The first and simplest method used in PD is the direct pressure above the fold in the direction somewhat cranial to the fold. You can also try to push the right and left in turn to translate the hanger in the oblique size of the pelvis. These techniques usually help with the I degree of DP (Fig. 52-31). The next most difficult reception of Woods or its modification (reverse reception of Woods). At the same time, pressure is exerted on the front surface of the posterior hanger (“screwing”). However, we must strive to bring both shoulders to the sternum. And at the reception of Woods, the shoulder, on the contrary, is withdrawn. Therefore, another author, Rubin, offered his method (fig. 52-32).
Fig. 52-31. The pressure above the pubis is dorsal (according to Mazzanti) or oblique-lateral (according to Rubin).
Fig. 52-32. Turn around Woods and take Rubin.
With a moderate DP, it was proposed to use a combination of Hibbard’s techniques and a reverse Woods technique. According to Hibbard, you should press on the head, trying to “push” her back into the vagina somewhat. The front shoulder is pushed towards the rectum; thus, the shoulder is removed from the symphysis. For this, an assistant is needed to first crush the shoulder and then apply pressure to the bottom of the uterus.
The sequence of steps: · press with the palm of your hand simultaneously on the head, jaws and the nuchal region towards the rectum and a little cranial to facilitate the release of the anterior shoulder; · after the release of the anterior shoulder, strongly press on the bottom of the uterus; the region shifts somewhat towards the rectum.
The method has several advantages. The main requirement is a fairly strong and constant pressure of the assistant on the bottom of the uterus. If the technique is applied correctly, the brachial plexus will not be damaged and it is possible to avoid hypoxic damage due to prolonged expulsion. It is also useful to try to first give birth to the back handle (fig. 52-32), as when throwing back the handles with pelvic presentation, but in the opposite direction.
In case of PD, it is necessary to apply Mac-Roberts technique (the only drawback is that two assistants are needed). The method is effective, easy, safe and fast in execution. The thighs are brought into contact with the abdomen, while achieving a reduction in lordosis and inclination of the pelvis (Fig. 52-33). This technique, of course, does not reduce the size of the small pelvis, but when the symphysis joint moves, cranial conditions arise for the release of the front shoulder. If there is no immediate effect, then all the above techniques should be added.
Fig. 52-33. The birth of the back handle.
Fig. 52-34. Cranial displacement of the pubic articulation and flattening of the lumbar lordosis (Mac-Roberts technique).
When unsuccessful attempt to give birth to the shoulder girdle (DP IV degree)
· Begin preparations for the CS; · begin an intensive tocolysis; · if necessary, perform cardiac monitoring; · quickly fill the head.
The head, according to the authors, is easy to start with a constant and quite energetic effort exerted by the palm. The head is bent and pushed up to the point “0” according to Bishop (which corresponds to the level “large segment in the pelvic cavity”). If necessary, the assistant keeps the head at this level of standing. Authors report 23 successful attempts.
Not much has been written about PD in Russian textbooks. Nevertheless, there is an information letter of the Ministry of Health of the Russian Federation of 2002 “Conducting pregnancy and childbirth in women with anatomically narrow pelvis” with recommendations that are quite relevant in PD:
· At birth, there are two obstetricologists who are familiar with the techniques for assisting with PD, an anesthesiologist and a neonatologist-resuscitator. · Mandatory dissection of the perineum under adequate anesthesia (preferably medial-lateral episiotomy). downwards, until the front shoulder at the border of the upper and middle third fits beneath the fold. At this time, the assistant exercises moderate pressure with his hand over the pubis. Then the head is raised anteriorly and the back shoulder is released. · Maximum flexion of the hip of the woman in the hip and knee joints and abduction towards the stomach. vagina, shifts the front shoulder in the direction of the breast and posterior. The assistant at this time holds moderate pressure on the bottom of the uterus and in the suprapubic area posteriorly and laterally toward the mother’s abdomen. · A midwife with a hand inserted under the back shoulder of the fetus, turning it 180 ° to the front and removing it.
All manual manipulations are performed sequentially as the complexity of execution increases. At first, they use less complex and less traumatic for the fetus, with their ineffectiveness they move to more complex ones.
Conducting labor in the II period with PD according to the above algorithm avoided perinatal losses and severe birth injury to newborns, reduced the number of births of children in hypoxia by 1.4 times and reduced the pathology of newborns directly or indirectly related to birth injuries by 1.6 times.
In the delivery room, the presence of an anesthesiologist and a neonatologist, who are familiar with the methods of neonatal resuscitation, is obligatory.
In the postpartum period, prophylaxis of purulent-inflammatory diseases is carried out, and uterus involution is monitored.
PREVENTION OF THE DISTRIBUTION DISTANCE
The best treatment for PD is its prevention, but, despite the known risk factors, unfortunately, it should be recognized that reliable prevention of PD does not exist. And yet one should strive for the antenatal identification of fetuses with a body weight >4500 g. Another mnemonic term used in English literature: DOPE (Diabetes, Obedity, Postdatism, Excessive fetal weight or maternal birth weight – diabetes, obesity, repopulation, macrosomia, or excessive weight gain during pregnancy).
If possible, in the II stage of labor it is necessary to restrain the woman in her as much as possible to push up until the moment of eruption (not to “stretch” a woman without need!). Elliot et al. (1982) suggested to consider the risk factor for PD state when, with ultrasound, the chest circumference exceeds the head circumference by 16 mm, and / or the circumference of the shoulder girdle exceeds the circumference of the head by 48 mm, especially in large fetuses in women suffering from diabetes.
Recently, great interest is shown in the weight of parents at their birth. According to many studies, the weight of parents at birth correlates with the weight of their children at birth. In fact, the mother’s weight at birth correlates more strongly with fetal macrosomia than the height and weight of the mother at the moment. It is also important to mention in the history of the birth of a large fetus and the DP. Large children are born more often in elderly mothers, in multipath, especially against the background of obesity and diabetes.