Indications and technique of imposing output obstetric forceps. Conditions for applying forceps, contraindications

The operation of applying obstetric forceps refers to delivery. Delivery operations are called operations with the help of which childbirth is completed. Delivery operations through the natural birth canal include: extraction of the fetus with the help of obstetric forceps, by vacuum extraction, extraction of the fetus by the pelvic horses, fruit-destroying operations.

The operation of applying forceps is extremely important in obstetrics. Domestic obstetricians have done a lot for the development and improvement of this operation, in particular, the indications for it and the definition of the conditions for its implementation have been developed in detail, their own varieties of the instrument have been created, and the immediate and long-term outcomes of the operation for the mother and child have been studied. The role of the obstetrician in providing prompt assistance to women in labor in cases of complicated childbirth is great and responsible. It is especially great during the operation of applying obstetric forceps. Therefore, among the few, but very responsible obstetric operations (not counting the light ones), the operation of applying obstetric forceps undoubtedly occupies a special place both in terms of the relative frequency of its use compared to other obstetric operations, and in terms of the beneficial results that this operation can give with timely, skillful and careful application.

Purpose and action of obstetric forceps

The following questions are most frequently discussed in the literature:

1. whether obstetric forceps only for the head (including the subsequent one), or they can also be applied to the buttocks of the fetus;
2. is it possible to use forceps to overcome the discrepancy between the size of the pelvis of the woman in labor and the head of the fetus, using force and, in particular, the force of attraction or compression of the head with spoons;
3. what is the nature of the extracting force of forceps;
4. whether it is permissible to rotate the head with tongs around its vertical or horizontal axis;
5. whether forceps have dynamic action;
6. whether the forceps should stretch the soft tissues of the birth canal, preparing them for the eruption of the fetal head.

The first question - about the admissibility of applying forceps to the buttocks - was resolved positively in domestic obstetrics. Almost all guidelines allow the application of forceps to the buttocks, provided that the latter are already firmly inserted into the pelvic inlet and it is impossible to put a finger behind the inguinal fold to extract the fetus. Traction should be performed carefully due to the ease of slipping of the forceps.

On the second question - about overcoming the discrepancy between the head of the fetus and the pelvis of the woman in labor with the help of forceps, domestic obstetricians have a unanimous opinion. Forceps are not designed to bridge the mismatch, and a narrow pelvis by itself is never an indication for surgery. It should be noted that compression of the head with forceps during the operation is inevitable and represents an inevitable disadvantage of the instrument. Back in 1901, in the dissertation work of A. L. Gelfer on the corpses of newborns, the change in intracranial pressure was studied when the head was passed with forceps through a narrow pelvis. The author came to the conclusion that when passing the head with forceps through a normal pelvis intracranial pressure increased by 72-94 mm Hg. Art. Only 1/3 of the cases of pressure increase depends on the compressive action of the forceps, and 1/3 - on the compressive action of the pelvic walls. With a true conjugate of 10 cm, intracranial pressure increased to 150 mm, of which 1/3 occurs when forceps were used, with a conjugate of 9 cm, intracranial pressure reached 200 mm, and at 8 cm - even 260 mm Hg. Art.

The most complete justification of the view regarding the nature of the extractive force and the possibility of using different kind rotational motions was given by N. N. Fenomenov. Currently, there is a clear provision that forceps are intended only for removing the fetus, and not for artificially changing the position of the head. In this case, the obstetrician follows the movements of the head and contributes to them, combining the translational and rotational movement of the head, as occurs in spontaneous childbirth. The dynamic action of forceps is expressed in increased labor activity with the introduction of forceps spoons, but this is not significant.

Indications for the imposition of obstetric forceps

Indications for forceps surgery are usually divided into maternal and fetal indications. In modern guidelines, the indications for the operation of applying obstetric forceps are as follows: acute distress (suffering) of the fetus and shortening of the II period. There is a significant difference in the frequency of individual indications for surgery. A. V. Lankovits in his monograph "The operation of applying obstetric forceps" (1956) indicates that this difference remains large, even if you do not adhere to the details of the division, and combine the indications into groups: indications from the mother, from the fetus and mixed. So, the testimony from the mother accounts for from 27.9 to 86.5%, and including mixed, from 63.5 to 96.6%. Indications from the fetus range from 0 to 68.6%, and including mixed, from 12.7 to 72.1%. Many authors do not indicate mixed indications at all. It should be noted that the general formulation of the testimony given by N. N. Fenomenov (1907) expresses the general that underlies the individual testimony and covers the whole variety of particular moments. So, N. N. Fenomenov gave the following general definition indications for surgery: “The application of forceps is indicated in all those cases in which, with the necessary conditions for their use, the expelling forces are insufficient to end the birth act in this moment. And further: “If during childbirth any circumstances arise that threaten the danger of the mother or the fetus, or both together, and if this danger can be eliminated by the speedy end of childbirth with the help of forceps, then the forceps are indicated.” The indications for the application of forceps are the threatening condition of the woman in labor and the fetus, which, as in the operation of extracting the fetus, requires an urgent end of the birth act.

These are: decompensated heart defects, serious illnesses lungs and kidneys, eclampsia, acute infection, accompanied by a rise in body temperature, fetal asphyxia. In addition to these general and other obstetric operations, there are special indications for forceps.

