Podalica del Feto position

Generality

The breech position of the fetus indicates the presentation of the unborn child with the buttocks, feet or knees facing the uterus.

This condition represents a risk factor for the health of the future mother or child, as vaginal delivery is more complex. Usually, in fact, the head is the first part to come out, as well as the most delicate, followed by the rest of the body; obviously, in the breech parts the opposite happens: the head is at the top, while the butt or feet are at the bottom, ready to channel into the birth canal.

The breech position of the fetus represents in itself an anomaly, when it occurs at the end of the pregnancy and, as such, must be managed with the help of the gynecologist and an experienced midwife, able to implement specific assistance maneuvers .

Interventions to correct the fetal's breech position before the expected date of birth are different. To encourage spontaneous inversion, it is possible to resort to external manipulation of the abdomen (carried out by medical and specialized personnel, in a hospital environment) or groped with alternative techniques (such as postural exercises and moxibustion). In the event that these approaches are not effective, a cesarean section may be indicated to facilitate the birth of the child.

What is the breech position of the fetus?

The breech position is an abnormal presentation of the fetus; when it occurs near the end of pregnancy or during labor, the baby's head is turned upwards, rather than being engaged in the maternal pelvis (ie towards the bottom of the uterus).

This particular condition affects about 4% of term pregnancies. Usually, in the period preceding the birth, most of the fetuses are in cephalic presentation, that is in the ideal position to be born, with the head turned downwards and the feet upwards.

Eutocical childbirth: what normally happens

Normally, around the 30th week of pregnancy, the child spontaneously assumes the most favorable position for childbirth:

The head is facing down, ready to channel into the birth canal, with the longitudinal axis of the body parallel to that of the future mother;
The legs are upward and are flexed;
The arms are gathered on the trunk;
The chin is resting on the chest.

In the cephalic position, the body of the unborn child offers the least possible resistance to the passage in the birth canal. When the fetus is breeching it means that it is positioned with the bottom seat and the legs are flexed or extended.

Causes

The fetus arrives at the end of pregnancy in a breech position in a small percentage of cases (equal to about 4% of gestations).

The causes of the breech position of the fetus have not yet been established with certainty. However, significant correlations have been observed with some known factors, concerning the characteristics of the current pregnancy, the child and the pregnant woman .

Some fetuses maintain or assume this position more often in the event of:

Placental complications : a defect in adherence or insertion of the placenta at an unusual depth (eg placenta previa, accreta, anterior, etc.) can, in some cases, favor this situation;
Polydramnios : when the amniotic sac contains an excessive amount of liquid, the fetus has greater freedom of movement.

Even the mother's bone structure seems to have a certain influence: a very narrow pelvis could cause a certain lack of space available to the child, to rotate on itself.

Other conditions that can predispose to the breech position of the fetus are:

Congenital malformation of the maternal uterus;
Fibroids or uterine myomas;
Pelvic tumors;
Structural anomaly of the skull or other fetal malformations;
Shortness of the umbilical cord;
Twin pregnancy.

Furthermore, the breech position of the fetus could be conditioned by:

Genetic predisposition (breech born parents have more frequently a son in breech position);
Excessive weight gain of the mother during gestation.

It should be noted, however, that the fetus often presents itself "to sit" or "to walk" without any particular risk factors.

Symptoms and Complications

The breech position can occur in different variants, in which the fetus is found with:

Hips and knees flexed: breech position of the complete fetus ;
One or both also partially or completely extended: breech position of the incomplete fetus ;
Even flexed and extended knees: breech position of the frank fetus (also called "buttock variant").

The breech position of the fetus can be associated with:

Low neonatal weight;
Preterm birth.

The vaginal delivery with breech presentation is not impossible: if the reduced dimensions of the unborn child in relation to the mother's pelvis allow it, it is possible to try the conventional modality, if the gynecologist, evaluating the relationship benefit / damage, confirms the feasibility.

In any case, vaginal delivery with the fetus in breech position involves risks that it is important to consider before planning this mode:

Trapping of the head : the expulsive phase of the birth can begin even if the dilation is still insufficient to make the head pass. There is the possibility, therefore, that the child begins the descent into the birth canal from the pelvis or feet, but the head remains blocked, since it has a larger diameter than the rest of the body, with a significant risk of asphyxia . Furthermore, in the case of a breech position of the fetus, it is possible that the rapid release of the legs favors the distension towards the top of the child's arms (normally, they are gathered on the chest). If this happens, the baby can get stuck at shoulder height.
Prolapse of the umbilical cord : during the expulsive phase, the escape of a part of the umbilical cord together with the legs and pelvis of the unborn child, can favor the compression of the same in the birth canal. In this case, the passage of oxygen is blocked (the cord is not able to supply the child engaged to be born); if prolonged, hypoxia can cause permanent neurological damage (for example: cerebral palsy) or death.

The difficulties associated with vaginal delivery in case of breech presentation can increase the child's chances of incurring the following complications :

Cerebral palsy;
Hip dysplasia;
Brachial plexus paralysis;
Perinatal mortality.

The vaginal delivery method is definitely not recommended when the following conditions exist:

The breech position of the fetus is not convenient, as it is particularly "complicated" (for example, in addition to the non-cephalic presentation, the child could also have the head extending upwards, as if turning his eyes to the sky);
The child is too big or too small for gestational age;
The pregnant woman has other complications, such as maternal preeclampsia (or gestosis).

For all these reasons, in the event that the child is a breech, it is usually preferred to have a caesarean section .

Preterm parts and breech position of the fetus

In preterm parts, breech presentation is frequent: often, premature babies have not yet had time to turn around in the womb. In some of these cases, it is possible to avoid the use of cesarean section, since the small size of the unborn child does not increase the risks of complications of labor and delivery.

