The head is located 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 take any position there. However, over time, the baby grows and its movements in the uterus become more limited. Thus, by about 28–30 weeks of gestation, it occupies a certain position - as a rule, longitudinal head down. This position of the baby is called head presentation. Normally, a baby is born head first. But sometimes a situation arises when the buttocks or legs of the child are installed above the entrance to the small pelvis by the end of pregnancy. In this case, they speak of a breech presentation of the fetus. The incidence of this complication varies within 2.7–5.4%.

There are several types of pelvic presentation of the fetus:

purely gluteal (the buttocks of the fetus are installed above the entrance to the small pelvis, while the legs are bent at the hip joints, unbent at the knees and extended along the body);
mixed gluteal (buttocks are presented with one or two legs bent at the hip and knee joints);
foot (complete - 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 can occur. Pure breech presentation is more often observed in primiparas, mixed breech and foot 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 is noted that breech presentation in multiparous occurs approximately 2 times more often than in primiparas.

Risk factors

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

narrow pelvis;
abnormal shape of the pelvis (for example, after rickets suffered in childhood);
malformations of the uterus (saddle-shaped, bicornuate uterus, the presence of a septum in the uterus);
uterine fibroids (its benign tumor) and tumors of the uterine appendages;
placenta previa (the placenta partially or completely blocks the exit from the uterine cavity). In this case, and other conditions listed above, the normal location of the fetus is disturbed, the head cannot take the correct position due to the presence of an obstacle, and it is more convenient for the child to sit down with the buttocks;
excessive mobility of the child with polyhydramnios or limited - with oligohydramnios, multiple pregnancy;
pathological hypertonicity of the lower segment of the uterus and a decrease in the tone of its upper sections. In this case, the fetal head, as the largest and densest part of the body, repels from the entrance to the pelvis and occupies a position in the upper part of the uterine cavity. Similar violations of the contractile activity of the uterus in the third trimester of pregnancy may be due to 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 is noted that those patients who themselves were born in a breech presentation often have a similar situation during their own pregnancy. These facts may testify in favor of a hereditary predisposition to breech presentation. However, this issue requires further study.

Diagnostics

It is possible to determine the location of the fetus in the uterus during a routine external examination by a doctor of the antenatal clinic. With breech presentation, the following signs are determined:

When feeling the abdomen, the fetal head is located in the bottom 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 head presentation, when the heartbeat is heard below the navel.

The nature of the fetal presentation is most accurately detected by ultrasound, in which it is important to establish the type of breech presentation, to trace the location of the legs in breech presentation, to determine whether the head is bent or unbent, 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 nature of the presentation is finally formed by the 34–36th week of pregnancy, before this period the baby can still roll over. Breech presentation of the fetus up to 28 weeks of gestation is the norm and does not require any remedial measures - just dynamic observation is enough. The cephalic rotation occurs spontaneously before delivery in 70% of multipregnant women and in 30% of breech-pregnant primigravidas.

If, at a gestational age of more than 28–30 weeks, the doctor detects breech presentation during examination and it is confirmed at the third screening ultrasound of the fetus (at 32–34 weeks of gestation), it is recommended that the pregnant woman perform a set of gymnastic exercises that contribute to the rotation of the fetus on the head. The essence of all these exercises is to create discomfort in a child in a certain position, after which he seeks to take a comfortable and comfortable position, turning over.

There are several methods for such exercises:

Methodology 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 location of the back of the child). Bend your legs at the knee and hip joints. In this position, you should spend about 5 minutes, and then straighten the upper leg and press it to the stomach while inhaling, while exhaling, straighten the leg, bending slightly forward. Repeat these movements 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 has an additional effect that creates inconvenience, and he tends to turn around in order to get into more comfortable conditions.

Method of Dikan I. F.

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

"Bridge". It is necessary to lie on a flat sofa or bed, you can on the floor, put a pillow under the lower back so that the pelvis is 20-30 cm above the head.In this position, you should stay for 10-15 minutes. Performed 2 times a day before meals. With this exercise, the head of the child strongly rests against the bottom of the uterus, creating significant discomfort for the baby, and he seeks to make a turn.

