EVALUATION OF THE EFFECTIVENESS OF EXTERNAL ROTATION OF THE FETUS ON THE HEAD IN THE GESTATION PERIOD OF 36 WEEKS OR MORE

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The frequency of abdominal delivery with pelvic presentation is 60-70% [1], this is associated with a high risk of complications with abdominal delivery, which we will expect in these patients in the near and distant periods, primarily, such as bleeding [2], purulent-septic complications 10% [3], thromboembolic complications 0.5% [4]. In the long term, this is the failure of the scar, placenta accretion, placenta previa, the threat of termination of pregnancy and other complications [5]. Childbirth through the natural birth canal in patients with pelvic presentation also entails a number of complications, such as birth trauma, the frequency of which is 20%, the risk of perinatal mortality is 2/1000 births, during childbirth in head presentation - 1 /1000, consequences in the form of fetal hypoxia and asphyxia of newborns [1, 6] The question of the method of delivery of patients with pelvic presentation remains very relevant and debatable [7]. Therefore, today, the external rotation of the fetus on the head (NPP) sounds more and more often in foreign and domestic literature. [8, 9]
The manipulation technique was comprehensively developed in the middle of the XX century by B.A. Arkhangelsky. To date, on average, the frequency of successful attempts reaches 40% in primiparous and 60% in repeat births [1].
The possible use of NPP on the head with an adequate assessment of indications and conditions, in case of a successful attempt, will reduce the frequency of cesarean section, reduce perinatal morbidity and mortality.
The purpose of the study.
To evaluate the expediency and safety of external obstetric preventive rotation of the fetus on the head in the gestation period of 36 weeks or more.

Materials and methods of research.
To achieve this goal, the examination and treatment of patients was carried out on the basis of the Altai Regional Clinical Perinatal Center" in the period from January 2020 to December 2021. A single-stage cross-sectional retrospective study included 90 patients with a singleton pregnancy, the absence of severe obstetric complications and clinically significant extragenital pathology and congenital malformations of the fetus. Depending on the management tactics, the patients were divided into three groups.
The main group (30 pregnant women) consisted of patients with pelvic presentation, in whom an attempt was made on the head at a gestation period of 36 weeks or more. The comparison group (30 people) included patients with pelvic presentation of the fetus and subsequent pelvic presentation planned through the natural birth canal, in this group there were no attempts to carry out NPP on the head. The control group (30 women) included patients with head presentation of the fetus without complicated course and premorbid background, delivered through the natural birth canal.
The criteria for inclusion in the main group were confirmed singleton pregnancy at gestation of 36 weeks or more with pelvic presentation of the fetus, the presence of informed voluntary consent to manipulation, satisfactory fetal condition (STV index for cardiotocography, Doppler examination of the blood flow of the umbilical arteries, uterine arteries), amniotic index of more than 10 cm, normal pelvic dimensions, the possibility of emergency abdominal delivery. The exclusion criteria were the gestation period of less than 36 weeks, as well as the presence of absolute and/ or relative contraindications to the NPP on the head, the patient's refusal.
The criteria for inclusion in the comparison group were: pregnant women with a gestation period of 36 weeks or more, who did not have an attempt at head surgery and had no indications for planned abdominal delivery, therefore, a plan for delivery through the natural birth canal was drawn up. The exclusion criteria were the gestation period of less than 36 weeks, as well as the presence of absolute and/or relative contraindications to childbirth, including the patient's refusal to give birth through the natural birth canal, refusal to participate in the study.
The criteria for inclusion in the control group were pregnant women with head presentation of the fetus, who had no indications for planned abdominal delivery, with a plan for delivery through the natural birth canal. The exclusion criteria were the gestation period of less than 36 weeks, as well as the presence of absolute and/or relative contraindications to childbirth, refusal to participate in the study.
External rotation of the fetus on the head was carried out in accordance with clinical recommendations, taking into account indications, contraindications, conditions for carrying out and in the absence of contraindications to natural childbirth [1].
Before the manipulation, all patients of the main group underwent CTG, Doppler examination of blood flow in the mother-placenta-fetus system. In all cases, hexoprenaline tocolysis was used, the uterine tone was normal, stable throughout the entire procedure. The procedure took no more than 5 minutes, was performed with complete relaxation of the uterus. A clear planned displacement of the fetus in the external direction was performed after fixing it by the pelvic and head ends while simultaneously shifting towards the anterior abdominal wall, with an interval of several seconds in the middle of the procedure. The procedure was carried out throughout with the maintenance of verbal control with the patient. After the turn, CTG was recorded with ultrasonic Doppler mapping. Further, the women were under continuous specialized medical supervision.
Data processing and graphical visualization were performed using the program Statistica 10.0 and Exel 2010. The Shapiro-Wilk W–criterion was used to test the null hypothesis that the distribution of a trait corresponds to the theoretically expected normal distribution. In cases of normal distribution of a quantitative trait, the Student's t-test was used to compare sample averages, and the Student's paired t-test was used to compare related samples. For values with an asymmetric distribution, the median (Me), minimum and maximum values of the indicator were calculated. The nonparametric Mann–Whitney criterion was used to check the equality of averages that do not meet the criteria of a normal distribution. The criterion χ2 was used to determine the reliability of differences between two independent groups with a qualitative trait. The significance level of p when testing null hypotheses was assumed to be equal to 0.05 in all cases.