1. Weakness of labor activity. The frequency of this indication is significant. The appearance of signs of compression of the soft tissues of the birth canal or the fetus makes it necessary to resort to surgery, regardless of the time during which the head was standing in birth canal. However, even without obvious signs of compression of the fetal head and soft tissues of the woman in labor, the obstetrician, if conditions are present, may resort to surgery after an average of 2 hours.
2. Narrow pelvis. For an obstetrician in the management of childbirth, it is not the narrow pelvis itself that is important, but the ratio between the size and shape of the pelvis of the woman in labor and the head of the fetus. It should be mentioned that for a long time the purpose and action of the forceps was seen in the compression of the head, which facilitates its passage through a narrow pelvis. Subsequently, thanks to the work of domestic authors, especially N. N. Fenomenov, this view of the action of forceps was abandoned. The author wrote: “Speaking on these grounds in the most categorical way against the doctrine that considers a narrow (flat) pelvis as an indication for forceps, I understand very well, of course, that the imposition of forceps will and should nevertheless take place with a narrow pelvis, but not for the sake of narrowing, but due to general indications (weakening of labor, etc.), if the conditions necessary for the forceps are present. After nature, with the help of an expedient configuration of the head, has eliminated or almost eliminated the initial existing discrepancy between the pelvis and the birth object, and when the head has already completely or almost completely passed the narrowed place and for the final birth needs only an increase in (weakened) straining activity, which can be replaced artificially, the operation of applying forceps in this case is quite an expedient benefit. Between this view of the forceps and the narrow pelvis and the above, the difference is vast and quite obvious. Thus, in my opinion, a narrow pelvis by itself can never be considered an indication for forceps surgery. After all, the indication obstetric operations in general, it is always the same - it is the impossibility of an arbitrary end of childbirth without danger to the mother and fetus.
3. The narrowness and inflexibility of the soft tissues of the birth canal and their infringement - these indications are extremely rare.
4. Unusual head inserts. Unusual insertion of the head cannot serve as an indication for surgery if it is a manifestation of a discrepancy between the pelvis and the head and this discrepancy has not been overcome. Forceps should not be used to correct the position of the head.
5. Threatened and accomplished uterine rupture. Currently, only N. A. Tsovyanov considers overstretching of the lower segment of the uterus among the indications for the imposition of forceps. A.V. Lankovits (1956) believes that if the head is in the pelvic cavity, or even more so in its outlet, then in such cases a caesarean section is not feasible, and the spoons of the forceps cannot have direct contact with the uterus, since the neck has already moved beyond the head . The author believes that in such a situation and the threat of uterine rupture, there is reason to consider the operation of applying abdominal and output forceps as indicated. It is quite obvious that the refusal of vaginal delivery in case of diagnosed uterine rupture during childbirth is the only correct position of the doctor.
6. Bleeding during childbirth is only in exceptional cases an indication for a forceps operation.
7. Eclampsia is an indication for forceps surgery quite often, from 2.8 to 46%.
8. Endometritis in childbirth. A.V. Lankovits, based on the observation of 1000 births complicated by endometritis, believes that only if attempts are unsuccessful to speed up the course of childbirth with conservative measures or if any other serious indications appear on the part of the mother or fetus, surgery is acceptable.
9. Diseases of cardio-vascular system- the issue should be resolved individually, taking into account the clinic of extragenital disease, together with the therapist.
10. Respiratory diseases - taken into account functional evaluation the state of the woman in labor with the determination of indications of the function of external respiration.
11. Intrauterine fetal asphyxia. When there are signs of asphyxia that has begun, which is not amenable to conservative treatment, immediate delivery is indicated.

Conditions necessary for the imposition of obstetric forceps

To perform the operation of applying forceps, a number of conditions are necessary to ensure a favorable outcome for both the woman in labor and the fetus:

1. Finding the head in the cavity or outlet of the pelvis. In the presence of the specified condition, all the others, as a rule, are present. Forceps operation at high standing head refers to the so-called high tongs and is not currently used. However, obstetricians still mean completely different operations by high forceps. Some under high forceps mean the operation of applying them to the head, which has been established as a large segment at the entrance to the small pelvis, but has not yet passed the terminal plane, others, when the head is pressed to the entrance, and still others, when the head is movable. By high forceps is meant such an imposition of them when the largest segment of the head, being tightly fixed at the entrance to the small pelvis, has not yet had time to pass the terminal plane. In addition, he quite rightly notes that determining the height of the head in the pelvis is not as simple as it might seem at first glance. None of the proposed methods for determining the height of the head in the pelvis (the implementation of the sacral cavity, the back surface of the womb, the reach of the cape, etc.) can claim to be accurate, since various factors can affect this determination, namely: the size of the head, degree and the shape of its configuration, the height and deformation of the pelvis, and a number of other circumstances that are not always accountable.

Therefore, it is not the head in general that is important, but its largest circumference. In this case, the largest circumference of the head does not always pass in the same section of the head, but is associated with the insertion feature. So, with an occipital insertion, the largest circle will pass through a small oblique size, with a parietal (anterocephalic) - through a straight line, with a frontal - through a large oblique and with a facial - through a sheer one. However, with all these varieties of insertion of the head, it will be practically correct to assume that its largest circumference passes at the level of the ears. By holding the semi-hand high enough (all fingers except the thumb) during vaginal examination, one can easily find both the ear and the innominate line, which forms the border of the entrance to the pelvis. Therefore, it is recommended to conduct a study before the operation with a half-hand, and not with two fingers, in order to reach the ear and determine exactly in which plane of the pelvis the largest circumference of the head is located and how it was inserted.

Below are the options for the location of the head in relation to the planes of the small pelvis (Martius scheme), which should be considered when applying obstetric forceps:

• option 1 - the head of the fetus is above the entrance to the small pelvis, the application of forceps is impossible;
• option 2 - the head of the fetus with a small segment at the entrance to the small pelvis, the application of forceps is contraindicated;
• option 3 - the head of the fetus with a large segment at the entrance to the small pelvis, the application of forceps corresponds to the technique of high forceps. Currently this technique not used, since other methods of delivery (vacuum extraction of the fetus, caesarean section) give more favorable results for the fetus;
• option 4 - the head of the fetus in a wide part of the pelvic cavity, abdominal forceps could be applied, however, the operation technique is very complicated and requires a highly qualified obstetrician;
• option 5 - the head of the fetus in the narrow part of the pelvic cavity, abdominal forceps can be applied;
• option 6 - the head of the fetus in the plane of exit from the small pelvis, best position for applying obstetrical forceps using the exit forceps technique.

A completely secondary role is played by the question of where the lower pole of the head is located, because with a different insertion, the lower pole of the head will be located at a different height, with the configuration of the head the lower pole will be lower. Great importance has mobility or immobility of the fetal head. Complete immobility of the head usually occurs only when its largest circumference coincides or almost coincides with the plane of entry.

1. Correspondence of the size of the pelvis of the woman in labor and the head of the fetus.
2. The average size of the head, i.e. the head of the fetus should not be too large or too small.
3. Typical insertion of the head - forceps are used to remove the fetus, and therefore should not be used to change the position of the head.
4. Full disclosure of the uterine pharynx, when the edges of the pharynx moved beyond the head everywhere.
5. A ruptured fetal bladder is an absolutely necessary condition.
6. Living fruit.
7. Accurate knowledge of finding the presenting part, position, including the degree of asynclitism.
8. The lower pole of the head at the level of the ischial spines. It should be noted that a pronounced birth tumor can mask the true position of the head.
9. Sufficient dimensions of the outlet of the pelvis - lin. intertubero more than 8 cm.
10. Sufficient episiotomy.
11. Adequate anesthesia (pudendal paracervical, etc.).
12. Emptying Bladder.

Without dwelling on the technique of applying obstetric forceps, which is covered in all manuals, one should dwell on the positive and negative aspects of applying forceps for both the mother and the fetus. At present, however, isolated works have appeared on a comparative assessment of the use of obstetric forceps and a vacuum extractor.

Forceps Models

Forceps - an obstetric instrument with which a live full-term or almost full-term fetus is removed from the birth canal by the head.

