Repositioning the Fetal Breech Location with Settings Knee Chest Position and Yoga Practice for Pregnant Women

Introduction

Maternal Mortality Rate (MMR) is one of the critical indicators of public health status. AKI describes the number of women who die from a cause of death related to pregnancy disorders or their management (excluding accidents or incidental cases) during pregnancy, birth, and in the puerperium (42 days after birth) without taking into account the length of pregnancy per 100,000 live births [1]. The most sensitive indicator in the success of maternal and child health programs is the perinatal and maternal mortality rate. This situation is caused by malpresentation, including abnormalities in the presentation of the buttocks or breech position. A breech position is a condition in which the fetus lies lengthwise with the head in the uterine fundus and the buttocks at the bottom of the uterine cavity. A breech presentation occurs when the fetus lies elongated with the lowest part of the breech, legs, or a combination of both [2].

Causes of the breech position include the narrow pelvis, twisting the umbilical cord or short umbilical cord, uterine abnormalities, tumors, placenta previa, and multiple pregnancies [2, 3]. A vital presentation occurs in primigravidas, especially older primigravidas, and is thought to occur because of the shape of the uterus and the frequent space for fetal and uterine growth [4, 5, 6]. There are three categories of breech presentation, depending on the position of the fetal lower limbs: pure in two-thirds of cases, complete in one-third, and less often, knees or feet.

In the prevention and management of breech presentation, three factors must be considered. The first is the prevention of deformities and complications due to vaginal delivery by moving the fetus to the vertex position before the time of delivery through a method called the external cephalic version. Second, avoid complications associated with vaginal delivery of a breech fetus by using a cesarean section, especially when the fetal head is hyperextended. Third, the management of all deformations and complications after delivery of a breech fetus [6]. Three ways are used to convert a breech presentation to a cephalic presentation: the chest- knee position in the mother and the external version related to maternal posture and moxibustion and acupuncture [4, 7].

Yoga is a holistic action involving the soul, mind, and body, which are carried out with a smooth motion system that does not stomp with harmonious breathing guidelines [8]. The logistic regression results showed that immediately after the intervention, mothers in the intervention group had a 3.8 times chance of fetal presentation turning cephalic than women in the control group and had a 3.43 times chance during labor. Conclusion: Mother’s knee-chest position can change the breech presentation to head. Therefore, it is recommended to use this position in conjunction with other prenatal care for eligible mothers in health care centers [9]. It is important to identify the effect of knee-chest and yoga on pregnant women repositioning the fetus in a breech position.

Methods

The design in this study is a quasi-experimental third- trimester pregnant woman as research respondents determined using purposive sampling technique based on inclusion criteria, namely being in the third trimester of pregnancy, the fetus is in a breech position, not experiencing physical disabilities and in good health. The entire sample was divided into two groups. Each group consisted of 27 respondents and would receive a different intervention. Before being given treatment, the researchers ensured that the respondent’s fetus was in a breech position. Furthermore, the researchers gave the knee-chest position treatment for the first group and the Adho Mukha Svanasana Yoga Pose treatment for the second group of respondents. Evaluation of the position of the fetus was carried out after giving treatment to both groups to determine the effect of each treatment or action on the position of the fetus.

Result and Discussion

The research was carried out at Psukesmas in South Sumatra Province for one week in January 2021. The first stage was a contract to respondents by filling in informed consent and setting a time for implementing the action when they checked their pregnancies at three puskesmas, five practice midwives, and three maternity clinics, located in the city of Palembang, South Sumatra, Indonesia. Pregnant women who met the inclusion criteria and intervened according to the agreed time.

In this study, the characteristics of all respondents can be seen in the Tables 1 & 2:

In this study, the treatment group was divided into two groups, namely the knee-chest position group and the Adho Mukha Svanasana Yoga Pose group. Each group was divided into those who received action and those who did not. The results obtained were repositioned and not repositioned.

The test results can be seen in the Table 3:

Based on the results of statistical tests using Chi- Square, p = 0.001 for the knee-chest relationship and fetal repositioning and p-0.0002 in Adho Mukha Svanasana Yoga Pose.

The results showed that the Adho Mukha Svanasana Yoga Pose treatment group experienced breech repositioning of the fetus in 83.3% of respondents, from breech presentation to head presentation. While in the knee-chest position treatment group, only 22.2% of respondents had a breech they repositioned the fetus.