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

a scar on the uterus (after a caesarean section in a previous birth or other operations on the uterus);
placenta previa;
the threat of premature birth;
oligohydramnios;
polyhydramnios;
multiple pregnancy;
preeclampsia (toxicosis of the second half of pregnancy, manifested by edema, increased pressure, the presence of protein in the urine);
uterine tumors;
severe maternal comorbidities (eg, heart disease, hypertension, diabetes mellitus).

The effectiveness of these exercises is, according to different authors, about 75%.

Hospital before delivery

Upon reaching the period of 38–39 weeks, all pregnant women with breech presentation are shown antenatal hospitalization in a hospital. There is an in-depth examination of a pregnant woman:

Ultrasound to determine the type of presentation (pure gluteal, mixed gluteal or foot), the degree of extension of the head (normally, the head of the fetus 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 or magnetic resonance imaging);
assessment of the state of the fetus using cardiotocography - a study of the fetal heartbeat and uterine tone, conducting a non-stress test (studying the reaction of the cardiovascular system of the fetus in response to its movements: with motor activity, an increase in heart rate occurs);
assessment of the readiness of a woman's body for childbirth.

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

TO I group include high-risk pregnant women:

the estimated weight of the fetus is more than 3600 g - a large fetus;
narrowing of the pelvis;
chronic hypoxia (lack of oxygen) of the fetus;
extragenital (not related to pregnancy) diseases that affect the condition of the fetus and labor activity, such as arterial hypertension, diabetes mellitus, renal failure;
primiparous older than 30 years.

These pregnant women, as a rule, perform a caesarean section in a planned manner.

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

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

Indications for surgery

Absolute indications for a planned caesarean section are:

extragenital diseases that require the exclusion of attempts (for example, heart defects, including those operated on, threatening retinal detachment, etc.);
pronounced violation of fat metabolism (obesity of the 2nd degree and above);
pregnancy after IVF;
prolongation of pregnancy (pregnancy 42 or more weeks);
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 pharynx of the cervix);
cicatricial changes in the cervix;
multiple pregnancy (breech presentation of the first, located closer to the entrance to the small pelvis, fetus). In other cases, a caesarean section is performed according to a combination of indications (for example, the age of the expectant mother is over 30 years old, complications during pregnancy, chronic fetal hypoxia).
The caesarean section rate in breech presentation is 80% or more.

How will the birth go?

The main difference between childbirth in the breech presentation through the natural birth canal from childbirth in the head presentation is as follows. The largest part of the fetus - the head - during childbirth in the head presentation, is the first to overcome all the narrow parts of the bone pelvis, while being configured due to soft sutures and fontanelles. If there is a discrepancy between the size of the head and the bone pelvis, then the child simply cannot be born on his own and an emergency caesarean section is performed. If the head successfully passed all the narrow parts of the pelvis and was born, then the rest of the baby is born without much effort. In breech presentation, the narrow sections of the pelvis are the first to overcome the buttocks of the child, which happens quite easily, but when it comes to the head, a discrepancy may occur, which will be critical, and surgical intervention will be required.

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

Premature discharge 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 fetal bladder is involved in the process of opening). This happens due to the strong pressure of small parts of the fetus on the lower pole of the fetal bladder.
Prolapse of small parts of the fetus and umbilical cord occurs with premature rupture of the membranes and outflow 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 activity occurs at the beginning of labor due to premature rupture of amniotic fluid and insufficient pressure, which is softer than the head of the pelvic end of the fetus on the cervix.
Secondary weakness of labor activity develops during childbirth due to the fact that the woman in labor is exhausted by protracted labor. It is manifested by weak contractions, in which the opening of the cervix is slowed down or stops.
When the fetal head passes through the birth canal, the umbilical cord may be pressed tightly against the walls of the pelvis. If it lasts more than 5-7 minutes, then fetal death may occur (since oxygen-carrying blood stops flowing to the fetus, and severe hypoxia occurs).
Throwing back the arms and extension of the head in the second stage of labor occurs reflexively at the birth of the body.
Aspiration of amniotic fluid - water entering the baby's airways 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 trauma to the fetus (traumatic brain injury with cerebral hemorrhage) occur when the birth of the head and shoulders of the fetus is difficult.

