement, moving it by hand is difficult. The fingers of the examining hands can be placed on both sides under the head only when the latter is displaced upward	Exploring fingers manage to reach the head, while it can move away. With outstretched fingers you can feel the cape, if it is reachable at all.
The head is fixed by a small segment at the entrance to the pelvis	The largest part of the fetal head, located above the plane of the entrance to the pelvis, is felt with your fingers, i.e. the forehead is felt on one side, and the back of the head on the other. The fingers of the examining hands diverge significantly to the sides	The lower pole of the head and the area of the small fontanel are easily reached with your fingers. The inner surface of the pelvic bones, the sacrum and partly the innominate line, can be felt over a considerable distance. The protruding point of the cape can only be reached with bent fingers
The head is fixed by a large segment at the entrance to the pelvis or located in a wide part of the pelvic cavity	The fingers of the examining hands easily approach each other, since a significant part of the head has already dropped below the plane of the entrance to the pelvis. According to Piskacek, the head is reached with difficulty with the finger	The lower pole (arch) of the head is in the interspinal plane. It is impossible to reach the cape with your fingers. The sacral cavity is not completely filled with the head. Only the last sacral vertebrae can be felt
The head is located in the pelvic cavity, more precisely in the narrow part of the latter	Exploring fingers palpate the cervical-brachial region of the fetus. According to Piskacek, the head is easily reached	The lower pole (arch) of the head is located below the interspinal plane. The sacral cavity is completely completed. It is impossible to palpate either the symphysis or the inner surface of the pelvic bones, including the ischial spines
Head at the pelvic outlet	Same	The head is on the pelvic floor. The vertebrae of the coccyx are difficult to feel. The soft parts of the vulva and vaginal opening are palpated. In the depths of the genital slit the scalp is visible

Table of contents of the topic “Fetal articulation (habitus).”:
1. Articulation of the fetus (habitus). Fetal position (situs). Longitudinal position. Transverse position. Oblique position.
2. Fetal position (positio). Type of position (visus). First position of the fetus. Second position of the fetus. Front view. Back view.
3. Presentation of the fetus (praesentatio). Head presentation. Breech presentation. Presenting part.
4. External techniques for obstetric examination (Leopold's techniques). Leopold's first move. Purpose and methodology of the study (reception).
5. Second appointment of external obstetric examination. Leopold's second move. Purpose and methodology of the study (reception).
6. Third appointment of external obstetric examination. Leopold's third move. Purpose and methodology of the study (reception).
7. Fourth appointment of external obstetric examination. Leopold's fourth move. Symptom of running. Purpose and methodology of the study (reception).

9. Auscultation of the fetus. Listening to the abdomen of a pregnant woman and woman in labor. Fetal heart sounds. Places of best listening to fetal heart sounds.
10. Determination of gestational age. Time of the first fetal movement. Day of the last menstruation.

Degree of insertion of the fetal head into the pelvis It is recommended to define as follows. During the fourth external examination of the obstetric examination, having penetrated the fingers of both hands as deeply as possible into the pelvis and pressing on the head, they make a sliding movement along it towards themselves.

Rice. 4.21. Occipital presentation. The head is above the entrance to the pelvis (the fingers of both hands can be placed under the head).

With a high position of the fetal head when it is movable above the entrance, during external examination it is possible to place the fingers of both hands under it and even move it away from the entrance (Fig. 4.21).

Rice. 4.22. Occipital presentation. The head is at the entrance to the pelvis in a small segment (the fingers of both hands, sliding along the head, diverge in the direction of the arrows).

If the fingers move apart, the head is at the entrance to the pelvis by the small segment m (Fig. 4.22).

Rice. 4.23. Occipital presentation. The head is at the entrance to the small pelvis with a large segment (the fingers of both hands sliding along the head converge in the direction of the arrows).