The high success rate of breech repositioning in the yoga pose treatment group is due to the principles adopted in yoga, namely mind, body, and soul. When pregnant women do yoga poses, attention is paid to the physical and unites the body, soul, and mind to have a harmonious relationship between the mother’s body and the fetus [4, 10]. Psychologically this condition is very beneficial because breech repositioning the mother invites her baby to cooperate by imagining the baby turning to the expected position [11, 12]. As the results of a study that examined the same thing, [13, 14] it was found that yoga had a more significant effect on fetal repositioning than knee-chest interventions.

Yoga philosophy in pregnancy when doing yoga asanas/ poses must pay attention to body posture because good posture will lengthen the abdominal space so the baby can rotate its position [15, 16, 17]. Relax in every movement because when you are more relaxed, the abdomen will give the baby more room to move. The relaxed state of the mother should be followed by deep and gentle breathing. During yoga poses, pregnant women do three breath cycles. Giving clear instructions has made it easier for mothers to follow according to the explanation given. Great curiosity and interest because respondents’ yoga poses are still considered new can underlie respondents in practicing it [15].

Yoga poses work based on the theory of Earth’s gravity [18, 19]. The fetus has a common or normal position where the head is down with the buttocks at the top. When the fetus is old enough, after 40 weeks of gestation, the fetus must open the birth canal. To the road’s opening, something round is needed, and in the human body, objects with a round shape are the back of the head and the buttocks. Therefore, the back of the head or buttocks must be in a down position when the fetus is ready to be born. This position can be obtained with the help of the Earth’s gravity which will rotate the position of the fetus [1, 20, 21]. It is known that the gravitational force will easily attract objects that have a large mass. The presence of gravity can make it easier for the fetal head to rotate and be at the bottom because the fetal head has a greater mass than the body. It is often said that fetal head development is faster than body development [6]. This is the reason why pregnant women do yoga poses in a breech position to reposition the fetus.

The yoga poses taught in this study include a person standing with both palms and feet firmly on the floor. The body is lifted upwards, the head looks towards the mother’s abdomen, the tailbone is pointing upwards, and the back is straight and extended [19, 21, 22]. After the mother’s pose is correct, taking deep breaths gently for three breath cycles is recommended. In this pose, the mother’s body has created maximum space for the fetus to rotate and work based on the gravity of the Earth [23, 24]. The process of deep breathing will relax the uterus and make it easier for the fetus to rotate.

The knee-chest position or the prostration position has applied the principle of Earth’s gravity. It’s just that the space in the mother’s stomach is not optimal for the fetus to rotate because the mother’s back is not in a straight position. In addition, when doing the knee-chest position is not accompanied by deep breathing. These two things differentiate between yoga and knee-chest. Even so, the knee-chest position still allows the baby to rotate at a lower percentage than the yoga pose in the deep knee- chest position [25]. They explained that one of the steps in the knee-chest position is to ensure that the chest and shoulders are on the floor and the knees remain flat on the floor. This position allows the baby’s space to rotate will be even narrower because if the knees remain on the floor, this results in pressure on the abdomen and thighs, making the baby’s space move narrower. This can also be seen in the comparison of the following two images of knee-chest and yoga positions.

The mother’s age can influence the success of repositioning the fetus, the majority of whom are less than 35 years old, so that the mother can still adjust the knee-chest and yoga positions to the maximum [22, 25, 26]. Maximum muscle flexibility determines the success of this intervention. In mothers who have not reached 35 years of age, their muscle strength is still very good, so they are able to move their muscles well [15, 19]. It is also known that, in general, the respondents are multigravida, so they have had previous childbirth experiences. This is in line with the results of the study [22]. This experience affects low levels of anxiety in the treatment of knee-chest and yoga [7, 27]. For someone who does not experience anxiety, that person is to follow the instructions given and be more cooperative in living it [14, 20, 28].

Conclusion

It can be concluded that the treatment of more fetuses experienced repositioning after pregnant women received yoga treatment compared to the knee-chest group. Based on the results of statistical tests using Chi-Square, it was found that there was an effect of knee-chest position treatment with a significance value of p = 0.001 and also on giving yoga exercise p = 0.002 on fetal repositioning in third-trimester pregnant women. Age and parity can be a driving factor for the success of giving knee-chest and yoga treatments.