Breech presentation

　　Before 30 weeks of gestation, breech presentation is more common, and most can naturally turn into cephalic presentation after 30 weeks of gestation. The reasons for the persistence of breech presentation during labor are not yet fully clear, and possible factors include:

　　1. The range of movement of the fetus in the uterine cavity is too large, there is too much amniotic fluid, the abdominal wall of the primipara is relaxed, and the amount of amniotic fluid in preterm infants is relatively excessive, making the fetus easy to move freely in the uterine cavity and form a breech presentation.

　　2. Restrictions on the range of movement of the fetus in the uterine cavity, such as uterine malformations (such as unicorne uterus, bicorne uterus, etc.), fetal malformations (such as hydrocephalus, etc.), and insufficient fetus and amniotic fluid, are prone to breech presentation.

　　3. Obstructed breech delivery due to narrow pelvis, placenta previa, tumor obstruction of the pelvic cavity, etc., is also prone to breech presentation. Among all parts of the fetus, the fetal head is the largest, the fetal shoulder is smaller than the fetal head, and the fetal buttocks are the smallest. In the vertex presentation, once the fetal head is delivered, the other parts of the body are delivered immediately. However, in breech presentation, the smaller and softer buttocks are delivered first, and the largest fetal head is delivered last. To adapt to the conditions of the birth canal, the fetal buttocks, shoulders, and head need to adapt to the conditions of the birth canal in a certain mechanism to be delivered, so it is necessary to master the delivery mechanism of the fetal buttocks, shoulders, and head.

　　The most common complications of breech presentation during pregnancy are premature birth, premature rupture of membranes, cord prolapse, prolonged labor, perineal laceration, uterine rupture, and puerperal infection, followed by intrauterine growth restriction of the fetus. Breech delivery has a significant impact on the prognosis of both mother and infant and is considered to be in the high-risk category.

　　1. Breech delivery has a significant impact on perinatal infants, with more complications

　　(1) Premature birth: It is a common complication, in addition to the impact of premature birth itself on the fetus or infant, breech delivery is more dangerous than vertex delivery, mainly reflected in low birth weight and high mortality. Statistics show that neonates with breech delivery have lower birth weight than those without breech presentation in the same gestational age group. Moreover, due to the greater discrepancy in head-to-hip circumference between premature infants and full-term infants, they are more prone to asphyxia and injury, so the risk of delivery is greater, and the mortality rate increases accordingly.

　　(2) Cord prolapse: The incidence of cord prolapse in breech delivery is 4% to 5%, which is ten times that of vertex presentation. Among them, the incidence of cord prolapse in a single breech presentation where the presenting part is completely filled in the cervical os is the lowest, followed by complete breech presentation. Footling breech is the most likely complication, as the presenting part is small and cannot fill the pelvic inlet well. When uterine contractions occur, amniotic fluid flows into the anterior amniotic sac, which is easy to cause premature rupture of membranes, especially when the cervix is dilated and uterine contractions are strong, it is more likely to suddenly rupture the membranes, and the umbilical cord prolapse.

　　(3) Fetal asphyxia: In breech labor, especially after membrane rupture, it is easy for the umbilical cord to prolapse or be compressed, leading to fetal hypoxia in the uterus. During the process of assisting breech delivery, the fetal body is stimulated by cold air, which may cause premature breathing and aspiration of amniotic fluid and vaginal secretions. If there is difficulty in delivering the posterior fetal head, the baby often presents with varying degrees of asphyxia after delivery, even death.

　　(4) Neonatal pneumonia: Caused by asphyxia or aspiration of amniotic fluid and secretions, resulting in aspiration pneumonia in the fetus.

　　(5) Intracranial hemorrhage: The position and posture of the fetal head, whether it is upright, extended, lateral, or reverse, are difficult to estimate in breech presentation. During the process of delivery, due to insufficient estimation, it is often difficult to deliver the baby's head, or intracranial hemorrhage may occur due to excessive traction. There is no condition for checking the disproportion between the pelvis and the fetal head in breech delivery, and it often leads to fetal death due to insufficient estimation. On the other hand, due to the difficulty of traction, prolonged cerebral hypoxia may cause diffuse hemorrhage in the brain substance, which can bring lifelong sequelae. In addition, there is so-called 'minimal brain damage', which is often found in early childhood when children are lagging behind normal children in intellectual performance such as reading, writing, understanding, and communication. The incidence of breech presentation is twice that of vertex presentation.

