Obstetric rotation (versio obstetrica) is aimed at changing the incorrect position of the fetus to a longitudinal one. In breech presentation, the rotation is performed on the head. Currently, obstetric rotation is extremely rare due to low efficiency (the fetus often returns to its original position) and the risk of complications.

With external obstetric rotation, only external techniques are used through the abdominal wall without any influence from the vagina. The external-internal rotation of the fetus involves the action of two hands, of which one is inserted into the uterine cavity, the second contributes to the rotation from the outside. In most cases, a turn is made on the pedicle of the fetus. In multiparous, with an overstretched uterus, the oblique and transverse position of the fetus is sometimes easier to translate into a breech presentation.

Variants of the classic obstetric turn:
- turn on the leg;
- turn on legs;
- rotation on the buttocks;
- turn on the head.

The effectiveness of the rotation is low, after it is carried out, the fetus often returns to the breech presentation.

In connection with the introduction of ultrasound and β-agonists into practice, interest in external obstetric cephalic rotation has revived. Ultrasound makes it possible to follow the movement of the fetus, and the introduction of β-agonists helps to relax the myometrium.

Indications for use:
Obstetric rotation of the fetus is performed when the fetus is in the wrong position: transverse or oblique. In breech presentation, the rotation is performed on the head. Incorrect positions of the fetus occur with a frequency of 0.2-0.4%. Breech presentation occurs in 3-5% of pregnancies. You can talk about the position of the fetus from 22 weeks of pregnancy, especially in the case of threatening preterm birth. The incorrect position may be temporary, especially in oblique position of the fetus and in multiparous women.

With the onset of labor, the position of the child may spontaneously improve. Therefore, it is more correct to talk about the wrong position in the development of labor activity.

The reasons leading to the incorrect position of the fetus are varied.
The following factors are of primary importance:
- decreased tone of the myometrium, flabbiness of the anterior abdominal wall, which is especially typical for multiparous women;
- anomalies of development and tumors of the uterus;
- anomalies in the development of the fetus (tumors of the neck, sacrococcygeal teratoma, hydrocephalus);
- excessive or severely limited fetal mobility;
- polyhydramnios or oligohydramnios;
- placenta previa;
- anomalies of the pelvic bones (narrowing of the size, structural features, malformations, tumors, traumatic injuries);
- multiple pregnancy.

Diagnosis of malposition of the fetus
The transverse and oblique position of the fetus in most cases is diagnosed without much difficulty.

A preliminary diagnosis of malposition of the fetus is established at 30 weeks of gestation, the final diagnosis is at 37-38 weeks.

Signs of abnormal fetal position include:
- shape of the uterus - elongated in the transverse direction;
- an increase in the circumference of the abdomen with a relatively low standing height of the fundus of the uterus;
- when using Leopold's techniques, there is no large part of the fetus in the bottom of the uterus, which is found in the lateral sections of the uterus;
- the fetal heartbeat is best heard in the navel;
- the position of the fetus is determined by the head: in the first position, the head is determined on the left, in the second - on the right;
- the type of fetus is determined by the back: the back is facing forward - front view, the back is backward - rear.

A vaginal examination made during pregnancy or at the beginning of labor with a whole membranes confirms the absence of the presenting part. After the outflow of amniotic fluid with a sufficient opening of the cervix (45 cm), you can determine the shoulder, shoulder blade, spinous processes of the vertebrae, inguinal fold.

Ultrasound is the most informative diagnostic method that allows you to determine not only the incorrect position, but also the estimated body weight of the fetus, the position of the head, the location of the placenta, the amount of amniotic fluid, cord entanglement, the presence of anomalies in the development of the uterus, fetus, and its tumor.

The course and tactics of pregnancy
Pregnancy with the wrong position of the fetus passes without any special deviations from the norm. There is an increased risk of premature rupture of amniotic fluid, especially in the third trimester. The greatest risk is birth in a transverse position, which is pathological. Spontaneous delivery through the natural birth canal with a viable fetus in this case is impossible. If childbirth begins at home or there is not enough observation of the woman in labor, then complications can begin already in the first period. In the transverse position of the fetus, there is no division of amniotic fluid into anterior and posterior, therefore, untimely discharge of amniotic fluid is often observed. This complication may be accompanied by prolapse of the loops of the umbilical cord or the handle of the fetus. Deprived of amniotic fluid, the uterus tightly fits the fetus, a neglected transverse position of the fetus is formed. The only way delivery in the transverse position of the fetus, regardless of the gestational age, is a caesarean section.

