Abnormal fetal position

　　The most common abnormal fetal position is breech presentation and posterior枕骨位, transverse position and facial position are less common, the cause is not very clear, and it may be related to the following factors:

　　The fetal head entering the pelvis is obstructed: such as malpresentation of the head and placenta previa, etc.;

　　The range of fetal movement increases: such as excessive amniotic fluid, relaxed abdominal wall in multiparas, twins, and premature infants, etc.;

　　③ Uterine malformation: Factors that can cause dystocia include macrosomia and fetal malformation.

　　With the current level of cesarean section technology and medical care in China, the safety of the fetus is higher during cesarean section for malpresentation compared to vaginal delivery. Vaginal delivery has more uncertain factors and is difficult to control. Currently, with fewer pregnant women giving birth, for the safety of both the mother and the fetus, most doctors still recommend cesarean section as the priority choice for malpresentation.

　　1. High risk of natural delivery

　　Although vaginal delivery is also one of the options for malpresentation, not all forms of malpresentation can be delivered naturally. More importantly, natural delivery still carries a higher neonatal perinatal mortality and morbidity rate for malpresentation fetus.

　　2. High risk of complications

　　Abnormal presentations have a higher risk of complications during labor. For example, after the waters break, due to malpresentation, the fetal head will not get stuck at the cervix, and the umbilical cord is easy to prolapse and slip out through the gap between the fetus and the cervix. As the uterus contracts and the fetus descends, the umbilical cord will easily be compressed by the fetus, leading to interruption of blood circulation. If not treated promptly, the fetus may be at risk of death due to oxygen deficiency.

　　3. Prolonged labor is easy

　　Due to malpresentation, the fetus's body parts do not pass through the shortest diameter of the birth canal, which is easily prone to prolonged labor. When the normal fetal head is below, during the process of delivery, the fetal head will continuously deform as it slowly descends through the birth canal. After the fetal head is born, the body will naturally follow out; however, in the case of breech vaginal delivery, it often happens that the buttocks are born, but the head, due to insufficient time for deformation, gets stuck in the pelvic cavity and cannot be born, which is very dangerous. Even in the case of emergency cesarean section, it is difficult to ensure the safety of the fetus's life.

　　After 28 weeks of pregnancy, an abnormal presentation is confirmed by abdominal and vaginal ultrasound examination. The most common abnormal presentations are breech and transverse positions.

　　1. Breech position

　　Abdominal examination shows the uterus is oval-shaped vertically, and the fetal head, which is round and hard with a floating ball sensation when pressed, can be felt at the bottom of the uterus. The buttocks, which are soft, wide, and irregular, can be felt above the pubic symphysis. The fetal heartbeat is most clearly heard on the left or right side above the umbilicus. Ultrasound examination shows the fetal head below the ribcage. Above the pubic symphysis, it is the arm or foot.

　　2. Transverse position

　　The uterus is oval-shaped horizontally, and the fetal head can be felt on one side of the mother's abdomen. The pubic symphysis is relatively empty. The fetal heartbeat is most clear on both sides of the umbilicus. Ultrasound examination shows the fetal head on one side of the mother's abdomen.

　　Common abnormal presentations include the fetus's buttocks at the pelvis inlet (breech position), the fetus's longitudinal axis perpendicular to the mother's longitudinal axis (transverse position), or oblique position, etc. Abnormal presentations can cause dystocia during delivery and often require surgical assistance. If not handled properly, they may even endanger the mother and fetus's lives. There is no better preventive measure, and early detection and early treatment are crucial.

　　1. Elective cesarean section should be performed for transverse position. For breech presentation, cesarean section is often performed for nulliparas; for multiparas, if the fetus is small and the pelvis is large enough, vaginal delivery can be considered.

　　2. If the transverse position is not treated in time, it may lead to umbilical cord prolapse, intrauterine fetal death, and even the risk of uterine rupture.

　　3. There is a possibility of umbilical cord prolapse after the amniotic fluid breaks in breech presentation, there is a risk of posterior vertex extraction during the delivery process, which can cause fetal asphyxia in utero, and even death.

　　4. Make good prenatal examinations, pre-diagnose malpresentation, and treat in a timely manner. If it has not changed to vertex position, the choice of delivery method should be made in advance, and hospitalization for delivery should be arranged in advance. This can prevent malpresentation during delivery and avoid serious consequences caused by malpresentation.

　　In summary, in addition to actively resting and paying attention to diet during pregnancy, women need to do more exercise to prevent the occurrence of abnormal fetal position, and it is also necessary to find abnormalities in a timely manner. Once abnormalities are found, they can be corrected in time.

　　It is difficult for pregnant women without medical knowledge to judge whether the fetal position is correct themselves. During the late pregnancy period (after 28 weeks of pregnancy), prenatal examination is usually performed every 2 weeks. Generally, doctors can determine the position of the fetal head and buttocks through the four-step palpation method, or determine it through ultrasound.

　　1. Ultrasound

　　Ultrasound detection is intuitive and clear, and can directly observe whether the fetal position is correct.

　　2. Four-step palpation method

　　The four-step palpation method is the most commonly used method in prenatal examination, starting after 24 weeks of pregnancy. Through the four-step palpation method, the position and size of the fetus, whether the size of the uterus is consistent with the gestational age, can be determined, and the fetal presentation, presenting part, and position can be determined, and the amount of amniotic fluid can be estimated.