Birth management

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

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

Childbirth with a breech presentation of the fetus is taken by a doctor, in contrast to physiological childbirth, which is taken by a midwife under the supervision of a doctor. In the second stage of labor (during attempts), it is desirable to control cardiotocography, while during normal childbirth, sometimes it is enough to simply listen to the fetal heartbeat between attempts with an obstetric stethoscope. OXYTOCIN (a drug that increases the contractile activity of the uterus) is administered intravenously to prevent weakness of attempts. It is mandatory to cut the perineum (episiotomy) to accelerate 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 the eruption of the presenting part, special obstetric benefits are provided (actions that the obstetrician-gynecologist performs). The most common is the allowance for Tsovyanov - it is used for pure breech presentation. It is based on the preservation of the normal articulation of the fetus (the legs are held 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 extending the head. Next, perform the classic manual manual for breech presentation (release of the shoulder girdle and fetal head).

With a mixed breech presentation, benefits are provided from the moment the lower corners of the shoulder blades appear from the genital gap; it is aimed at releasing the shoulder girdle of the fetus and facilitating the birth of the head.

A generic tumor (swelling of the soft tissues of the presenting part) with breech presentations is located on the buttocks, with legs - on the legs of the child, which become swollen and blue-purple. Often, the birth tumor passes from the buttocks to the external genitalia of the fetus, which looks like swelling of the scrotum or labia.

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

when loops of the umbilical cord or small parts of the fetus fall out;
with a deterioration in the condition of the fetus due to an increase in hypoxia;
with uncorrected weakness of labor activity for 2–3 hours or with ineffective labor stimulation during this time during prenatal outflow of water;
with premature detachment of a normally located placenta.

In conclusion, it should be said that no matter how your baby is located and no matter how he is born, the most important thing is that he is born healthy. And do not be upset if the doctors recommended you a caesarean section. When you are next to your child, you will forget all your doubts and just enjoy happy motherhood! But if the doctor talks about the possibility of natural childbirth and does not see indications for a caesarean section, do not be afraid of natural childbirth. 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 rebuilt from the state of “preserving pregnancy” to the 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 childbirth, or maybe a few hours before them. 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.

Causes and mechanisms of preparing the body for childbirth

1. Aging of the placenta

A large role in the development of labor belongs to the hormones of the placenta. From the 36th week of pregnancy, the placenta begins to change the amount of hormones produced: there is an increase in estrogen levels and a decrease in progesterone. 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 an increase in uterine contractions.
Estrogens activate the synthesis of uterine contractile proteins, by increasing the sensitivity of uterine muscle cells to irritation. Thus, without causing contractions of the uterine muscle, estrogens, as it were, 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 the act of labor, causing contraction of the uterine muscle.

2. Generic dominant

It is believed that the normal course of childbirth is possible only with the formed "birth dominant" in the brain of a pregnant woman. 1.5-2 weeks before birth, there is a significant increase in the electrical activity of the brain regions responsible for the birth act, which also increases the production of oxytocin in the pituitary gland, the main hormone of childbirth.

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 tightly. In response to stress, the adrenal glands of the fetus begin to secrete large amounts of cortisol, the stress hormone. Fetal cortisol also contributes to the production of prostaglandins in the mother's body. 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 activity will begin as soon as the necessary 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 childbirth readiness

By the end of pregnancy, the fetal head descends to the entrance to the small pelvis and tightly pressed against the bone ring of the pelvis, so the fetus is preparing for birth. He 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 takes 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, because due to the large size and softness of the baby's ass, it cannot be inserted into the bone ring of the maternal pelvis.

By the end of pregnancy, the woman's body produces a hormone-relaxin, which relaxes all the ligaments and muscles, preparing them for childbirth. The lower segment of the uterus before childbirth becomes softer and stretches. With the first pregnancy, this happens a few weeks before the birth, and with subsequent ones, just before the birth.

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

This harbinger of childbirth 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 already in the process of childbirth ... In a healthy woman with a good hormonal background, the cervix is mature by the time of birth, which means it is ready for the onset of childbirth. If a woman, for some reason, has reduced the formation of prostaglandins, then the cervix is not mature enough at the time of delivery and it may need medical preparation (introduction of artificial prostaglandins). Signs of maturity of the cervix appear at full-term pregnancy, starting at 38 weeks.