Diagnosis

To check the breech position of the fetus, the pregnant woman is subjected to ultrasound examination, approximately at the 32nd week of gestational age. This assessment allows you to:

Measure the amount of amniotic fluid;
Ensure that the growth of the unborn child is normal;
Check the position of the placenta.

During the visit, usually, cardiotocographic monitoring (CTG) is also performed to assess fetal well-being.

If a fetal position is diagnosed, the expectant mother is subjected to a manual evaluation by palpation or, in case of doubt, to an ultrasound scan every week .

Is spontaneous fetal rotation possible?

Between the 28th and 32nd week of pregnancy, spontaneous rotation of the child in the cephalic position is possible and occurs in about half of all fetuses up to that moment breech. With the progress of the weeks of gestation, instead, the probability of spontaneous version is reduced.

Treatment and Remedies

The breech position of the fetus can be corrected with various approaches:

Between the 36th and 37th week of waiting, in a hospital setting, it is possible to resort to turning over or cephalic version from the outside. In practice, the gynecologist exerts a delicate pressure on the abdomen of the future mother, pushing the fetus to do a sort of somersault. The procedure is effective in 40-60% of cases.
Before arriving at the 36th week of waiting, the future mother can implement some strategies to "encourage" the spontaneous rotation of the fetus. An attempt consists in "convincing" the unborn child to spontaneously turn around, adopting positions that favor their movements. Alternatively, it is possible to resort to gentle techniques such as acupuncture (insertion of a needle into the little finger of the foot) and moxibustion (thermal stimulus at the same point), which do not guarantee turning, but favor it.

Reversal maneuver (or external cephalic version)

The turning maneuver consists of the external manipulation of the mother's abdomen to push the fetus into a podalic position to rotate in the cephalic position. This procedure is performed only by expert personnel, in cases where the specific conditions of pregnancy allow it.

The turning maneuver is less risky than a vaginal delivery with breech presentation of the fetus and less invasive than the cesarean section.

The procedure is usually performed between the 36th and 37th week of gestation : in this period, the child is unlikely to be able to turn around spontaneously. If this attempt is successful and, in the following days, the unborn child does not return to the breech position again, this intervention allows to proceed with the vaginal birth .

Warning! The external cephalic version is a maneuver that must be performed by an experienced gynecologist. This procedure is performed only in some hospital facilities, due to the fact that its execution requires considerable skill, in addition to a specific preparation.

How to do it. The turning maneuver is performed in a hospital environment, with an operating room ready in case of the need for an emergency cesarean delivery (ie if forced rotation should cause a rupture of the placenta or damage to the umbilical cord).

Under constant echographic control, the gynecologist exerts controlled pressures on the abdomen of the future mother, gently pushing the unborn child's head downwards to facilitate rotation and place him in the right position.

Before the maneuver, they are administered to the pregnant woman with tocolytic drugs, which help to relax the uterus, favoring the success of the procedure.

What are the contraindications . The maneuver is not painful, but may cause some discomfort (although this perception is completely subjective). The turning maneuver can be practiced until the onset of labor, before the amniotic sac is broken. The major risks of forced rotation are detachment of the placenta, hemorrhage or rupture of the uterus and damage to the umbilical cord.

The external cephalic version is contraindicated in the following cases:

Anterior Placenta : the gynecologist does not have access to the fetus by manipulating the abdomen of the woman and, if the placenta is positioned to cover the orifice of the neck of the uterus, the vaginal birth is still not practicable;
Oligodramnios : the low amount of amniotic fluid prevents the child's rotational movement;
Twin pregnancies : if the first twin, that is the one positioned lower down in the pelvis, is cephalic, it is possible to proceed with the vaginal delivery and the gynecologist can give a rotation to the second child after the expulsion of the first. When both fetuses are podalic, the use of cesarean is preferable.
Multiple or large fibroids;
Past cesarean section .

Furthermore, it is not possible to proceed with this technique if:

The fetal heart rate presents anomalies;
The woman has vaginal bleeding;
Membrane rupture has already occurred;
Labor has begun.

Alternative methods

Before arriving at the 36th week of waiting, when the fetus still has room to try to turn around on its own, the future mother can implement some strategies. These different interventions have the advantage of not being traumatic, but their effectiveness is reduced or not fully validated.

Alternative methods to encourage spontaneous fetal rotation in breech position include:

Postural techniques: they consist in performing movements or in taking positions that can favor the turning of the unborn child. For example, it is possible to try to relax by staying a few minutes with the pelvis raised and held higher than the trunk by means of a pillow. Alternatively, you can opt for a genupettorale position (with elbows and knees bent and resting on the ground) or supine on the ground, with the legs raised as a team and resting on the wall.
Moxibustion (or Moxa) : is a technique that originates from traditional Chinese medicine. This involves the stimulation of the BL 67 or Zhiyin acupuncture point (outer margin of the little toe, near the nail), through the heat generated by the combustion of a mugwort cigar, made with dried and compressed herbs. The hot tip of this cone should be kept in place for a few seconds, then it is removed as soon as there is a sense of discomfort. The stimulation of these points on the fingers (according to Chinese tradition, corresponding to the bladder meridian connected to the uterus) would cause an increase in fetal movements, inviting the child to turn around. Moxibustion (whether or not associated with acupuncture) can be performed at home by a midwife or a naturopath (not many hospitals practice it).
Acupuncture : involves the insertion of a needle in the same points stimulated with moxibustion.
Sport : swimming is the most suitable activity for the spontaneous version of the fetus that is in a breech position; increasing the buoyancy, the child could be encouraged to turn around.