Correction of the incorrect position of the fetus
When diagnosing an incorrect position of the fetus after 30 weeks, corrective gymnastics is initially possible. Contraindications to performing gymnastic exercises are the threat of premature birth, placenta previa, low attachment of the placenta, anatomically narrow pelvis II-III degree and other conditions.

Recommend position on the side opposite to the position of the fetus, knee-elbow position for 15 minutes 2-3 times a day. Methods exercise were proposed by I.I. Grishchenko, A.E. Shuleshova and I.F. Dikan.

Correction of the incorrect position of the fetus by external obstetric rotation is possible from 32 weeks of gestation and should be performed only in an obstetric hospital, since emergency abdominal delivery is indicated in case of complications.

In most cases, with expectant management of pregnancy, fetuses that had an incorrect position are located longitudinally to the onset of labor. Only less than 20% of fetuses that were transverse before 37 weeks' gestation remain in this position at the onset of labor. Thus, waiting for the term of labor reduces the number of unnecessary attempts at external rotation. If the oblique or transverse position of the fetus is maintained by the time of delivery, an attempt can be made to externally rotate the fetus to the head during full-term pregnancy or with the onset of labor. After successful correction of the position of the fetus, induction of labor is possible. The external rotation of the fetus on the head in the case of a full-term pregnancy leads to an increase in the number of physiological births in the cephalic presentation. After a successful external cephalic rotation, reverse spontaneous rotations are less common.

Before the operation, the purpose and essence of the manipulation being performed are explained to the pregnant woman, and informed consent is issued for its implementation. Conditions for external obstetric rotation:
- satisfactory condition of the pregnant woman and the fetus, the absence of developmental anomalies;
- the presence of one fetus;
- estimated fetal body weight - normal uterine tone;
- normal location of the placenta;
- sufficient mobility of the fetus in the uterus;
- a sufficient amount of amniotic fluid, a whole fetal bladder;
- normal size of the pelvis;
- the presence of an experienced qualified specialist who owns the technique of turning;
- the possibility of conducting an ultrasound assessment of the position and condition of the fetus before and after the rotation;
- readiness of the operating room to provide emergency care in case of complications.

If you experience difficulty in turning, the operation should be stopped. Contraindications for external obstetric rotation
- aggravated obstetric and gynecological history (recurrent miscarriage, perinatal losses, history of infertility, etc.);
- extragenital diseases (arterial hypertension, severe cardiovascular diseases, kidney diseases, etc.);
- multiple pregnancy;
- outpouring of amniotic fluid;
- anomaly of the location of the placenta;
- large fetus, entanglement of the umbilical cord around the neck and trunk of the fetus;
- fetal distress;
- complications of pregnancy (preeclampsia, the threat of premature birth, polyhydramnios, oligohydramnios, bleeding, placental abruption, fetal hypoxia);
- changes in the birth canal (narrowing of the pelvis and exostoses, tumors and cicatricial deformities of the cervix and vagina);
- the presence of a scar on the uterus;
- uterine fibroids large sizes, multiple, with low localization of nodes, tumors of the appendages.

Technique for external obstetric rotation
Before the operation, an ultrasound is necessarily performed, in which the condition of the fetus, its size, the location of the placenta, the umbilical cord are assessed, if necessary, dopplerometry is performed, and possible contraindications are determined.

The readiness of the female body for childbirth is also assessed. Preparation for surgery consists in emptying the intestines and bladder. The operation, especially in multiparous women, can be done without anesthesia. However, perhaps 30 minutes before the operation, the introduction of 1 ml of a 1% solution of promedol. 20 minutes before the start of the rotation on the head with a breech presentation of the fetus or its incorrect position, intravenous drip administration of β-adrenergic agonists is started, which is continued during the rotation. With oblique positions of the fetus, it is necessary to lay the woman in labor on the side towards which the presenting part is deviated. For example, in the first position, the woman is laid on her left side. In this position, the bottom of the uterus, together with the buttocks of the fetus, deviates to the left, and the head in the opposite direction, towards the entrance to the small pelvis.