There are over 600 different models of obstetric forceps (French, English, German, Russian). They differ mainly in the structure of the spoons of the tongs and the lock. Forceps Levre (French) have crossed long branches, a hard lock. Negele tongs (German) - short crossed branches, the lock resembles scissors: on the left spoon there is a rod in the form of a hat, on the right there is a notch that fits the rod. Lazarevich forceps (Russian) have non-crossing (parallel) spoons with only a head curvature and a movable lock.

V Lately most obstetricians use forceps of the Simpson-Fenomenov model (English): crossed spoons have two curvatures - head and pelvic, the lock is semi-movable, there are side protrusions on the handle of the forceps - Bush hooks.

General rules for applying obstetric forceps

To perform the operation, the woman in labor is placed on the Rakhmanov bed in the position for vaginal operations. Before the operation, bladder catheterization and treatment of the external genital organs are performed. The operation of applying obstetric forceps is performed under general anesthesia or epidural anesthesia. An episiotomy is usually performed before the operation.

The main points of the operation of applying obstetric forceps are the introduction of forceps spoons, closing the forceps, performing tractions (trial and working), removing the forceps.

The main fundamental points that should be observed when applying obstetric forceps are dictated by triple rules.

1. The first triple catch concerns the insertion of the jaws (spoons) of the forceps. They are introduced into the genital tract separately: first, the left spoon is inserted with the left hand into the left half of the pelvis (“three from the left”) under the control of the right hand, the second, the right spoon is inserted with the right hand into the right half of the pelvis (“three from the right”) under the control of the left hand.
2. The second triple rule is that when closing the forceps, the axis of the forceps, the axis of the head and the wire axis of the pelvis must coincide (“three axes”). To do this, forceps should be applied so that the tops of the spoons are turned towards the wire point of the fetal head, capture the head along the largest circumference, and the wire point of the head is in the plane of the forceps axis. Correctly applied forceps auricles fruit are between the spoons of forceps.
3. The third triple rule reflects the direction of traction when removing the head in forceps, depending on the position of the head (“three positions - three tractions”). In the first position, the fetal head is located as a large segment in the plane of the entrance to the small pelvis, while the traction is directed from top to bottom (on the toes of the shoes of the seated obstetrician). Extraction of the fetal head located at the entrance to the small pelvis, using obstetric forceps (high forceps) is currently not used. In the second position, the fetal head is in the pelvic cavity (abdominal forceps), while traction is performed parallel to the horizontal line (in the direction of the knees of the seated obstetrician). In the third position, the head is in the plane of exit from the small pelvis (exit forceps), traction is directed from the bottom up (to the face, and at the last moment - in the direction of the forehead of the seated obstetrician).

Obstetric forceps technique

The exit forceps are applied to the fetal head, located in the plane of the exit from the small pelvis. In this case, the swept seam is located in the direct dimension of the exit plane, the forceps are applied in the transverse dimension of this plane.

The insertion of the forceps spoons is carried out according to the first triple rule, the closing of the forceps according to the second triple rule. Spoon tongs close only if they lay down correctly. If the spoons do not lie in the same plane, then, pressing on the Bush hooks, the spoons must be turned out into one plane and closed. If it is impossible to close the forceps, the spoons should be removed and the forceps should be reapplied.

After closing the spikes, traction is performed. First, to check the correct application of forceps, I perform! trial traction. To do this, with the right hand, cover the handle of the tongs from above so that the index and middle fingers of the right hand lie on the Bush hooks. left hand put on top of the right so that forefinger touched the head of the fetus. If the forceps are applied correctly, then during the test traction, the head moves behind the forceps.

If the forceps are applied incorrectly, the index finger moves away from the fetal head along with the forceps (forceps slip). Distinguish between vertical and horizontal slipping. In the case of vertical slipping, the tops of the forceps spoons diverge, slide along the head and exit the genital tract. When horizontal slipping, the forceps slide from the head up (to the womb) or back (to the sacrum). Such slippage is only possible with a high-positioned head. At the first sign of slipping of the forceps, the operation should be stopped immediately, the spoons of the forceps should be removed and reinserted.

Working tractions (actual tractions) are performed after they are convinced of the success of the trial traction. The right hand remains on the forceps, and the handles of the forceps from below cover the left hand. The direction of traction corresponds to the third triple rule - first on the face, then on the forehead of the seated obstetrician. The strength of traction resembles attempts - it gradually increases and gradually weakens. Like sweating, traction is performed with pauses, during which it is useful to relax the forceps to avoid excessive squeezing of the head.

After the appearance of the nape of the fetus above the perineum, the obstetrician should stand on the side of the woman in labor, grab the handles of the forceps with his hands and direct the traction upwards. After the eruption of the head, traction is carried out with one hand up, and the perineum is supported with the other.

After removing the largest perimeter of the fetal head, the forceps are removed in reverse order (first the right spoon, then the left). After that, the head and shoulders of the fetus are removed by hand.

Technique for imposing output (typical) obstetric forceps in posterior occipital presentation

In the posterior view of the occipital presentation, forceps are applied in the same way as with front view, however, the nature of traction in this case is different. The first tractions are directed steeply down until the region of the large fontanel is brought under the pubic symphysis, then the crown is brought out by traction upwards.

After the appearance of the back of the head above the perineum, the handles of the forceps are lowered down, the fetal head unbends and its front part appears in the genital slit.

Technique for applying abdominal (atypical) obstetric forceps

Abdominal forceps are applied to the fetal head located in the pelvic cavity. In this case, the swept suture is located in one of the oblique dimensions (right or left) of the pelvis, the forceps are applied in the opposite oblique dimension of this plane. At the first position (arrow-shaped seam in the right oblique size), forceps are applied in the left oblique size, in the second position (arrow-shaped seam in the left oblique size) - in the right oblique size (Fig. 109).

The introduction of forceps spoons is carried out according to the first triple rule (“three on the left, three on the right”), but in order for the forceps spoons to lie in an oblique size of the pelvis, one of the spoons must be shifted upward (towards the womb). That spoon, which, after being introduced into the pelvic cavity, does not move, is called fixed. Spoon, shifted to the bosom, is called wandering. In every separate case, depending on the location of the swept seam, either the right or the left spoon will be fixed. In the first position (arrow-shaped seam in the right oblique size), the fixed spoon will be the left one, in the second position (arrow-shaped seam in the left oblique size) - the right one.

Closing forceps, trial and working traction is carried out according to the rules described above.

In addition to the complications associated with the incorrect technique of the operation, ruptures of the perineum, vagina, large and small labia, and the clitoris can be observed. Possible violations of the act of urination and defecation in the postpartum period.

The operation can also be traumatic for the fetus: damage to the soft tissues of the head, cephalohematoma, retinal hemorrhage, impaired cerebral circulation, trauma to the bones of the skull.