True harbingers of childbirth

It is customary to call the harbingers of childbirth external, really tangible for the expectant mother, manifestations of those changes in her body that are direct preparation for the onset of labor. 2-3 weeks before childbirth appear:

"Drop" of the abdomen
Approximately 2-3 weeks before giving birth, a woman feels that her stomach has dropped. This is due to the fact that the head of the fetus is tightly pressed against the entrance to the small pelvis. At the same time, the height of the fundus of the uterus, which increases by 1 cm every week 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 flatter, sloping from above. Between the chest and stomach, the palm now easily fits. As a result of the movement of the child, pressure is removed from the diaphragm (the partition separating the chest cavity from the abdominal cavity) and the stomach, it becomes easier to breathe, shortness of breath disappears due to the fact that there is more space for the lungs, heartburn disappears, since the lowered bottom of the uterus no longer presses so hard on the stomach. But pain may appear in the lower abdomen and in the legs, because now the baby is pressing on the muscles, ligaments and nerve endings.

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

Relaxation of the "stool"
The hormones of childbirth affect the intestines of a woman, leading to a decrease in the tone of its wall, and cause a relaxation 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 false urge to defecate).

Weight loss
Before the onset of childbirth, some women lose weight from 1 to 2 kg, mainly due to the release of the body from 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 excreted 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 clotting increases, which helps to reduce blood loss during childbirth.

Removal of the mucous plug
As the cervix matures, its canal begins to open slightly. During pregnancy, thick cervical mucus in the form of a cork prevented harmful microorganisms from entering the uterus, and by the time of delivery it liquefies. Liquefaction of mucus is facilitated by estrogens, the level of which rises for childbirth. All this leads to the fact that a lump of colorless, yellowish, or blood-colored mucus is pushed out of the cervical canal. More often, the mucous 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 discharge of the mucous plug is an equally significant criterion for the readiness of the body for childbirth, it usually occurs 1-3 days before childbirth (rarely 5 days). Every woman has a question, but is it amniotic fluid? After all, both those and other discharges are liquid, and at first observation they seem to be similar.
Water, unlike the mucous plug, is clear, warm and constantly leaking, but may be yellowish or greenish. In order to decide, you can use a simple cough. When coughing, the water will flow more strongly, and the amount of mucous plug will not change. You can also put a gasket, which, when the water drains, will completely get wet after a while.

Harbingers - sensations

Change in appetite
Appetite may change just before childbirth. More often it decreases. This is due to the influence of the changed hormonal background on the muscular membrane of the gastrointestinal tract and its enzymatic activity. The body is preparing to spend energy on childbirth, and not on the digestion of 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 abandon meat and fish broths, replacing them with vegetable and milk soups, rich broths require high activity of intestinal enzymes. Explain why.

"Training" bouts
“Training contractions mostly appear 2-3 weeks before delivery. They are also called "false" contractions, or Braxton Higgs contractions. O. The purpose of preterm contractions is to prepare the muscles of the uterus and birth canal, and specifically, to promote the maturation of the cervix. In order for the muscle to successfully complete the marathon in 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, it seems to “reduce”, the stomach becomes harder than usual to the touch, and pulling sensations may occur in the lower abdomen or lower back.
Precursor contractions are irregular, begin long before childbirth, come 4-6 times a day, but not more than 2 hours in a row, last a few seconds, rarely - up to a minute, their intensity weakens or does not change over time, stop with a change in body position and after massage, warm bath.
True contractions are regular, begin with the onset of labor, their frequency and intensity increases over time.
If these sensations are not very pleasant and tiring, you can lie on your side and wait until they pass.

Change in fetal activity
After lowering the head, the child will tightly press the head against the bone 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 is reduced. The movements of the fetus become more like swaying, it can calm down a little, then move more actively. Fixing the head prevents the baby from turning over and makes it easier to start the birth process.

Mood change
There may be an emotional upsurge, sudden euphoria, causeless sadness, tearfulness, irritability, drowsiness increases, and by the end of pregnancy there is a feeling of fatigue, there is a desire to bring the hour of childbirth closer. Sometimes these feelings quickly replace each other during the day. Mood changes 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 often have to get up to the toilet, “training” contractions at night disturb you much more often, in addition, cramps in the muscles of the legs during sleep may bother you. All this leads to restless, interrupted sleep.
The manifestation of the harbingers of childbirth is very individual and optional. They can appear during the last two to three weeks before childbirth, their presence, as well as their absence, is the norm and does not require a visit to a doctor. It is important to learn to listen to the preparations of your body, not to be afraid of changes in well-being associated with prenatal preparation. If you are in doubt, consult a doctor, he will evaluate this or that symptom from a medical point of view.