　　(6) Fractures and other injuries: During breech delivery, the fetus has more opportunities to be injured, such as cerebral tent tear, fracture, visceral injury, nerve injury. Regardless of vaginal delivery or cesarean section, improper assistance during delivery can lead to fractures, common ones include limbs, clavicle, skull. Other injuries include joint dislocation, vertebral dislocation, brachial plexus palsy, mass in the sternocleidomastoid muscle, facial nerve palsy, etc., or due to the excessive lateral flexion of the fetal head after birth, causing cervical nerve palsy and leading to atelectasis. It is best to take an X-ray abdominal film before delivery to help diagnose whether the fetal head is hyperextended or flexed, so as to assist in delivery with foresight.

　　(7) Malformation: The incidence of congenital malformations such as hydrocephalus, anencephaly, congenital dislocation of the hip joint, etc., in breech presentation is higher than that in vertex presentation. The incidence of malformation in breech presentation is about 1-2 times higher than that in vertex presentation.

　　2. Breech delivery also has adverse effects on the mother.

　　(1) Premature rupture of membranes: The irregular shape of the presenting part in breech presentation causes uneven pressure on the amniotic sac, making it prone to premature rupture of membranes. This is mainly due to the small and irregular shape of the presenting part of the fetus, causing uneven transmission of pressure in the amniotic cavity, thus forming a weak point at the cervix, leading to premature rupture of membranes. In the case of breech premature rupture of membranes, if the cervix is relaxed or the os has dilated, the umbilical cord of the fetus may prolapse through the os or become trapped between the uterine wall and the presenting part, affecting blood supply and endangering the fetus's life. On the other hand, breech premature rupture of membranes, with communication between the amniotic cavity, vagina, and the outside world, is prone to infection.

　　(2) Prolonged labor: Due to the irregular shape of the presenting part, it is not easy to closely adhere to the lower uterine segment and the cervix, which can easily cause uterine contraction weakness, leading to prolonged labor.

　　(3) Soft birth canal injury: If the cervix has not fully dilated and an early breech extraction is performed, or if the breech delivery technique is not properly mastered, or if the actions are rough, it can lead to vaginal lacerations, even third-degree perineal tears, cervical lacerations, and in severe cases, may involve the lower uterine segment, even uterine rupture.

　　(4) Infection: Due to vaginal manipulation, prolonged labor, premature rupture of membranes, and birth injuries, the incidence of postpartum infection is also higher than that of vertex presentation.

　　The main manifestation of breech presentation is that pregnant women often feel a sense of distension in the hypochondrium. During labor, due to the inability of the fetal buttocks and feet to fully dilate the lower uterine segment and the internal os of the cervix, it often leads to uterine contraction weakness and prolonged labor. In addition, there are the following clinical manifestations.

　　The first sign of labor: The soft and irregular fetal buttocks, feet, or knees can be felt during rectal examination.

　　The second sign of labor: The uterus is palpated in a longitudinal oval shape, the fundus can be felt as a round and hard fetal head, and pressing it gives a distinct floating ball sensation; if it has not engaged, an irregular, soft, and wide fetal buttock can be felt above the pubic symphysis; the fetal heart sound is most clear when listened to above the left or right upper abdomen; if it has engaged, the fetal heart sound is most clear below the navel.

　　The third sign of labor: If rectal examination cannot determine the condition, vaginal examination is necessary. If the amniotic membrane has ruptured, the fetus's anal opening, ischial tuberosities, and sacrum can be directly palpated, and at this time, attention should be paid to differentiate from the facial features. If it is the fetal buttocks, the anal opening and two ischial tuberosities can be felt in a straight line, there is a contraction sensation when the finger is inserted into the anal opening, and the fetal meconium can be seen on the finger cot when it is taken out. If it is the face, the mouth and the prominent zygomatic bones form a triangular shape, and the alveolar ridge and mandible can be felt when the finger is inserted into the mouth. Accurate palpation of the sacrum is very important for diagnosing the fetal position.