The operation of applying obstetric forceps to the present time remains a rather traumatic method of operative delivery through the natural birth canal. The outcome of childbirth for the fetus largely depends on the weight of his body, the height of the head, the position of the head, the duration of the operation, the qualifications of the doctor, the condition of the fetus at the beginning of the operation, and the quality of neonatal care.

• soft tissue damage;
• hemorrhages in the brain and cranial cavity;
• asphyxia;
• rare injuries to the bones of the skull, eyes, nerves, collarbone, etc.

Exit forceps showed no increase in perinatal morbidity and mortality. With regard to abdominal forceps, the issue remains not entirely clear to this day. Some authors believe that the reduction in perinatal morbidity and mortality is due to the increased use of caesarean section, and obstetrical forceps are offered only for difficult births.

In conclusion, we can say with good reason that even Russian-type tongs - the most advanced of all types of this instrument - do not represent a completely safe tool and should not be used without good reason.

An obstetrician can follow this only correct path only if obstetric care is well organized, creative development of the heritage of the Russian obstetric school, continuous improvement of his knowledge and experience, thoughtful clinical evaluation the whole body of a woman giving birth. The difficulties of such a path are not small, but quite surmountable.

The content of the article:

If the woman's efforts are not enough for a successful delivery, then alternative methods are used: caesarean section, childbirth with forceps or a vacuum extractor. Most expectant mothers are not familiar with the devices used in obstetrics, and therefore are afraid of their use. But tools are used in cases where it is justified and ignoring the problem can lead to undesirable consequences for both the mother and the child.

When are tongs or a vacuum extractor used?

These medical instruments are justified to be used if the cervix is ​​fully open and the widest part of the child's head has already passed into the area under the pubic bone. This placement of the fetus indicates that it will successfully pass through the pelvic bones, and forceps or a vacuum extractor should be used in order to stretch the soft tissues of the perineum without unnecessary injury.
If the child's skull has not yet reached the mother's pelvis, then instrumental intervention is not justified and can be harmful - a head injury is possible. With this arrangement and weak labor activity, the method of caesarean section is more often used.

With a long 2nd stage of labor or fetal distress, 2 types of auxiliary instruments for delivery are used: a vacuum extractor and obstetric forceps.

Vacuum extractor: the mechanism of action of the tool. Consequences of application and features of use

The tool consists of a bowl, a flexible hose and a mechanism that provides pressure (up to 0.8 kg / cm2).

There are several types of vacuum extractor: with a metal cup (Mallstrom extractor), with a rigid polyethylene bowl and soft silicone (disposable). Cups with front and rear fixation of the tube have also been developed. This allows you to create a vacuum acentrically and successfully apply them depending on the position of the child's head.

With modern medicine, disposable flexible silicone cups are predominantly used.

How is a vacuum extractor used?

The procedure is carried out in stages:

● the cup is inserted into the woman's vagina;
● a vacuum is created using a tool;
● traction behind the child's head;
● Removing the bowl from the newborn's head.

The bowl of the vacuum extractor in a vertical-lateral position is inserted and fixed on the child's head. Then the instrument is correctly positioned: the bowl is attached closer to the leading point on the child's head, avoiding the fontanelles. After confirming the correct position of the bowl, a negative pressure is created.

The fixation stage should be carried out with the utmost care: it is unacceptable to attach the cup to the soft tissues of the mother's body.

When choosing a direction, it is important to take into account the biomechanism of childbirth: the wire point of the child's head moves along the wire axis of the mother's pelvis. When deviating from such a trajectory, bowl distortion and separation of the instrument from the surface of the fetal head are possible.

Tractions should be performed synchronously with attempts and not exceed 4 times; when the cup slips, it can be reapplied again, but no more - the risk of injury to the fetus increases.

During the procedure, an episiotomy is used. With successful extraction of the newborn, the cup is removed, gradually reducing the pressure.

If an attempt at vacuum extraction fails, then conditions arise for childbirth with obstetric forceps.

Complications after vacuum extraction in mother and child

During childbirth with the use of a vacuum extractor for the mother, there are risks of rupture of the soft tissues of the small, large labia, vagina, perineum, clitoris.
The child can get the following complications:
● cephalohematomas;
● injury to the soft tissues of the head;
● hemorrhages.
The silicone bowl of the vacuum extractor is the safest type to use.

Contraindications to the use of a vacuum extractor. When is a tool banned?

There are a number of contraindications, in the presence of which delivery using this instrument is unacceptable. These include:
● dead fetus;
● high straight standing of the child's head;
● frontal or facial insertion of the head;
● incomplete opening of the cervix;
● breech (low) presentation;
● miscarriage (delivery before 30 weeks);
● extragenital or obstetric pathology, which involves the exclusion of the 2nd stage of labor.

Indications for vacuum extraction and prerequisites for the procedure

Indications for the procedure can be from the side of the woman in labor, and from the side of the fetus.

For a future mother, the prerequisite for the procedure may be pregnancy pathologies that require a reduction in the 2nd period of labor:

● septic, infectious diseases, accompanied high temperature;
● weakness of labor activity in the 2nd stage of labor.

A vacuum extractor should be used if fetal distress is observed (in the 2nd stage of labor) and there is no possibility to perform a caesarean section.

Conditions for performing the vacuum extraction procedure:

● living child;
● full disclosure of the cervix;
● lack of fetal bladder;
● anatomical correspondence in the size of the birth canal and head of the child;
● the head should be in the small pelvis of the woman in labor.

Obstetric forceps. Tool structure, types

Obstetric forceps - a medical instrument made of metal, shaped like tweezers. They consist of 2 parts, each of them includes a spoon, a handle and a lock. Spoons are designed with curvature in mind and serve to girth the head; the handle is designed for traction. Depending on the type of lock, there are several types of tongs. On the territory of the Russian Federation, the Simpson-Fenomenov tool is used.
Classification of the instruments used depending on the location of the fetus: there are low abdominal (typical) forceps - for applying to the child's head, located in the narrow part of the pelvic cavity, and atypical - when located in the wide part.

Why are forceps used during childbirth?

In modern obstetrics, the instrument is used for delivery if:
● missed time for caesarean section;
● diagnosed with severe preeclampsia, not amenable to treatment;
● weak attempts, labor activity is not amenable to medical correction;
● a woman in labor has extragenital pathologies that require the elimination of attempts;
● there is acute fetal hypoxia.
Contraindications for childbirth with forceps are considered a large fetus and prematurity.

Indications for the use of obstetric forceps

The imposition of forceps during childbirth is used if:

● the fetus is alive;
● the cervix is ​​fully dilated;
● the fetal bladder is absent;
● the size of the head of the child and the birth canal of the woman correspond;
● the head of the fetus is located in the narrow part of the pelvic cavity of the woman in labor.