Results and their discussion.
The compared groups included women aged 18 to 38 years. The average age of women in the main group was 29.5±6.4, in the comparison group - 30.6±5.9 (p>0.05), in the control group - 30.1±5.1 (p>0.05). The analysis of obstetric and gynecological anamnesis did not reveal significant differences, so the groups were completely comparable. The ratio of first- and second-born in the compared groups did not differ (in the main group, 43.3 and 56.7%, respectively; in the comparison group, 36.7 and 63.3%; in the control group, 46.7 and 53.3%; p>0.05).
A comparison of the prevalence of extragenital pathology in patients of the compared groups also revealed no significant differences. The most common of the somatic diseases was anemia of pregnant women, but no significant differences were found in the compared groups, respectively 40.0%; 63.3%, and in the control group -50.0% (p>0.05).
The attempt of external rotation of the fetus to the head successfully ended in 28 pregnant women (93.3%), in 2 patients (6.7%), as a result of the rotation, it was not possible to change the presentation of the fetus. In two patients (7.1%) of the successful cases of rotation after 2 days, the fetus returned to its original position. None of the above clinical cases required an emergency Caesarean section. An analysis of the possible causes of the unsuccessful attempt to turn revealed the following: the body mass index in this group of women was significantly higher, compared with patients who managed to make a turn, respectively 23.6 ± 4.4 and 30.5± 2.1 kg/m2 (p=0.035).
When analyzing the hemodynamic changes in the blood flow of the uteroplacental and fetoplacental complexes, before and after the attempt of external rotation of the fetus to the head, no significant changes were detected (p>0.05), however, as when comparing the same parameters with the parameters of the blood flow of a physiologically occurring pregnancy with fetal head presentation, at the same gestation period (p>0.05).
The indicators of the resistance index (IR) in the right uterine artery before and after the NPP, as well as in the control group were: before the turn 0.61 ± 0.1 after the turn 0.6 ± 0.1, in the control group 0.47 ± 0.12 (p> 0.05). In the left uterine artery IR, respectively, before turning 0.63 ± 0.7, after 0.58± 0.1 (p> 0.05), in the control group 0.45± 0.12 (p> 0.05).
The indicators of the pulse index (PI) in the right uterine artery before and after the NPP, as well as in the control group were: before the turn 0.67 ± 0.17 after the turn - 0.59 ± 0.26, in the control group 0.85± 0.33 (p> 0.05). In the left uterine artery PI, respectively, before turning 0.65 ± 0.16, after 0.59± 0.25 (p> 0.05), in the control group 0.93± 0.37 (p> 0.05).
The indices of resistance index (IR) in the umbilical artery before and after were 0.58±0.1 and 0.58± 0.1 (p>0.05), in the control group 0.56±0.1 (p>0.05).
Special attention was paid to cardiotocography for the functional assessment of the fetal condition of the fetus. The average index of the STV index was calculated before and after the rotation of the fetus on the head, the STV index before and after the NPP was compared with the STV index in the control group. The STV index before the turn was 9.55±2.5, after the turn it was 9.64±3.0 (p>0.05), which does not significantly differ from the similar indicator in the control group of 9.76±3.0 (p>0.05). Fetal heart rate in the main group before NPP was 140.2±6.5, after 144.6±6.1 (p>0.05) and in the control group 148.2±6.5 (p>0.05), which confirms the satisfactory condition of the fetus and the absence of signs of acute hypoxia before and after NPP on the head.