　　① Maternal position: After urination, take a supine position, slightly raise the head, expose the abdomen, slightly bend the legs slightly apart, so that the abdomen is relaxed.

　　② Examiner: Stand on the right side of the pregnant woman to examine; face the pregnant woman when performing the first three steps of the technique; face the foot end of the pregnant woman when performing the fourth step of the technique.

　　③ Technique:

　　The first step: The examiner places the hands on the fundus of the uterus, measures the height of the fundus, and estimates whether the size of the fetus is consistent with the gestational age. Then, the fingertips alternate and gently push to judge the position of the fetus at the fundus. If it is the fetal head, it is hard and round with a floating ball sensation; if it is the fetal buttocks, it is soft, wide, and slightly irregular in shape.

　　The second step: The examiner places the hands on the left and right sides of the abdomen, fixes one hand, and gently presses down with the other hand to check, alternating from top to bottom. The flat and full part felt is the fetal back, and determine whether the fetal back is forward, to the side, or backward. The deformed uneven part felt is the fetal limbs, and sometimes the movement of the fetal limbs can be felt.

　　The third step: The examiner separates the right thumb from the other four fingers, places them above the symphysis pubis to hold the presenting part, and further checks whether it is the fetal head or buttocks, then pushes left and right to judge whether it is engaged. If the presenting part can still move left and right, it means that it has not yet engaged with the pelvis. If it has engaged, the presenting part cannot be moved.

　　The fourth step: The examiner places the left and right hands on either side of the presenting part of the fetus, pressing down deeply along the pelvic inlet to further confirm the accuracy of the judgment of the presenting part and determine the degree of engagement of the presenting part. When the presenting part is the fetal head, one hand can smoothly enter the pelvic inlet, while the other hand is blocked by the bulge of the fetal head, which is called the fetal head bulge. When the occiput is the presenting part, the fetal head bulge is the frontal bone, on the same side as the fetal limbs; when the face is the presenting part, the fetal head bulge is the occipital bone, on the same side as the fetal back.

　　Patients with abnormal fetal position cannot change their fetal position through diet. As for diet, it is only necessary to ensure a balanced diet, rich in nutrition, and suitable for pregnant women. During pregnancy, do not overeat and drink, and develop a scientific dietary habit.

　　Abnormal fetal position is one of the causes of difficult labor, commonly seen in three types: transverse position, oblique position, and breech position. The author believes that the main cause of this disease is Qi stagnation and Qi deficiency. The following is an introduction to the differentiation and treatment.

　　1. TCM Syndrome Differentiation

　　Abnormal fetal position often occurs in the later stage of pregnancy. The abdominal shape is transverse and large, or small above and large below, and one side of the abdomen can touch the fetal head, or the opposite side can touch the fetal buttocks, which is mostly transverse position; the fundus of the uterus can touch a round, hard, floating fetal head, which is mostly breech position.

　　Symptoms such as wiry and slippery pulse, dark tongue, chest tightness and shortness of breath, or abdominal distension are due to Qi stagnation leading to abnormal fetal position. It is because blood gathers to nourish the fetus during pregnancy, leading to Yin deficiency and blood deficiency, liver Qi being excessive, and in addition, as the fetus grows larger, it obstructs the ascending and descending of Qi mechanism, causing Qi mechanism to be obstructed, blood circulation to be blocked, the fetus to naturally have less power to turn, and thus leading to this condition. Symptoms such as thin and slippery pulse, pale tongue with thin fur, and a sense of descent in the abdomen are due to Qi deficiency leading to an abnormal fetal position. It is because the body is deficient in Qi, and after pregnancy, blood is used to nourish the fetus, which further leads to Yin blood deficiency, Qi and blood deficiency, slow blood circulation, and unable to turn the fetus, leading to this condition. In clinical practice, it is also common to have Qi deficiency and Qi stagnation simultaneously.

　　2. Treatment Method and Medication

　　Treatment is based on the method of regulating Qi and blood to turn the fetus, using the formula of Danggui Zisu Decoction with modifications: Danggui 15g, Chuanxiong 9g, Zhike, Zisu twig each 6g, Sharen 3g. In this formula, Danggui and Chuanxiong nourish blood and activate blood, can warm the meridians and vessels, and turn the fetus; Zhike, Su twig, and Sharen smooth the Qi and widen the middle, can warm and smooth the Qi mechanism, relax the abdominal wall muscles, and prepare conditions for the fetus to turn.

　　For Qi deficiency, add Dangshen, Huangqi, and Gancao to tonify Qi and generate blood to carry the fetus, and help the circulation of Qi and blood; for heat, add stir-fried Huangqin; for cold, add Aiye; for those with a low fetal position that is difficult to move, add a small amount of Chuanma to tonify Qi and elevate it.

　　3. Caution

　　The main causes of abnormal fetal position are Qi deficiency and Qi stagnation, which affect blood circulation, cannot promote the normal operation of the fetus, and lead to this condition; secondly, if the abdominal wall of a primipara is narrow or lacks activity, it can also lead to this disease. In clinical practice, treatment should be based on the strength of the constitution, with the method of regulating Qi and nourishing blood, or tonifying Qi and raising Yang, or nourishing the kidneys and calming the fetus, so that Qi and blood are harmonized, and blood circulation is normal, then the fetal position will be corrected. The dosage of medication in the later stage of pregnancy or before delivery should be large enough to achieve a complete effect.