　　How to prevent breech presentation? Before 30 weeks of gestation, breech presentation is more common, and most can naturally turn into cephalic presentation after 30 weeks of gestation. Clinically, advanced ultrasound and fetal heart sound monitors are used to make a comprehensive assessment of breech presentation fetus and make a correct choice of delivery method.

　　The laboratory tests needed for breech presentation include abdominal examination, rectal examination, vaginal examination, and ultrasound examination.

　　1. Abdominal examination: The four-step palpation of the uterus presents a longitudinal oval shape, the fetal head can be felt round and hard at the fundus, and there is a significant floating ball sensation when pressed; if it has not engaged, an irregular, soft, and wide fetal buttocks can be felt above the symphysis pubis, and the fetal heart sound is most clear when listened to above or to the left or right of the umbilicus; if it has engaged, the fetal heart sound is most clear when listened to below the umbilicus.

　　2. If rectal examination or vaginal examination cannot confirm the cephalic or breech position as in abdominal examination, rectal examination can be performed. If the pelvic cavity is empty, a round and hard fetal head cannot be felt, but a higher, soft and irregular fetal buttocks can be felt, or the fetal feet can be felt, which can be diagnosed as breech presentation. If rectal examination still cannot confirm the diagnosis, vaginal examination can be performed to distinguish the types of breech presentation, understand the condition of the cervical os, and determine whether there is umbilical cord prolapse. If the amniotic membrane has ruptured, the fetal buttocks, external genitalia, and anal opening can be palpated directly. If the palpated part resembles the fetal foot, it can be distinguished from the fetal hand or foot by the difference between the toes and fingers and whether there is a heel, and attention should be paid to differentiate from the face position when palpating the fetal buttocks. In breech presentation, the anal opening and both ischial tuberosities form a straight line, and there is a sensation of the circular sphincter contraction when the finger is inserted into the anal opening, and the fetal meconium can be felt on the tip of the finger; while the mouth and the two zygomatic bones of the face position form an isosceles triangle distribution, and the alveolar ridge and mandible can be felt when the finger is inserted into the mouth.

　　3. Vaginal examination: If rectal examination cannot determine the condition, vaginal examination is necessary. If the amniotic membrane has ruptured, the fetus's anal opening, ischial tuberosities, and sacrum can be directly palpated, and at this time, attention should be paid to differentiate from the facial features. If it is the fetal buttocks, the anal opening and two ischial tuberosities can be felt in a straight line, there is a contraction sensation when the finger is inserted into the anal opening, and the fetal meconium can be seen on the finger cot when it is taken out. If it is the face, the mouth and the prominent zygomatic bones form a triangular shape, and the alveolar ridge and mandible can be felt when the finger is inserted into the mouth. Accurate palpation of the sacrum is very important for diagnosing the fetal position. In the case of complete breech presentation, the fetus's feet can be palpated, and the position of the thumb can be used to distinguish between the left and right feet, and at the same time, it should be differentiated from the fetal hand. As the fetal buttocks further descend, the external genitalia can still be palpated, and attention should be paid to whether there is umbilical cord prolapse.

　　4. Ultrasound examination: B-ultrasound examination can not only determine the breech position but also clarify whether the fetus has any malformations. It can also measure the biparietal diameter, head circumference, and abdominal circumference of the fetus to estimate the size of the fetus.

　　Food suitable for patients with breech presentation:

　　Millet Porridge

　　Ingredients: 45 grams of millet, an appropriate amount of brown sugar.

　　Method: Cook millet with water until it is soft, and add an appropriate amount of sugar.

　　Nutritional analysis: Millet contains a variety of vitamins, amino acids, fats, and carbohydrates, making it nutritionally rich. Unlike other grains, millet contains beta-carotene, with 0.12 milligrams per 100 grams, and a high content of vitamin B1. In addition, millet has a high sugar content and produces more heat than rice. It has a good nourishing effect on patients with breech presentation.

　　Lotus Root Porridge

　　Ingredients: 250 grams of lotus root, 100 grams of glutinous rice.

　　Method:

　　1. First, clean the lotus root and cut it into thin slices.

　　2. Rinse the glutinous rice and then cook it with the lotus root in a pot of water to make porridge. It is ready to eat when cooked.

　　Nutritional analysis: Lotus root contains a large amount of starch, vitamins, and minerals. After boiling, it can strengthen the spleen and stomach, and clear the accumulated blood stasis in the mother's abdomen. It is very suitable for mothers who have just given birth, are physically weak, and have not finished lochia.