The operation of external obstetric rotation is carried out under the control of ultrasound and continuous cardiotocographic monitoring. The pregnant woman is placed on a hard couch on her back, her legs are slightly bent and drawn to her stomach. At the time of the operation, the presence of an anesthesiologist and a neonatologist is necessary due to the risk of complications and the occurrence of indications for emergency surgery caesarean section.

Technique of turning on the head with a breech presentation of the fetus
The doctor sits on the right side (facing the pregnant woman) on the edge of the couch. The operation is performed with two hands. One hand is located at the pelvic end, the second - on the head.

At the first position of the fetus, the pelvic end is retracted to the left, at the second position - to the right. Systematically, carefully and gradually, the pelvic end of the fetus is displaced towards the back, the back towards the head, and the head towards the entrance to the pelvis.

With a palm with spread fingers, they cover the head of the fetus, advance it so that the back of the head not only passes over the plane of the entrance to the small pelvis, but also moves somewhat further from the central point of the pubic articulation. This position of the nape allows the head to be inserted into the mother's pelvis in a bent position during childbirth. With the second hand, the buttocks are transferred to the bottom of the uterus. All these manipulations should be done persistently, but extremely carefully. After a successful turn in 80% of cases, births occur in the head presentation, the rest remain in the breech presentation.

After external rotation surgery, the possibility of recurrence is not ruled out, so it is necessary to fix the longitudinal position of the fetus. To this end, Arkhangelsky proposed a special bandage in the form of a tape 10 cm wide, which is fixed on the pregnant woman's abdomen at the level of the navel or slightly below it; this contributes to an increase in the vertical and a decrease in the horizontal diameter of the uterus. The bandage should not be removed for 1-2 weeks to exclude the possibility of the fetus moving into a transverse position. Keeping the longitudinal position of the fetus after external rotation to the head can be done using two rollers rolled from sheets placed on both sides of the fetus, followed by bandaging the abdomen.

Technique of external rotation in the transverse and oblique position of the fetus
As a rule, in the transverse and oblique position of the fetus, a turn is performed on the head. Pregnant emptied bladder and lay her on a hard couch on her back with her legs bent at the knees. The obstetrician places his hands on the head and pelvic end, shifts the head to the entrance to the pelvis, and the pelvic end to the bottom of the uterus. If the back of the fetus is facing the entrance to the pelvis, then first a breech presentation is created (so as not to lead to an extensor presentation of the head), and then the fetus is transferred to the head presentation by turning the torso of the fetus by 270 °. Wiegand's external rotation involves simultaneous action on the head and buttocks, guided solely by the ease of movement, without taking into account the position of the fetus, the latter is gradually transferred to a longitudinal position. The transfer of the fetus from the transverse to the oblique position is performed using separate hand movements, resembling finger strikes on the back of the head.

When performing these techniques, the fetus, after turning, is in the anterior view. With this technique, the fetus, while maintaining the correct articulation and shape of the ovoid, remains in a flexion position, which is most favorable for its rotation in the uterine cavity. The disadvantages of external rotation of the fetus in expectant pregnancy management is the possibility of premature rupture of the membranes and the onset of labor before the planned attempt to implement this procedure. The risk of complications during external rotation is reduced, since the procedure takes place directly in the delivery room with continuous monitoring of the fetal condition.

Complications during external obstetric rotation
The most common complications during external obstetric rotation are: premature detachment of a normally located placenta, fetal distress, uterine rupture. In the case of careful and skilled execution of the external rotation of the fetus on the head, the frequency of complications does not exceed 1%. If complications develop, an emergency caesarean section is indicated.

External-internal rotation of the fetus
The classic obstetric combined external-internal rotation of the fetus is aimed at changing the incorrect position of the fetus to a longitudinal one. The combined turn, as a rule, is made on the leg. The classic combined (external-internal) rotation of the fetus on the leg involves the action of two hands, of which one is inserted into the uterine cavity, the second contributes to the rotation from the outside.

Types of classic obstetric turn:
- external-internal classic (combined) - with full opening of the cervix;
- external-internal (combined) - with incomplete opening of the cervix of the uterus - according to Braxton Hicks.

Over the past 5 years, there have been no studies regarding the implementation of the obstetric turn and the evaluation of its effectiveness.

