internal breech inversion

Intra-breech reversal is an obstetric surgery. It is a surgery in which the fetus is pulled into the uterine cavity to pull the fetal foot, and the transverse or head fetus is inverted into a breech position. This type of surgery is prone to uterine rupture, high maternal and child mortality, and was once considered the most dangerous surgery in obstetrics. However, in the past, cesarean section indications have strict age and poor medical conditions, and have been one of the quick and effective means to solve the horizontal production, especially the neglect of the horizontal position to save the mother and child. In addition, it has also been used in the head position umbilical cord prolapse, the frontal position, the squat position and the high straight position caused by dystocia and the twins are the horizontal position or fetal distress. In recent years, in some big cities, the neglect of the horizontal position is almost extinct, and the perinatal health care has greatly reduced the horizontal production. In addition to the advancement of the cesarean section technology, the above indications are used in addition to the twins. Intra-position reversal has been rarely applied or nearly abandoned. However, in remote or poor areas, cases of neglected horizontal positions still occur from time to time. The local obstetrician or midwife should still be proficient in the indications and methods of operation in the breech presentation and some of the terrible surgery. Even if doctors in big cities lack practical opportunities on weekdays, they should also be aware of relevant knowledge and skilled operation techniques. Otherwise, it will inevitably one day be in a situation where conditions are extremely poor and there is nowhere to ask for help. Faced with the endangered state of mother and child, they will not be able to return to heaven. Lose the opportunity to rescue. According to Wang Hongxia and other 1997 reports, the incidence of lateral position was 0.32% (45/14155), of which the neglected horizontal position accounted for 66.7% (30/45), mainly due to the lack of prenatal examination. Curing disease: Indication 1, transverse live birth, unconditional cesarean section. 2, the position, the posterior or high straight position caused by dystocia, no cesarean section conditions. 3, the head position is not in the basin and the umbilical cord prolapse, can not immediately vaginal delivery, but also failed, and no cesarean section conditions. 4, through the maternal transverse position, the palace mouth is open, the membrane is not broken, no head basin is not called. Those who have just lost the amniotic fluid can still fight for it. 5, the second child of the twins is in the horizontal position, or the fetal distress, umbilical cord prolapse can not be delivered immediately through the vagina. 6, individual transverse stillbirth, the fetus is small, or the neck is high, making the decapitation difficult to carry out. Contraindications 1, it is estimated that the head basin is not called, can not be delivered through the vaginal live birth. 2. Aura of uterine rupture or uterine rupture. 3, uterine scars, prone to uterine rupture. 4, the membrane has been broken, not much amniotic fluid in the uterine cavity. No room for manoeuvre. Preoperative preparation 1. Review the medical history, including the time of labor and rupture of the membrane, the time of limb prolapse, whether there is a history of unclean vaginal operation, and whether there are important complications such as heart disease. Abdominal examination of the uterus contour, degree of expansion of the lower segment, presence or absence of pathological contraction ring, frequency and intensity of contractions, presence or absence of tenderness and rebound tenderness; identification of fetal head position and fetal head orientation, whether the limb is clearly accessible. Blood pressure, pulse, infusion, blood preparation, continuous fetal heart rate, uterine contraction monitoring. Prepare the emergency cesarean section on the spot as much as possible, and prepare the newborn for resuscitation. The position of the bladder lithotomy, disinfection of the vulva, catheterization to see the amount of urine and color. Vaginal examination of the limbs is hand or foot, left or right hand, palm up or down, tension and autonomous activities, combined with abdominal examination is roughly judged as the left shoulder, the left shoulder, the right shoulder or the right shoulder, etc.; Whether there is umbilical cord prolapse and its tension and pulsation; whether the cervix is open, whether the amniotic fluid is exhausted, and whether the palace body is tightly wrapped around the carcass. Based on the above situation, the diagnosis is confirmed, the key points are mastered, and the necessity and feasibility of reversing the breech position are judged. 2, general anesthesia plus muscle relaxant, so that the uterine wall is completely relaxed, in order to facilitate operation. 