　　Pregnancy period: Before 30 weeks of pregnancy, most fetuses are in buttock position. Those who are still in buttock or transverse position after 30 weeks need to be corrected. However, it varies from person to person, and some babies may turn to the correct position by themselves before delivery. Common correction methods are as follows:

　　(1) Kneeling chest position: After 30 weeks of pregnancy (7 and a half months)

　　Method: Kneel on the bed with legs apart at the same width as the shoulders, with the knees forming a 90-degree angle with the bed. Press the chest as close to the bed surface as possible, and raise the buttocks as high as possible. Perform this exercise on an empty stomach in the morning and before going to bed, for as long as you can bear, and try to persist for 15-20 minutes each time.

　　This method utilizes the change in fetal center of gravity and the pregnant woman's transverse resistance, increasing the chance of the fetus turning to the head position. A course lasts for 7 days, and if not successful, it can be done again for another 7 days. The efficiency is 60%-70%. Some pregnant women may experience dizziness, nausea, and palpitations while doing the knee-chest position, and cannot persist, in which case other methods should be used to correct the fetal position.

　　Serious attention: During the fetal turning, there is a possibility that the umbilical cord may wrap around a part of the fetus, or even strangle the neck, leading to fetal hypoxia and abnormal fetal movement. Therefore, it is necessary to undergo weekly reexamination and monitoring of fetal heart rate under the guidance of a doctor, and record and compare abnormal fetal movements.

　　(2) Self-correction method for buttock position:

　　Method: Lie flat on the bed, with the waist elevated by 20 centimeters (1-2 pillows), and the two lower legs naturally hanging over the edge of the bed. Perform this exercise twice a day, morning and evening, for 10-15 minutes each time, with a course lasting 3 days.

　　Precautions: This method should be arranged between 30-34 weeks of pregnancy for the best effect, and correction should be done before meals. During correction, breathing should be calm, muscles should be relaxed, the pad should be soft, comfortable, and of moderate height; if there is vaginal discharge, bleeding, or a sudden change in the fetal heart sound (those with conditions can monitor), this method should be stopped.

　　(3) Laser Therapy or Moxibustion at the 'Zhiyin' Point: Use laser therapy or moxibustion at the 'Zhiyin' point (0.3 cm beside the lateral corner of the nail of the little toe), once a day, for 15 to 20 minutes each time, and 5 to 7 days as one course.

　　(4) Other: Methods such as manual version and lateral position. Staying in the left lateral position while sleeping can also be very helpful for the baby's turning.

　　(5) External Version: If the above methods are ineffective and there is no nuchal cord, external version can be performed between 32 to 34 weeks of pregnancy. External version has the risks of inducing premature rupture of membranes, placental abruption, umbilical cord entanglement, and preterm labor. Caution should be exercised when using it. The pregnant woman lies on her back, with her lower limbs slightly flexed and slightly abducted, exposing the abdominal wall, checking the position of the fetus, and listening to the fetal heart rate. First, loosen the presenting part of the fetus, that is, the operator's hands insert under the presenting part of the fetus and pull it upwards to loosen it, and then turn the fetus. The specific method is: hold the two ends of the fetus with both hands, one hand moves the fetal head along the fetal abdomen, maintaining the fetal head flexed, gently pushing it into the pelvis, and the other hand pushes the fetal buttocks upwards, coordinating with the action of pushing the fetal head until the fetus is in vertex presentation. The movements should be gentle and intermittent. If frequent and severe fetal movements or abnormal fetal heart rate are found during the operation, the rotation should be stopped and the original position should be returned, and the position should be strictly observed until it returns to normal.

　　Be cautious when using external version of the fetus in the following situations: with pelvic tumors, malformations of the uterus, scarred uterus, membranes broken, placenta previa, placenta attached to the anterior wall of the uterus, active labor period, and excessive or insufficient amniotic fluid, etc.

　　No matter which method is used, there is potential danger to the baby. Pregnant women should be cautious. Most babies will turn themselves around actively because they will choose the most favorable position for themselves. Therefore, pregnant women should not be too forceful and should correct the position when conditions permit, with the safety of the baby as the top priority. If it is still not possible to turn, cesarean section can be chosen.