Complications and postoperative rehabilitation after childbirth with the use of forceps

During the rehabilitation period:

● control examination of the uterus in order to verify its integrity;
● monitoring the work of the pelvic organs;
● prevention of inflammatory processes.

Which is better: vacuum extractor or tongs?

There are many stories about how the fetus was damaged by pulling it with forceps during childbirth. The fears of a woman who worries about her child are quite natural. If the pregnancy proceeds with pathologies, then anxiety increases: will such instruments be used and how dangerous is it?

The safety of using the extractor and forceps largely depends on the experience and skills of the doctor.
For a child, the imposition of a bowl can result in a hematoma and swelling of the tissues, and the use of forceps is fraught with cuts.
Vacuum extraction involves less pain relief for the woman in labor, soft tissue ruptures are less common, and rehabilitation is easier.
Efficiency for accelerating labor is approximately the same.

If there are indications for the use of forceps or a vacuum extractor, you should carefully choose a specialist who will take delivery, because the choice and success of using the instruments depends on his skills, experience and knowledge.

exit forceps

1. Preparation:

• laying a woman in labor on a "transverse" bed;
• processing the hands of the operator and assistant (the method is the fastest possible under these conditions);
• treatment of the surgical field (external genitalia, inner thighs, perineum) with an antiseptic solution;
• bladder catheterization;
• anesthesia (preferably general anesthesia, pudendal anesthesia - with exit forceps);
• picking up tongs and laying branches on the work table (Fig. 1);
• internal examination with a "half-hand" or two fingers to clarify the state of the birth canal, presentation, type, position, position, sagittal suture and determine the level of the head.

Rice. 1. Collecting tongs and stacking branches on the work table

2. Operation technique:

• insertion and placement of forceps spoons. Four fingers of the right hand are inserted into the left half of the pelvis in the direction of the sacroiliac joint (Fig. 2). With the left hand, the left spoon of tongs is taken by the handle in the form of a bow or with three fingers, its tip is set in the groove between the index and middle fingers, and the handle deviates to the opposite groin. Under the control of the hand inserted into the vagina, thumb moves along the lower branch, without violence the spoon itself is placed on the head along its greatest curvature, the parietal tubercle is captured. The handle of the left spoon is easily lowered. The spoon is passed to the assistant, who holds it in a given position. The right spoon is also introduced under the control of the left hand (Fig. 3).

Rice. 2. Placing the left spoon of the tongs

Rice. 3. Introduction of the right spoon forceps

• forceps closure: the right spoon, when properly applied to the head, easily enters the lock of the left one: Bush hooks are at the same level for cushioning, a diaper is laid between the branches (Fig. 4),

Rice. 4. Closing the forceps

• control of the correct application of the forceps: with two fingers of the right hand, it is checked whether the cervix is ​​​​captured between the jaws of the forceps and the head. The left hand supports the tongs by the handles,
• trial traction (Fig. 5). We place the right hand from above on the handle of the tongs - the left hand is superimposed on the right, middle finger touches the head. Light traction is produced. If this does not increase the distance between the head and the finger - therefore the forceps do not slip off - they are applied correctly. If the distance increases - the tongs are applied incorrectly, it must be removed by removing the spoons in reverse order first the right one, deflecting the handle of the forceps to the left groin of the woman in labor, and then the left one;

Rice. 5. Trial traction

• actual traction. Hand position: 1) classic - the right hand grabs the handles in such a way that the index and middle fingers rest on the hooks (Fig. 6). The left hand repeats the position of the right, or also grabs the handles of the tongs from below. 2) according to Tsovyanov - after the introduction of the spoons and the closing of the tongs, the second and third fingers of both hands, bent with a hook, capture the outer and upper surfaces of the instrument at the level of Bush's hooks. The main phalanges of the index fingers are located on outer surface handles, and Bush's hooks pass between the main phalanges of the index and middle fingers. The fourth and fifth fingers grasp the parallel forceps. thumbs located under the handles of the tongs.

Rice. 6. Actually traction

Tractions are made along the axis birth canal taking into account the biomechanism of labor and the nature of the operation (abdominal or weekend). Tractions are made in the horizontal direction and upwards (in 2 positions). The amount of traction depends on the position of the head in the cavity or at the exit of the pelvis.

2) If the wire point is facing right, the forceps are applied in the right oblique size, the fixing spoon will be the right one.

Since the forceps are not a rotating, but a pulling instrument, during traction, the head makes an internal turn, and the forceps follow the head. After turning the head and establishing the swept seam in a straight size, the head is removed by the method described above with exit forceps.

During the eruption of the parietal tubercles, an episiotomy is performed on one or both sides.

Ed. K.V. Voronin

The name itself will surely evoke associations with the distant Middle Ages for most readers. In a sense, they will be right: obstetrical forceps were invented at the end of the sixteenth century. At that time it was a real advance in obstetrics. Caesarean section was practically not used then, and if some healer undertook such a dangerous operation, it was only for the sake of saving the life of the child - the woman in labor did not have a single chance. Forceps helped the baby to be born, facilitated too difficult childbirth and saved the life of the mother.

The sight of this instrument will certainly not cause much confidence among the uninitiated: the third millennium and - some kind of tongs! In fact, this “outdated” and “backward” instrument, albeit in rare cases, is still indispensable. Certainly, medical science and practice, compared with the 17th century, have risen to cosmic heights. Many methods quickly become obsolete, something is improved, something is abandoned altogether. But the imposition of forceps is used in the generic practice of experienced obstetricians in all countries of the world to this day. Over the past three centuries, their design and indications for use have changed significantly, and the benefits disproportionately outweigh the risk of complications.

Application conditions

Receiving the application of obstetric forceps is possible only in the second stage of labor with the full opening of the cervix, when the fetal head is in the pelvic cavity or at the exit from it.

The operation of applying obstetric forceps is quite painful: the born head of the fetus will have big sizes because of the spoons of tongs imposed on it, therefore, it provides for mandatory anesthesia. Most often given short-term intravenous anesthesia, but if the woman is giving birth under epidural anesthesia, the anesthesiologist simply injects an additional amount of the pain medication used.

The use of forceps is often accompanied by an episiotomy - an operation to cut the perineum to expand the birth canal. This will prevent the formation of deep tears in the woman in labor.