External prophylactic rotation to the head, according to B. A. Arkhangelsky, significantly improved the results of external rotation.
Indications for external rotation according to B. A. Arkhangelsky: transverse or oblique position of the fetus and breech presentation. Contraindications - lack of good fetal mobility, previous bleeding, twins, polyhydramnios, a sharp narrowing of the pelvis. A novice doctor can only be recommended to rotate with the transverse position of the fetus.
Conditions for this turn:
accurate knowledge of the position of the fetus, type and, mainly, presentation;
a state of complete rest of the uterus and abdominals;
full mobility of the fetus, i.e., the preservation of a sufficient amount of water with a whole bladder.
The rotation should be made at the end of the 35th or at the beginning of the 36th week of pregnancy, timing it to the time of the issuance of prenatal leave.
Technics. External rotation of the fetus can be done in consultation (B. A. Arkhangelsky); but most authors prefer to produce it in a hospital. In a pregnant woman, the intestines are cleaned in the morning, and before the operation, she empties her bladder; then she is laid on a hard couch. For all types and positions, oblique and transverse positions and pelvic presentations of the fetus, the general rule for rotation is: "shift of the buttocks towards the back, back towards the head, head towards the abdominal wall of the fetus."

Figure: External rotation of the fetus according to B. A. Arkhangelsky: the buttocks are shifted towards the back, the back - towards the head, the head - towards the tummy.

As a result of rotation according to this rule, the fetus passes into the anterior view, but remains in a physiological articulation, which provides the shape of the ovoid, the most favorable for the rotation of the fetus in the uterine cavity.
With transverse and oblique positions of the fetus, the rotation technique depends on the species. In the front view, the head should be displaced with a “raking motion”, directing it not only down, but also forward, in order to avoid going into the rear view. When viewed from the rear, the head is easier to capture; the pelvic end is shifted towards the hypochondrium. The technique of turning is significantly different in the transverse position of the fetus, if the back is facing the entrance to the pelvis.

Drawing: The same. Turn at the transverse position of the first position. a - in the front view and the back facing the fundus of the uterus: displacement of the buttocks towards the back and the method of "raking" the head from the hypochondrium; b - turn in the rear view with the back facing the fundus of the uterus.

Drawing: The same. Turning in the transverse position of the first position, front view with the back facing the entrance to the pelvis. a - turning the fetus into a breech presentation; b - further turn into head presentation.

In these cases, in the anterior view, it is necessary to make a turn of 270 °: first, the fetus is turned into a breech presentation, and from the breech to the head. In the rear view, the turn is also made by 270 °, and when turning to the buttocks, they do not allow the head to move into the hypochondrium. In order to preserve the head presentation, B. A. Arkhangelsky prescribed a wide bandage, which is put on the pregnant woman’s stomach, at the level of the navel, and worn for 1-2 weeks.
External cephalic rotation technique in breech presentation (first position, anterior view). The first moment of rotation is to cover the buttocks with the hand and move them towards the position of the fetus. The downward displacement of the head begins when the buttocks are displaced to the side from the entrance to the pelvis. The left hand covers the suboccipital region of the head, shifts it to the right, and then down. The most crucial moment comes when the fetus has taken a transverse position; further advancement of the head to the entrance to the pelvis is easy. After turning, you need to check the fetal heartbeat. A woman should lie down for 20 minutes and keep calm throughout the day. There is no need to bandage the stomach.
The technique of turning in the second position is the same, but the buttocks are moved to the right. Turning is particularly easy in rear views, as the head is easily accessible.
According to B. A. Arkhangelsky, the external prophylactic rotation reduces the percentage of stillbirth by 10 times in breech presentations and 25 times in transverse positions of the fetus.

Not always a baby, already ready to be born, seeks to help his mother in this difficult matter. For the birth to be successful, the baby must be turned head down; however, it often happens that instead he "sits on the priest" (breech presentation, legs down) or even settles across (transverse presentation). Both greatly complicate the process of childbirth.

Of course, even with a breech presentation, you can try to give birth naturally - doctors can help the baby by pulling him by the legs. Just remember: this is fraught not only with prolonged childbirth and particular pain, but also with harm to the health of the baby - it is not uncommon for this to lead to dislocations of the hip joints in babies.