3, the mother takes the bladder lithotomy position, disinfection of the vulva, drape, catheterization. If the membrane is not broken, the membrane is broken. 4, for vaginal examination, to understand whether the cervix is a meeting, the first exposed and the fetal position. 5, ready to rescue newborns before surgery. Surgical procedure 1. After the uterus is relaxed, under general anesthesia, the surgeon wears sterile long-barrel gloves. Those who have not broken the membrane first rupture the membrane, and one hand penetrates through the membrane of the membrane to try to make the amniotic fluid flow out as little as possible. The other hand gently presses the bottom of the palace through the abdomen to match the fetal foot. 2, take the fetal foot. The operator's hand takes the fetal foot through the ventral surface of the fetus. The identification of the fetal foot and the fetal hand is: 1 fetal foot has a heel, the toe is short like a bean, and the five toes are flattened and cannot be curled in the palm. The baby's hand has no heel, the fingers are as thin as a stick, the thumb is obviously shorter than the other 4 fingers, and can be curled in the palm. 2 fetal feet with legs connected to the buttocks, while the fetal hands are connected to the armpits and shoulders. It is best to pull out the feet at the same time. If it is not easy, you can pull out one of the feet. As for which fetal foot is taken for surgery, it depends on the fetal position. In principle, it is necessary to make the anterior anterior position after reversal, in order to give birth to the breech. When the scapula is in the front position, the foot is removed. The operator's palm is facing forward, and the armpit is inserted into the armpit. The armpit or ankle is taken along the lower thigh. The right foot is taken in the front of the left shoulder and the left foot is taken in the front of the right shoulder. When the shoulder is in the back position, take the foot, reach the front of the carcass (ventral surface), and take the foot of the foot along the upper leg. The right shoulder is taken from the left shoulder and the left foot is taken from the right shoulder. If the head position is difficult to produce in the line, if the height is not timely, the hips can be lowered by the abdominal pressure. 3. After holding the foot, pushing the head, and grasping the fetal foot, use the index finger and the middle finger to clamp the ankle. If the foot is held, use the middle finger and the ring finger to clamp the other foot, and slowly pull it. At the same time, the other hand pushes the fetal head through the abdominal wall. As long as the ride is smooth, the tire head will automatically slide to the top and smoothly complete the reverse. If you encounter resistance during traction, you must not pull it hard. There may be three reasons for resistance: 1 uterine contraction, or amniotic fluid dry, the wall of the palace is tightly wrapped around the carcass; 2 take the wrong limb, such as mistakenly taking the baby's hand, or remove the foot when the shoulder is in the back position, so that the other side of the hip is embedded in the pubic symphysis Above; 3 is stuck by other limbs. After excluding the first possibility, try changing the direction of traction to eliminate the drag. If there is still resistance, you should reach out and probe for any physical blockage. Try to open it by hand. The wrong limb should be corrected in time. In the case of difficulty in taking the foot after the shoulder, the lower foot can be changed, but the rotation is guided when pulling down to avoid the hips from being embedded in the shame and turning the back to the front. When the wall of the palace wall is tightly wrapped, the cesarean section should be changed in time. If there is no cesarean section condition, you can adjust the anesthesia, add uterine muscle relaxant, suspend intrauterine operation, or inject 500-1000ml sterile saline into the uterine cavity, wait for the opportunity to try again. The deceased has been converted to a fetus. 4. When the pulled knee reaches the vaginal opening, the buttocks have reached the uterus, and the fetal head should be in the upper abdomen. If the cervix is indeed open, the fetus is delivered according to the breech traction method. Listen to the fetal heart during intermittent operation, taking care to avoid the umbilical cord being wrapped around the lower limbs or being straddled between the legs. In the case of inhalation anesthesia, the inhalation can be stopped, the oxygen can be infused, the oxytocin can be administered intravenously, and the breech support can be performed after the uterine contraction is strengthened. If the cervix is not yet fully open, the traction should be suspended. Only use the hand to gently lift the foot, so that the buttocks block the cervix to prevent the umbilical cord from prolapse, and at the same time strengthen the contractions, waiting for the cervix to open after the breech Midwifery or traction.

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