The capture of the baby's head is carried out only when it is already almost at the exit from female pelvis which further increases the safety of the procedure. The shape of the tool is maximally adapted to gently and safely for the fetus, but securely grab the head of the newborn. With the help of practiced professional movements (the so-called traction) an experienced obstetrician helps a newborn baby to pass through the birth canal. In addition, a sterile towel is usually placed between the handles of the forceps, which reduces the risk of excessive squeezing of the fetal head to almost nothing. We repeat that this procedure is used only in case of serious difficulties in the natural passage of the child or the need to complete the birth process as soon as possible and it is impossible to use other methods of childbirth. However, the baby's head should correspond to the average size of the head of a full-term fetus. Obstetricians formulate this condition a little differently: it should not be too large or too small. This is due to the size of the forceps, which are designed for the average size of the head of a full-term fetus. The use of obstetric forceps without taking this condition into account can lead to too much injury for the baby and mother.

Forceps become a very dangerous tool even with a narrow pelvis, so their use is contraindicated. The operation of applying obstetric forceps is carried out only if all of the above conditions are present.

Mechanism of action

The purpose of the forceps is to tightly grasp the head of the fetus and replace the expelling force of the uterus and abdominals with the pulling force of the doctor. The process of "pulling out" the baby can not be called violent: traction are applied almost effortlessly, no artificial turns or any displacement of the fetal head are made. The movements of the obstetrician diligently copy the movements of the head and shoulders of the child, which he would produce in the process of natural childbirth.

In progress traction the doctor can make rotational movements but only following the natural movement of the fetal head. In this case, the doctor does not prevent the head from turning, but, on the contrary, contributes to them.

Indications for use

There are several indications for this procedure. Firstly, the state of health of the woman in labor, which requires the maximum shortening of the period of expulsion of the fetus, the exclusion of attempts and stress of the woman in labor: diseases of the cardiovascular and broncho-pulmonary systems, kidneys, heart failure, very severe late toxicosis. Secondly, obstetric forceps are superimposed with weak attempts or weakness of labor activity. In this case, the fetal head is in the same plane of the pelvis for more than 2 hours, which can lead to excessive fatigue of the woman in labor and very serious obstetric complications. In the second stage of labor, the fetal head passes through a rather narrow bone ring - the pelvic cavity. Difficulty in moving the fetal head is fraught with unpleasant consequences for both the child and the mother: the pelvic bones squeeze the fetal head, the bones of the skull, in turn, put pressure on the soft tissues of the woman's birth canal, which leads to various injuries. Therefore, if medications, for example, intravenous administration of oxytocin, which causes the uterus to contract, does not help the birth of a child, you have to resort to using forceps. Thirdly, bleeding in the second stage of labor, due to premature detachment of a normally located placenta, rupture of the umbilical cord vessels during their shell attachment. Fourth, with acute intrauterine hypoxia (oxygen starvation) of the fetus, when the delay in childbirth will inevitably lead to the death of the child and the count goes literally for minutes (with a short umbilical cord, its entanglement around the child's neck).

Preparation and conduct of the operation

Based on the well-known truth “forewarned is forearmed”, and, I would add, “calm down”, I will try to describe in detail what awaits you during the preparation for the operation and its implementation.

Preparation for the operation of applying obstetric forceps includes several points: the choice of the method of anesthesia, preparation of the woman in labor, examination of the vagina and determination of the position of the fetus, checking the forceps.

During the operation of applying obstetric forceps, the woman in labor lies on her back, with her legs bent at the hips and knees. The bladder must be emptied before the operation. The external genitalia and inner thighs are treated with a disinfectant solution.

We repeat once again that due to the fact that when removing the fetal head with forceps, the risk of perineal rupture increases, the application of obstetric forceps is combined with an episiotomy. When introducing spoons, the obstetrician grabs the handle of the forceps in a special way: special kind capture avoids the application of force when it is introduced.

The left spoon of tongs is introduced first. Standing, the doctor inserts four fingers of the right hand into the vagina into the left half of the pelvis, separating the fetal head from the soft tissues of the birth canal. The thumb remains outside. Taking the left spoon with the left hand, the handle is taken to the right side, setting it almost parallel to the right inguinal fold. Then, carefully, without any effort, the spoon is advanced between the palm and the head of the fetus deep into the birth canal. In this case, the trajectory of movement of the end of the handle, as it were, describes an arc. The advancement of the entire branch into the depths of the birth canal is carried out practically due to the instrument's own gravity. The hand located in the birth canal is a guide hand and controls the correct direction and location of the branch. With its help, the obstetrician makes sure that the top of the spoon does not go into the vault, onto the side wall of the vagina and does not capture the edge of the cervix. Further, under the control of the left hand, the obstetrician introduces the right branch with the right hand into the right half of the pelvis in the same way as the left one.

Spoons capture the baby's head in the widest place in such a way that the parietal tubercles are in the windows of the forceps spoons, and the line of forceps handles faces the leading point of the fetal head. traction they try to carry out simultaneously with contractions, thus strengthening the natural expelling forces.

Possible Complications

We emphasize once again that timely and correctly applied forceps do not have a negative impact on the health of a woman and a child.

Complications in the baby. Most often, the consequences of using obstetric forceps are expressed in reddish loop-shaped traces that remain on the head and face of the baby. Usually these marks disappear within the first month without any medical intervention. Due to too much pressure of forceps spoons on the presenting part of the fetus, hematomas may occur, damage to the skin or facial nerve.In exceptional cases, infants have eye injuries, nerve damage brachial plexus(manifested by a “hanging” handle in a child). The use of forceps can also cause damage to the uterus, bladder or roots. sciatic nerve.

Mom's complications. These include possible ruptures of the vagina and perineum, less often - the cervix. Severe complications can be ruptures of the lower segment of the uterus and damage to the pelvic organs: the bladder and rectum. But such things can happen only if the conditions for the operation and the rules of its technique are violated, which is basically impossible in modern maternity hospitals.

But still!...

Of course, the application of obstetric forceps is an unpleasant procedure, it, like, in fact, any operation, has dangerous moments. I assure women that just like that, with a "preventive" purpose, no one will resort to this procedure. It is produced only when absolutely necessary, when there is no other way out and it is really about saving the baby's life. But if you happen to experience the techniques of ancient obstetrics in modern conditions- do not panic, but perceive it simply as a conscious need to help your long-awaited baby see the light.

Obstetric forceps were invented by the Scottish physician William Chamberlain in 1569.For many years, this instrument remained a family secret, passed down only by inheritance: the doctor's family and his descendants made considerable wealth from this invention. As it happened with many scientific discoveries, 125 years later, in 1723, obstetric forceps were again "invented" by the Dutch surgeon I. Palfin. These were already more enlightened times, so the surgeon immediately published his invention and submitted it for testing to the Paris Academy of Sciences, for which he was rewarded: the priority in the invention of obstetric forceps belongs to him. Although it is believed that these forceps are less perfect than Chamberlain's instrument. In Russia, obstetric forceps were first used in 1765 in Moscow by Professor of Moscow University I.F. Erasmus. However, the merit of introducing this operation into everyday practice belongs to another outstanding doctor, the founder of Russian scientific obstetrics, Nestor Maksimovich Maksimovich-Ambodik. Mine personal experience he described in the book The Art of Weaving, or the Science of Womanhood, published in 1786. According to his drawings, the Russian "instrumental" master Vasily Kozhenkov in 1782 made the first models of obstetric forceps in Russia. Later, domestic obstetricians Anton Yakovlevich Krassovsky, Ivan Petrovich Lazarevich and Nikolai Nikolaevich Fenomenov made a great contribution to the development of the theory and practice of the operation of applying obstetric forceps.