If the fetus is in the wrong position, there is a chance that the child will roll over by itself if the mother does special exercises. If this did not happen, and time is running out, doctors offer either a caesarean section or an obstetric coup. However, the coup will not be offered to you everywhere - in many countries this procedure has been abandoned for a long time, and in Russia, few undertake it.

What is an obstetric revolution?

This is a method by which the doctor helps the child to take the correct position, convenient for childbirth. It happens externally - when the doctor moves the baby by pressing on the belly of a pregnant woman, and internally - when with one hand inserted into the uterus, the child is grabbed by the leg and turned over.

This method has a very long history, it has been used in obstetrics for centuries. This does not mean that it is "tested by time", safe and useful - once mercury was used for medical purposes, not knowing that it seriously poisons the patient.

Why is this procedure dangerous?

As already mentioned, most doctors have long abandoned this method of fetal flipping, and only a few are still taking up this matter. It's simple: the likelihood of harming the health of the mother and child is much greater than the likelihood that the baby will be able to turn over "without incident." Perhaps a hundred or two years ago it was a good alternative to cesarean section, but today the level of development of medicine allows you not to worry about the life of a woman in labor and a baby during cesarean section.

Risk obstetric coup:

• There is a high chance of uterine rupture. That is why a strict contraindication to such a procedure is any scars on the walls of the uterus.
• There is a serious risk of placental abruption, which is very dangerous for the baby.
• Often causes premature birth.
• The child may return to their original position after the procedure, especially in a transverse presentation.
• Obstetric coup can cause severe pain mother.
• The danger of this procedure is that the baby can wrap itself around the umbilical cord and suffocate.

Agree or refuse?

In order for the obstetric revolution to be successful, the doctor must be, as they say, "from God." Of course, you may or may not be lucky. The health and life of a little man should not depend on such accidents. Despite all the disadvantages and risks of a caesarean section, it is much safer than an obstetric coup, so it is better to abandon this dubious procedure.

The indication for surgery is the breech presentation of the fetus.

Preparation for the operation. The operation is performed on an empty stomach, after cleansing the intestines with laxatives or an enema (the night before). The bladder is emptied just before the operation.

The pregnant woman is laid on a hard couch, on her back, dressed only in a shirt. The doctor sits down to her right. The position, position, type and presentation of the fetus are established by external methods. Narcosis is not shown.

Operation technique. Very carefully, manipulating both hands at the same time, they move the buttocks away from the entrance to the pelvis high up - above the iliac crest, and the head - down. The turn is considered complete when the head is located above the entrance to the pelvis, and the buttocks are in the bottom of the uterus.

At the end of the operation, small soft rolls of diapers are placed on both sides of the uterus and the entire abdomen is not tightly bandaged with a long towel to keep the fetus in the uterus in the position reached.

The outcome of the operation. Not in all cases, even with a successful external rotation, the achieved longitudinal position of the fetus is preserved.

In modern conditions, the operation of the external prophylactic rotation is practically not used due to the lack of effectiveness and a significant incidence of serious complications (PONRP, uterine rupture, premature onset childbirth, etc.).

Combined obstetric rotation with full opening of the uterine os

Indications: transverse (and oblique) position of the fetus; unfavorable presentation of the head - frontal insertion, anterior view of the facial insertion (chin backwards) high straight standing of the sagittal suture; prolapse of small parts of the fetus and umbilical cord - in the transverse position and head presentation; threatened conditions of the woman in labor and the fetus, requiring the immediate end of childbirth.

Conditions: complete or almost complete opening of the uterine os; absolute mobility of the fetus; accurate knowledge of the position of the fetus; the condition of the uterus and solid parts of the birth canal, allowing the birth of the fetus through the natural birth canal; good condition of the fetus.

The first two conditions are absolute ; with incomplete opening of the uterine pharynx, it is impossible to penetrate with the whole hand into the uterine cavity, with limited fetal mobility, and even more so with incomplete immobility, the production of a classic turn on the leg in order to avoid inevitable uterine rupture in such cases contraindicated.

Preparation for the operation. Preparing for surgery is the usual for vaginal surgery. Deep anesthesia is indicated to relax the uterus and abdominal wall. The position of the fetus and the state of the birth canal are studied in detail by external techniques and vaginal examination. The doctor performs the operation while standing.

