Engagement of the child in the birth canal

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Catherine Le Nevez
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cephalic childbirth

Among the various phases that precede the birth of the child there is what is called "commitment" of the part presented. As we know there are three types of presentation: cephalic, breech and shoulder. Since the latter does not allow spontaneous childbirth, and the breech presentation in the country in most cases leads to a caesarean section, to understand what the commitment is we will exploit the cephalic presentation.





By taking a quick rundown of the events of the last few days before delivery, we can observe significant changes in the baby's position. In fact, it prepares itself in the position in which it will have to be born: head turned down, arms and legs bent. In this position he can also stay for a long time without lowering himself towards the "exit", towards the birth canal.

Read also: Childbirth: what does the fetus look like?

Your belly will be bulky as always and any difficulties arising from the volume (breathing difficulties, stomach acid) of the uterus will remain unchanged. But there will come a time when you feel like you are breathing better, that the belly has dropped. And it really is. Your baby has lowered and is now comparing his pelvis to figure out which diameter to use. Let's say that he is rehearsing to understand how he manages to do better.



Once you understand how to pass, it lowers a little more and here comes the commitment. In practice, when the baby falls below the level of the pubic bone and begins to channel itself millimeter after millimeter towards the birth we speak of commitment. From this position the baby will no longer be able to move, that is, once engaged with his head he will no longer be able to rotate, for example returning to the breech.

When does this commitment take place?

There is no particular moment, it is not necessary that the labor has already begun some time ago, indeed sometimes it is the commitment of the baby's head that causes the loss of the mucous plug and the start of labor. If it occurs before labor, you can notice it by squeezing your belly: before it is committed, in fact, if you press both hands from the hips towards the pubic bone, you will find that you are able to perfectly delimit the hard mass of the head and that your hands tend to join. Once the commitment has been made, however, you will come to delimit the head up to a certain point and then the hands will end up on the pubic bone. This is one of the external maneuvers that we obstetricians are taught to assess the situation at the time of the last visit before giving birth.



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The assessment of the degree of commitment is then completed by a vaginal exploration that establishes how committed it is, i.e. how close it is to the vaginal canal and therefore ready for the expulsive period and birth.

How do we find out?

We use our fingers as centimeters and evaluate with respect to two protruding ossicles (the ischial spines) how many centimeters are above and how far below. If the child's head is above the ossicles we will assign a negative score (- 3; -2; -1 cm), if it is at the level of the ischial spines it will be 0 and if it has already passed them it will have a positive score (+ 1 ; +2; +3 cm) and normally at this point the hair emerges from the external genitalia and is ready to be born.

But if the commitment doesn't happen, what happens?

If even once labor has begun the contractions should not be able to push the child down you have to go and investigate the reason. The contractions may be too weak, the baby's head may be too large, the umbilical cord may be short, or it may have coiled around a part of the body. Once the cause has been identified, an attempt is made to correct it to favor birth. In the case of weak contractions, labor is allowed a little time to progress but if this does not happen, synthetic oxytocin is administered. The case involving the cord that is too short is usually rare because the last ultrasound would show it, while the coiling is less rare.

By changing the position of the mother, you try to encourage the baby to move the arm or leg and unroll. The case of the big head not passing through the pelvis can also be said to be rare. Ultrasound estimates the size of the skull and allows you to understand if it is suitable for the pelvis or not. In case of very slight difficulty in passing, it will be sufficient to make the mother change position to help him rotate his head in the easiest way to progress. And if all this does not work, do not despair, they will not let you go on forever, we will proceed with the birth through Caesarean section that maybe it is not the preferred option by the mother but, I repeat, it is always and in any case to be preferred over risking the life of mother and child.

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