Obstetric forceps - are designed to extract a live fetus by the head in strict accordance with the natural biomechanism of childbirth.

The frequency of use of obstetric forceps in modern obstetrics is 1%.

The following types of obstetric forceps are distinguished: a) Simpson's forceps - used for traction in anterior occipital presentation; b) Tooker-McLean forceps - used to rotate from the rear view of the occipital presentation to the anterior view of the occipital presentation and extraction of the fetus; c) Keelland and Barton forceps - with a transverse arrangement of the sagittal suture for turning into an anterior view of the occipital presentation; d) Piper forceps - designed to extract the head in breech presentation.

The device of obstetric forceps. The forceps have 2 spoons (branches), each of which consists of three parts - the spoon itself (which captures the head of the fetus, it is fenestrated, the length of the window is 11 cm, the width is 5 cm); castle part; handle (hollow, the outer side of the handle is wavy). On the outer side of the forceps, near the lock, there are protrusions, Bush hooks, which, when the forceps are folded, should be turned in different directions, i.e. laterally, and lie in the same plane. Most models of forceps have two curvatures - head (calculated for the circumference of the head) and pelvic (goes along the edge of the spoon, curvature along the plane of the pelvis). The ends of the spoons when folded do not touch each other, the distance between them is 2-2.5 cm. The head curvature in the folded forceps is 8 cm, the pelvic curvature is 7.5 cm; the largest width of the spoons is not more than 4-4.5 cm; length - up to 40 cm; weight - up to 750 g.

Indications for the imposition of obstetric forceps:

1. Indications from the part of the woman in labor: the weakness of labor is not amenable to drug therapy, fatigue; weakness of attempts; bleeding from the uterus at the end of I and II periods of labor; contraindications for exertive activity (severe gestosis; extragenital pathology - cardiovascular, renal, high myopia, etc.; feverish conditions and intoxication); severe forms of neuropsychiatric disorders; chorioamnionitis in childbirth, if the end of labor is not expected within the next 1-2 hours.

2. Indications from the fetus: acute intrauterine fetal hypoxia; prolapse of umbilical cord loops; threat of birth trauma.

Contraindications for the imposition of obstetric forceps: dead fetus; hydrocephalus or microcephaly; anatomically (II - III degree of narrowing) and clinically narrow pelvis; deeply premature fetus; incomplete opening of the uterine os; frontal presentation and front view of facial presentation; pressing the head or positioning the head with a small or large segment at the entrance to the pelvis; threatening or beginning uterine rupture; breech presentation fetus.

Conditions for applying obstetric forceps:

1. Full disclosure of the uterine pharynx.

2. Opened fetal bladder.

3. Empty bladder.

4. Head presentation and finding the head in the cavity or at the exit from the small pelvis.

5. Correspondence of the size of the fetal head with the size of the pelvis of the woman in labor.

6. Average head sizes.

7. Living fetus.

Complications after applying obstetric forceps:

1. For the mother: damage to the soft birth canal; rupture of the pubic joint; damage to the roots of the sciatic nerve with subsequent paralysis lower extremities; bleeding; uterine rupture; formation of a vaginal-vesical fistula.

2. For the fetus: damage to the soft parts of the head with the formation of hematomas, paresis of the facial nerve, damage to the eyes; bone damage - depression, fractures, separation of the occipital bone from the base of the skull; brain compression; hemorrhages in the cranial cavity.

3. Postpartum infectious complications.

Three triple rules for applying obstetric forceps:

1. About the sequence of insertion of forceps spoons:

the left spoon is inserted with the left hand into the left half of the pelvis of the woman in labor ("three from the left"), under the control of the right hand;

the right spoon is inserted with the right hand into the right half of the pelvis under the control of the left hand ("three on the right").

2. Orientation of the spoons on the fetal head with forceps applied:

the tops of the spoons of the tongs should be facing the wire point;

forceps should capture the parietal tubercles of the fetus;

the wire point of the head must lie in the plane of the forceps.

in the plane of the entrance - obliquely down, to the socks of the seated obstetrician;

in the pelvic cavity - horizontally, on the knees of a seated obstetrician;

in the exit plane - from the bottom up, on the face of the seated obstetrician.

Moments of the operation of applying obstetric forceps:

1. Introduction of tongs spoons. Produced after a vaginal examination. The left spoon of tongs is introduced first. Standing, the doctor inserts four fingers of the right hand (half-hand) into the vagina into the left half of the pelvis, separating the fetal head from the soft tissues of the birth canal. The thumb remains outside. Taking the left branch of the forceps with the left hand, the handle is taken to the right side, setting it almost parallel to the right inguinal fold. The top of the spoon is pressed against the palmar surface inserted into the vagina of the hand, so that the lower edge of the spoon is located on the fourth finger and rests on the retracted thumb. Then, carefully, without any effort, the spoon is advanced between the palm and the head of the fetus deep into the birth canal, placing the lower edge between the III and IV fingers of the right hand and leaning on the bent thumb. In this case, the trajectory of movement of the end of the handle should be an arc. The promotion of the spoon into the depths of the birth canal should be carried out by virtue of the own gravity of the instrument and by pushing the lower edge of the spoon 1 with the finger of the right hand. The half-hand, located in the birth canal, is a guide hand and controls the correct direction and location of the spoon. With its help, the obstetrician makes sure that the top of the spoon does not go into the vault, onto the side wall of the vagina and does not capture the edge of the cervix. After the introduction of the left spoon, in order to avoid displacement, it is passed to the assistant. Further, under the control of the left hand, the obstetrician inserts the right branch into the right half of the pelvis with the right hand in the same way as the left branch.

2. Closing the lock of the tongs. To close the tongs, each handle is grasped with the same hand so that the first fingers of the hands are located on Bush's hooks. After that, the handles are brought together, and the tongs close easily. Properly applied forceps lie across the swept seam, which occupies a median position between the spoons. The elements of the lock and Bush hooks should be located on the same level.