Lingering Harbingers

Sometimes the period of precursors of childbirth 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 the maturation 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, which are irregular in nature and do not pass 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 a woman of sleep and rest. With pronounced painful preliminary pains that deprive a woman of rest and sleep, it is better to consult a maternity hospital doctor after 6-7 hours, as this is very tiring for a woman in labor and interferes with the development of normal labor activity.
The essence of the pathological preliminary period is the increased tone of the uterus, while there are no changes in the cervix. The presenting part of the fetus is not pressed against the entrance of the small pelvis, due to the constant increased tone of the uterus, the fetus suffers oxygen starvation.
The pathological preliminary period is often accompanied by pronounced disturbances in well-being (sweating, sleep disturbance, pain in the sacrum and lower back, palpitations, shortness of breath, impaired bowel function, increased and painful fetal movement).
In this case, it is necessary to consult a doctor, sometimes a few hours of full medical sleep is enough to restore strength for normal labor activity. In the absence of treatment, the pathological preliminary period often turns into the primary weakness of labor activity; 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 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 downward with its head or pelvic end. That part of the fetus, which 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, head presentation occurs in 96.5%, breech presentation - in 3.5% of cases.

When examining external methods, the head is felt in the form of a dense spherical body. To palpate the presenting part, both hands are placed flat on the lower lateral sections of the abdomen and with outstretched fingertips they try to gradually penetrate the pelvic cavity in order to bring the fingers closer together if possible; the latter succeeds if the presenting part is absent or is above the plane of entry into the pelvis.

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

Table 2. Determining the position of the fetal head in relation to the planes of the pelvis in occiput presentation

Head location	External study data	Vaginal examination data
The head is balloting (or movable) over the entrance to the pelvis	The head moves freely to the sides. The fingers of the examining hands can be easily brought under the head on both sides	It is possible to reach the head with fingers only if the outer hand presses it against the entrance to the pelvis. The cape can be felt with outstretched fingers, if it can be reached at all. In addition to the cape, you can feel the entire inner surface of the small pelvis (the upper edges 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 is limitedly mobile	The head is deprived of freedom of movement, moving it by hand is difficult. The fingers of the examining hands can be brought on both sides under the head only when the latter is shifted upward	Exploring fingers manage to reach the head, while it can move away. With outstretched fingers, you can feel the cape, if it is achievable at all.
The head is fixed with 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 probed with fingers, that is, the forehead is probed 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 region of the small fontanel are easily reached with the fingers. Over a considerable distance, the inner surface of the pelvic bones is felt, the sacral bone and partly the innominate line. 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 is located in a wide part of the pelvic cavity	The fingers of the investigating hands easily approach each other, since a significant part of the head has already sunk below the plane of the entrance to the pelvis. According to Piskacek, the head is reached with a finger with difficulty	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 with the head is not completely executed. Only the last sacral vertebrae can be palpated
The head is located in the pelvic cavity, more precisely in the narrow part of the latter	Investigating fingers feel the cervical-shoulder 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 feel either the symphysis or the inner surface of the pelvic bones, including the ischial spines
Head in the outlet of the pelvis	Same	Head on the pelvic floor. The vertebrae of the coccyx are palpated with difficulty. The soft parts of the vulva and the entrance to the vagina are palpated. In the depths of the genital fissure, the scalp is visible

Table of contents for the topic "Articulation of the fetus (habitus).":
1. Articulation of the fetus (habitus). The position of the fetus (situs). longitudinal position. transverse position. Oblique position.
2. Position of the fetus (positio). Position type (visus). The first position of the fetus. The second position of the fetus. Front view. Back view.
3. Presentation of the fetus (präsentatio). Head presentation. Pelvic presentation. Presenting part.
4. External methods of obstetric research (Leopold's methods). The first reception of Leopold. The purpose and methodology of the study (reception).
5. The second reception of external obstetric research. The second reception of Leopold. The purpose and methodology of the study (reception).
6. The third reception of external obstetric research. The third reception of Leopold. The purpose and methodology of the study (reception).
7. The fourth reception of external obstetric research. The fourth reception of Leopold. Symptom of balloting. The purpose and methodology of the study (reception).