The analysis of the outcomes of childbirth showed that 26 patients (92.9%) from the main group gave birth through the natural birth canal, the remaining four (13.3%) by caesarean section (two patients with an unsuccessful attempt at NPP, one patient had a detachment of the normally located placenta on the 3rd day after the turn, and one woman with spontaneous rotation of the fetus). Induced labor occurred in 11.6% of the patients in the main group. In the comparison group, where patients with pelvic presentation had a plan for delivery through the natural birth canal, with spontaneous onset of labor, labor ended in an emergency with operative delivery in 12 women (40.0%; p<0.05), while in 16.7% (p<0.05). the indication was fetal hypoxia, in 83.3% - anomalies of labor activity (p< 0.05).. Premature discharge of amniotic fluid was not detected in the main group, in the comparison group in 36.7% of cases (p<0.05). Acute fetal hypoxia in the main group was detected in 3.3% of cases, while in the comparison group in 16.7% (p<0.05). In 96.2% of women of the main group, no cases of maternal birth trauma were detected during childbirth, only 3.8% of cases had a grade 1 perineal rupture, in the comparison group 66.7% (p<0.05) of cases had a vaginal, perineal rupture, in 16.7% (p<0.05) manual examination of the uterine cavity was performed. The above indicators were analyzed in the control group, so the frequency of abdominal delivery was 13.3%, which does not significantly differ from the indicator of the main group (p>0.05) and significantly less than in the comparison group (p<0.05). The analysis of the duration of labor in the main and control groups also revealed no significant differences, since the 1st period was 7.9±1.9 h and 7.8±2.1 h (p>0.05), respectively, the second period was 30.5±2.1 min and 29.3±3.6 min (p>0.05), the third period was 12±3.5 min and 13±2.2 min (p>0.05).
All newborns of the main group had a satisfactory score on the Apgar scale at 1 minute – 7 points (Me 7; min 6, max 8) and at 5 minutes – 8 points (Me 8; min 7, max 9), in the comparison group at 1 minute - 7 points (Me 7; min 6, max 8) and at 5 minutes - 8 points (Me 7; min 7, max 9), which does not significantly distinguish them from the control group at 1 minute – 7 points (Me 7; min 7, max 9) and at 5 minutes -7 (Me 7; min 7, max 9) (p>0.05). The weight of newborns in the main group was 3379±408.7 g, in the comparison group - 3224±363.6 g and in the control group - 3512±460.2 kg, did not differ significantly (p>0.05).
The condition of the newborns was characterized to a greater extent by stable indicators of vital functions, in none of the cases did emergency resuscitation care need to be provided. The most common nosology in the compared groups was cerebral ischemia, mild excitation syndrome 26.4% and 16.6% (p>0.05)., in the control group 46.2% (p<0.05), respectively. A twofold increase in the incidence of ischemic brain lesions in the control group reflects the fact that the NPP on the head does not adversely affect the fetal condition and perinatal outcomes (p>0.05). There were no cases of perinatal mortality in any of the compared groups.
Therefore, the NPP per head is quite effective and expedient, as it allows to reduce the percentage of cesarean sections by 3.0 times (13.3 and 40.0% (p<0.05)). NPP also reduces the incidence of birth injuries (3.8 and 66.7%) by 18 times (p<0.05), reduces perinatal morbidity (26.4 and 46.2%) by 1.75 times (p>0.05).
Conclusion
Thus, taking into account the possible absolute and relative contraindications, as well as possible conditions, conducting an NPP on the head, followed by careful monitoring of the condition of the fetus and mother, in institutions of group 111, is quite effective and safe.

About the authors

Nadezhda Zhiveteva

Altay State Medical University

Author for correspondence.
Email: nadyazhiveteva@gmail.com
ORCID iD: 0000-0003-2456-5033
SPIN-code: 0000-0000

A student of the 6th year of the medical University

Russian Federation, Barnaul, Lenin Ave., 40

References

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