If the hands sliding along the head converge, then the head or located in a large segment at the entrance, or walked through the entrance and went down into the deeper sections (planes) of the pelvis (Fig. 4.23).

If the fetal head penetrates so deeply into the pelvic cavity that it completely fills it, then usually palpate the head externally no longer possible.

During the expulsion period, repeated external obstetric examinations are carried out to determine the progress of the presenting part along the birth canal. The third and fourth methods of external obstetric examination determine the relationship of the head to various planes of the small pelvis. With a vaginal examination, it is possible to clarify the position of the head. These relationships are usually formulated as follows. The head is above the entrance to the pelvis ( rice. 101,a). The entire head is placed above the entrance to the pelvis; it is mobile, moves freely with pushes (ballots) or is pressed against the entrance to the pelvis. During a vaginal examination, it turns out that the pelvis is free, the head stands high, does not interfere with the palpation of the nameless lines of the pelvis, the promontory (if it is at all accessible), the inner surface of the sacrum and symphysis; the sagittal suture is usually located in transverse size at the same distance from the symphysis and promontory, the large and small fontanelles are at the same level (in case of occipital presentation). The head is at the entrance to the pelvis with a small segment ( rice. 101, b). The head is motionless, most of it is located above the entrance to the pelvis, a small segment of the head is below the plane of the entrance to the pelvis. A vaginal examination reveals that the sacral cavity is free; you can approach the promontory with a bent finger (if it is reachable). The inner surface of the symphysis is accessible to research, the small fontanel is lower than the large one (flexion). The arrow-shaped seam stands in a transverse or slightly oblique dimension. The head is at the entrance to the pelvis with a large segment ( rice. 101, in). During external examination, it is determined that the head with its greatest circumference is below the plane of the entrance to the pelvis (sank into the cavity). The smaller segment of the head is palpated from above. A vaginal examination reveals that the head covers the upper third of the symphysis and sacrum, the promontory is unreachable, and the ischial spines are easily palpable. The head is bent, the small fontanel is lower than the large one, the sagittal suture is in one of the oblique sizes. The head is in the wide part of the pelvic cavity ( rice. 101, g). During external examination, only a small part of the head (forehead) is palpable. A vaginal examination reveals that the head has passed the plane of the widest part of the pelvic cavity with its greatest circumference; two-thirds of the inner surface of the symphysis pubis and the upper half of the sacral cavity are occupied by the head. The IV and V sacral vertebrae and ischial spines can be easily palpated. The arrow-shaped seam is in one of the oblique sizes. The head is in the narrow part of the pelvic cavity ( rice. 10.1, d). During external examination, the head is not detected. A vaginal examination reveals that the upper two thirds of the sacral cavity and the entire inner surface of the pubic symphysis are occupied by the head. The ischial spines are difficult to reach. The head is close to the bottom of the pelvis, its internal rotation is not yet completed, the sagittal suture is in one of the oblique sizes, close to straight. Head at the outlet of the pelvis ( rice. 101, e). During external examination, the head cannot be felt at all. The sacral cavity is completely filled with the head, the ischial spines are not defined, the sagittal suture is in the direct dimension of the pelvic outlet. Rice. 101. The relationship of the fetal head to the planes of the pelvis. a - head above the pelvic inlet; b - the head is a small segment at the entrance to the pelvis; c - the head is a large segment at the entrance to the pelvis; g - head in the wide part of the pelvic cavity; d - head in the narrow part of the pelvic cavity; e - the head at the outlet of the pelvis. To control the forward movement of the head during the expulsion period, the Piskacek-Genter method is used. During the normal course of labor, there is a sequential movement of the head through the birth canal; it does not stand for a long time in one plane of the pelvis. Prolonged standing of the head in the same plane of the pelvis indicates the occurrence of some obstacles to the expulsion of the fetus or a weakening of labor. When the head stands in one plane for a long time, long-term compression of the soft tissues of the birth canal and bladder occurs, followed by poor circulation.