9. Fetal auscultation. Listening to the abdomen of a pregnant woman and a woman in labor. Fetal heart sounds. Places of the best listening to fetal heart tones.
10. Determining the duration of pregnancy. Time of first fetal movement. The day of the last menstruation.

The degree of insertion of the fetal head into the pelvis it is recommended to define as follows. Penetrating at the fourth external obstetric examination with the fingers of both hands as deep as possible into the pelvis and pressing on the head, they make a sliding movement along it towards themselves.

Rice. 4.21. Occipital presentation. Head above the entrance to the small pelvis (fingers of both hands can be brought under the head).

With a high standing of the fetal head, when it is movable above the entrance, you can, with an external examination, bring 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 at the entrance to the small pelvis in a small segment (the fingers of both hands sliding along the head diverge in the direction of the arrows).

If at the same time the fingers diverge, the head is at the entrance to the small pelvis by a small segment m (Fig. 4.22).

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

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

If the fetal head penetrates so deeply into the pelvic cavity that it completely fulfills it, then usually palpate the head with external methods is no longer possible.

In the period of exile, repeated external obstetric studies are carried out to find out the progress of the presenting part along the birth canal. The third and fourth methods of external obstetric research determine the relationship of the head to various planes of the small pelvis. With vaginal examination, it is possible to clarify the position of the head. These relations are usually formulated as follows. The head above the entrance to the small pelvis ( rice. 101,a). The entire head is placed over the entrance to the small pelvis; it is mobile, moves freely with shocks (ballots) or is pressed against the entrance to the small pelvis. During vaginal examination, it turns out that the pelvis is free, the head is high, does not interfere with the palpation of the nameless lines of the pelvis, the cape (if it is achievable at all), the inner surface of the sacrum and symphysis; the sagittal suture is usually located in the transverse dimension at the same distance from the symphysis and the promontory, the large and small fontanelles are at the same level (with occipital presentation). The head at the entrance to the small pelvis with a small segment ( rice. 101b). The head is motionless, most of it is above the entrance to the pelvis, a small segment of the head is below the plane of the entrance to the pelvis. Vaginal examination reveals that the sacral cavity is free, the cape can be approached with a bent finger (if it is achievable). The inner surface of the symphysis is accessible to research, the small fontanel is lower than the large one (flexion). The sagittal suture is transverse or slightly oblique. The head at the entrance to the small pelvis with a large segment ( rice. 101, in). With an external examination, it is determined that the head with its largest circumference is below the plane of the entrance to the pelvis (descended into the cavity). The smaller segment of the head is palpated from above. During vaginal examination, it turns out that the head covers the upper third of the symphysis and sacrum, the cape is unattainable, 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 dimensions. The head in the wide part of the pelvic cavity ( rice. 101, g). With an external examination, only a small part of the head (forehead) is probed. During vaginal examination, it turns out that the head with the largest circumference has passed the plane of the wide part of the pelvic cavity; two thirds of the inner surface of the pubic articulation and the upper half of the sacral cavity are occupied by the head. IV and V sacral vertebrae and ischial spines are freely palpable. The swept seam is in one of the oblique dimensions. The head in the narrow part of the pelvic cavity ( rice. 10.1, d). On external examination, the head is not determined. A vaginal examination reveals that the two upper thirds of the sacral cavity and the entire inner surface of the pubic articulation 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 dimensions, close to straight. head in the outlet of the pelvis ( rice. 101, e). On external examination, the head is not palpable at all. The sacral cavity is completely filled with the head, the ischial spines are not defined, the sagittal suture is in the direct size of the pelvic outlet. Rice. 101. The ratio of the fetal head to the planes of the pelvis. a - the head above the entrance of the small pelvis; b - head with a small segment at the entrance to the pelvis; c - head with a large segment at the entrance to the pelvis; g - head in a wide part of the pelvic cavity; e - head in the narrow part of the pelvic cavity; e - the head in the exit of the pelvis. To control the translational movement of the head during the period of exile, the Piskachek-Genter method is used. In the normal course of childbirth, there is a consistent advancement 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 the weakening of labor activity. With prolonged standing of the head in one plane, a prolonged compression of the soft tissues of the birth canal, the bladder occurs, followed by a violation of blood circulation.