3. Trial traction. This necessary moment allows you to make sure that the forceps are applied correctly and that there is no danger of them slipping. It requires a special position of the hands of the obstetrician. For this, the doctor's right hand covers the handles of the forceps from above so that the index and middle fingers lie on the hooks. He puts his left hand on the back surface of the right, and the extended middle finger should touch the head of the fetus in the region of the leading point. If the forceps are correctly positioned on the fetal head, the tip of the finger is in constant contact with the head during trial traction. Otherwise, it moves away from the head, which indicates that the forceps are not applied correctly and, in the end, they will slip off. In this case, the forceps must be applied again.

4. Actually traction for the extraction of the fetus. After a trial traction, after making sure that the forceps are correctly applied, they begin their own traction. Traction of the fetal head with forceps should mimic natural contractions. For this you should:

imitate a fight by strength: start traction not abruptly, but with weak sipping, gradually strengthening and again weakening them by the end of the fight;

when producing traction, do not develop excessive strength by leaning back the torso or resting your foot on the edge of the table. The elbows of the obstetrician should be pressed to the body, which prevents the development of excessive force when removing the head;

between tractions it is necessary to pause for 0.5-1 min. After 4-5 tractions, the forceps are opened for 1-2 minutes to reduce the pressure on the head;

try to produce traction simultaneously with contractions, thus strengthening the natural expelling forces. If the operation is performed without anesthesia, it is necessary to force the woman in labor to push during traction.

Rocking, rotational, pendulum movements are not allowed

5. Removing the forceps. To remove the tongs, each handle is taken with the same hand, the spoons are opened and removed in the reverse order: the first is the right spoon, while the handle is taken to the inguinal fold, the second is the left spoon, its handle is taken to the right inguinal fold.

1. The head is movable above the entrance to the small pelvis; during external examination, it ballots.

2. The head is slightly pressed against the entrance to the small pelvis - this means that during external examination it is motionless, and during vaginal examination it is repelled.

3. The head is pressed into the small pelvis - this is the norm in the absence of childbirth in primiparas.

4. The head is a small segment at the entrance to the small pelvis, the smaller part of the head has passed the plane of the entrance.

5. The head is a large segment at the entrance to the small pelvis, most of the head has passed the plane of the entrance.

6. Head in the pelvic cavity:

a) in the wide part of the pelvic cavity b) in the narrow part of the pelvic cavity.

7. Head in the exit cavity.

Transverse and oblique positions of the fetus. Causes, diagnosis, obstetric tactics.

Transverse position - a clinical situation in which the axis of the fetus intersects the axis of the uterus at a right angle.

Oblique position - a clinical situation in which the axis of the fetus intersects the axis of the uterus at an acute angle. In this case, the lower part of the fetus is located in one of the iliac cavities greater pelvis. The oblique position is transition state: during childbirth, it turns either into a longitudinal or transverse.

Etiological factors:

a) Excessive fetal mobility: with polyhydramnios, multiple pregnancy (second fetus), with malnutrition or premature fetus, with sagging muscles of the anterior abdominal wall in repeaters.

b) Limited fetal mobility: with oligohydramnios; large fruit; multiple pregnancy; in the presence of uterine fibroids, deforming the uterine cavity; at increased tone uterus with the threat of abortion, in the presence of a short umbilical cord.

c) Obstacle to the insertion of the head: placenta previa, narrow pelvis, the presence of uterine fibroids in the region of the lower uterine segment.

d) Anomalies in the development of the uterus: bicornuate uterus, saddle uterus, septum in the uterus.

e) Anomalies in the development of the fetus: hydrocephalus, anencephaly.

Diagnostics.

1. Examination of the abdomen. The shape of the uterus is elongated in transverse size. The circumference of the abdomen always exceeds the norm for the gestational age at which the examination is carried out, and the height of the uterine fundus is always less than the norm.

2. Palpation. There is no large part in the bottom of the uterus, large parts are found in the lateral parts of the uterus (on the one hand, round dense, on the other, soft), the presenting part is not determined. The fetal heartbeat is best heard at the navel.

The position of the fetus is determined by the head: in the first position, the head is palpated on the left, in the second - on the right. The view of the fetus, as usual, is recognized by the back: the back is facing anteriorly - anterior view, the back is posteriorly - posterior.

3. Vaginal examination. At the beginning of labor with a whole fetal bladder, it is not very informative, it only confirms the absence of the presenting part. After the outflow of amniotic fluid with sufficient opening of the pharynx (4-5 cm), it is possible to determine the shoulder, shoulder blade, spinous processes of the vertebrae, axillary cavity. By the location of the spinous processes and the scapula, the type of fetus is determined, by the armpit - the position: if the cavity is facing to the right, then the position is the first, in the second position, the armpit is open to the left.

The course of pregnancy and childbirth.

Most often, pregnancy in transverse positions proceeds without complications. Sometimes, with increased fetal mobility, an unstable position is observed - a frequent change in position (longitudinal - transverse - longitudinal).

Complications of pregnancy in the transverse position of the fetus: premature birth with prenatal rupture of amniotic fluid, which is accompanied by the loss of small parts of the fetus; hypoxia and infection of the fetus; bleeding with placenta previa.

Complications of childbirth: early rupture of amniotic fluid; infection of the fetus; the formation of a neglected transverse position of the fetus - loss of fetal mobility with intensive early discharge of amniotic fluid; loss of small parts of the fetus; hypoxia; overstretching and rupture of the lower segment of the uterus.

When limbs fall out, it is necessary to clarify what fell into the vagina: a pen or a leg. The handle, lying inside the birth canal, can be distinguished from the leg by the greater length of the fingers and by the absence of the calcaneal tubercle. The hand is connected to the forearm in a straight line. The fingers are spread apart, the thumb is especially taken away. It is also important to determine which handle fell out - right or left. To do this, it is as if they “hello” with the right hand with a dropped handle; if this succeeds, the right handle falls out; if it fails, the left handle falls out. By the dropped handle, the recognition of the position, position and type of the fetus is facilitated. The handle does not interfere with the internal rotation of the fetus on the stem, its reduction is an error that makes it difficult to rotate the fetus or embryotomy. A dropped handle increases the risk of ascending infection during childbirth and is an indication for faster delivery.

Prolapse of the umbilical cord. If, during a vaginal examination, loops of the umbilical cord are felt through the fetal bladder, they speak of its presentation. Determination of loops of the umbilical cord in the vagina with a ruptured fetal bladder is called prolapse of the umbilical cord. The umbilical cord usually falls out during the passage of water. Therefore, for the timely detection of such a complication, a vaginal examination should be performed immediately. Prolapse of the umbilical cord in the transverse (oblique) position of the fetus can lead to infection and, to a lesser extent, to fetal hypoxia. However, in all cases of umbilical cord prolapse with a live fetus, it is necessary to urgent help. With a transverse position, full opening of the cervix of the uterus and a moving fetus, such help is the rotation of the fetus on the leg and its subsequent extraction. With incomplete opening of the pharynx, a caesarean section is performed.