Operation technique consists of three stages:

hand selection and insertion into the uterus;

finding and capturing the legs;

actual turn.

The first stage of the operation - the choice and insertion of the hand

When performing the first stage, you should pay attention to the following three points.

The rotation can be done with any hand inserted into the uterus. However, it succeeds if an easily remembered rule is observed: they introduce a hand of the same position.

The arm is inserted with the hand folded conically. To do this, all five fingers of the hand are pulled out to failure and brought together one with the other in the form of a cone. The fingers of the second ("outer") hand push the labia apart, after which the brush, folded with a cone, the back surface of which is turned backwards, can easily be inserted through the vaginal opening into the uterine cavity, pushing the perineum backwards. The hand is introduced necessarily outside the fight. If the fetal bladder is intact, it is opened in the center, and the brush is immediately carried out into the uterine cavity. In this case, if possible, prevent the rapid outflow of water from the uterus.

The hand should be held past the cape. If the presenting head interferes with the advancement of the brush into the uterine cavity, then it is pushed up inner hand and take it to the side of the back with the outer hand. In the same way, the presenting shoulder of the fetus is pushed aside in a transverse position.

It is known that in some pregnant women the fetus is in a breech presentation. There are many opinions about what kind of help such women need. And at the same time, there is a single position supported by all the leading obstetricians in the world and voiced by the World Health Organization. We came to a consensus because it was formulated on the basis of high-quality scientific research, and not on the opinion of individual experts. In this article, I will try to talk about the help that should be offered to a pregnant woman according to international recommendations.

Why obstetricians do not like breech presentation of the fetus?

Births in breech presentation have a greater risk to the health of the fetus.

What is known about the effectiveness of treatment for breech presentation?

First, you should not worry about how the fetus is located in the uterus until 36-37 weeks. It is likely that he can completely independently take the head presentation before this time. Gymnastics, which is often offered to pregnant women, turned out to be ineffective (the frequency of fetal rotations in those who perform and do not perform special exercises is the same). As a method of delivery, a caesarean section is usually offered, but independent childbirth is also possible (this can only be said after an ultrasound on the eve of childbirth and an analysis of the clinical situation by an experienced obstetrician).
Many clinics in the world have completely abandoned independent births in breech presentation, delivering such pregnant women by caesarean section. However, the argument often offered in the Russian Federation that breech birth in boys leads to male infertility has no scientific evidence. This story about male infertility is a topic exaggerated in Russian obstetric literature, and it was not heard about outside the USSR.

To avoid caesarean section in all industrialized countries, pregnant women are encouraged to undergo outer turn fruit per head. The obstetrician, by light pressure on the abdomen, rotates the fetus, and it becomes head presentation. This is the safest and most frequently performed procedure in obstetrics, which is practiced throughout the world. The method of turning is different from previously performed, and most importantly, it is carried out under the control of ultrasound and CTG, which means that the obstetrician has a good idea of ​​​​what is happening inside.
There are many speculations about this manipulation that I hear from both patients and medical workers. For many years of practice (I have been performing turns since 2001), I have not observed any complications of this manipulation. Although there is a risk of some complications, and it is negotiated with the pregnant woman before manipulation, the risk of such complications is extremely small. This risk is not comparable to that of a caesarean section or a breech birth.

The most common fear expressed by a pregnant woman is that the fetus can be injured or damaged. It is impossible to injure the fetus during the turn, it is in a state of hydroweightlessness and is protected amniotic fluid, and the rotation is carried out with light movements. In the world, such a complication has not been reported, although the manipulation is performed in large numbers.

Time manipulation lasts from a few seconds to several minutes. Although the whole process will take about 2-3 hours, because. ultrasound is preliminarily performed, CTG is recorded before and after the rotation. After the turn, the pregnant woman goes home. We usually ask to visit maternity hospital after 1-2 days. If the rotation is successful, then the woman will have a normal birth.

In about 30-40% of cases, the turn fails. The longer the gestation period, the more failures. Most often, the failure lies in the fact that in the process of examining a pregnant woman before turning, there are contraindications to its implementation. Less often, the rotation is carried out, but it is not possible to rotate the fetus. For those who want more scientific information, the World Health Organization Reproductive Health Library can be consulted. Fortunately, in 2008 her resume was translated into Russian.