MANAGEMENT OF MANAGEMENT OF UNSTABLE LIEUNSTABLE LIE

BYBY

DR T.K. NYENGIDIKIDR T.K. NYENGIDIKI

PRENATAL ASSESSMENTPRENATAL ASSESSMENT

CLINICALCLINICAL

INVESTIGATIONALINVESTIGATIONAL

-Ultrasonological-Ultrasonological

-Radiological-Radiological

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PRENATAL ASSESSMENT-PRENATAL ASSESSMENT-CLINICALCLINICAL

PRENATAL HISTORYPRENATAL HISTORY-Reliability of gestational assessment-Reliability of gestational assessment-Relevant family History-Relevant family HistoryPAST OBSTETRIC HISTORYPAST OBSTETRIC HISTORY--significant polyhydramnios-causesignificant polyhydramnios-cause-abdominopelvic tumors-abdominopelvic tumors

PELVIC EXAMINATIONPELVIC EXAMINATION-Pelvic shape,capacity, tumors etc-Pelvic shape,capacity, tumors etc-Must have excluded presence of placenta -Must have excluded presence of placenta previa.previa.

INVESTIGATIONSINVESTIGATIONS

Real time ultrasound scanReal time ultrasound scan

- fetal malformations,pelvic - fetal malformations,pelvic tumors,placenta uterine malformations.tumors,placenta uterine malformations.

RadiologicalRadiological

-No place in the presence of above.-No place in the presence of above.

-X ray Gross fetal malformations/pelvic -X ray Gross fetal malformations/pelvic size and shape.size and shape.

MANAGEMENTMANAGEMENT

PRENATAL PERIODPRENATAL PERIOD

INTRAPARTUM PERIODINTRAPARTUM PERIOD

POSTNATAL PERIODPOSTNATAL PERIOD

Prenatal managementPrenatal managementNON – INTERVENTIONNON – INTERVENTION

INTERVENTIONINTERVENTION

Non –interventionNon –intervention Spontanous version- 80% of casesSpontanous version- 80% of cases Exclude possible causes of obstructed labourExclude possible causes of obstructed labour Advice on the risk associated with unstable lieAdvice on the risk associated with unstable lie Need for prompt admission in the event of mb Need for prompt admission in the event of mb

rupture /labourrupture /labour Physical exercises-knee-elbow position for 10mins on Physical exercises-knee-elbow position for 10mins on

a no of occasions 5-10% of longitudinal liea no of occasions 5-10% of longitudinal lie Individualization of treatment in this enviroment.Individualization of treatment in this enviroment.

INTERVENTIONINTERVENTION

Hospitalization from 37weeksHospitalization from 37weeks

-Daily observation of fetal lie ,presentation-Daily observation of fetal lie ,presentation

-provides opportunity for correction of lie-provides opportunity for correction of lie

-provides immediate clinical assistance in -provides immediate clinical assistance in the event of labour/mb rupture.the event of labour/mb rupture.

-facilitates urgent mgt in the event of a non -facilitates urgent mgt in the event of a non longitudinal lie, fetal distress, cord longitudinal lie, fetal distress, cord presentation and prolapse.presentation and prolapse.

INTERVENTIONINTERVENTION

EXPECTANTEXPECTANT-Admitted-Admitted-Daily examination of lie-Daily examination of lie-Cephalic/breech is maintained >48 hours -Cephalic/breech is maintained >48 hours -Discharge home to report when in labour-Discharge home to report when in labour

..ACTIVEACTIVE-external cephalic version-external cephalic version-Stabilising induction -Stabilising induction -Elective Cesarean section at 38/39 weeks.-Elective Cesarean section at 38/39 weeks.

ACTIVE MANAGEMENTACTIVE MANAGEMENT

EXTERNAL CEPHALIC VERSION.EXTERNAL CEPHALIC VERSION.

-Procedure done in a facility for emergency -Procedure done in a facility for emergency C/sectionC/section

-Longitudinal lie is maintained -discharge -Longitudinal lie is maintained -discharge patientpatient

-Rhesus negative mothers- Anti D -Rhesus negative mothers- Anti D immunoglobulin prophylaxis at/before.immunoglobulin prophylaxis at/before.

-If unsuscessful patient to remain on admission.-If unsuscessful patient to remain on admission.

-Success rate of version antenatally 40-65%-Success rate of version antenatally 40-65%

STABILIZING INDUCTIONSTABILIZING INDUCTIONPerformed immediately after admission or within days or weeksPerformed immediately after admission or within days or weeks

FIRST METHODFIRST METHOD- In labour ward, ECV performed conversion to longitudinal lie and In labour ward, ECV performed conversion to longitudinal lie and

maintained.maintained.- Titrated oxytocin infusion commenced to stimulate contractions.Titrated oxytocin infusion commenced to stimulate contractions.- Aim of achieving of contractions within 10 minutesAim of achieving of contractions within 10 minutes- Low water amniotomy is performed while an assistance stabilises the head.Low water amniotomy is performed while an assistance stabilises the head.- Monitor labour normallyMonitor labour normally

- SECOND METHODSECOND METHOD- Perform an ECVPerform an ECV- Stimulate uterine contractions with titrated oxytocin infusionStimulate uterine contractions with titrated oxytocin infusion- Perform Hind water rupture using a Drew-Smythe catheterPerform Hind water rupture using a Drew-Smythe catheter- Reduces the risk of cord prolapseReduces the risk of cord prolapse

- Other methods of stimulation of uterine contraction include Prostalglandins Other methods of stimulation of uterine contraction include Prostalglandins but unpredictable.but unpredictable.

ELECTIVE CESAREAN SECTIONELECTIVE CESAREAN SECTION

Advocated in the presence of:Advocated in the presence of:

- contraindication to external cephalic - contraindication to external cephalic versionversion

- Failure of external version- Failure of external version

-Mechanical obstruction to vaginal delivery-Mechanical obstruction to vaginal delivery

INTRAPARTUM MANAGEMENTINTRAPARTUM MANAGEMENTWhen the membranes rupture or labour occursWhen the membranes rupture or labour occurs

-Longitudinal lie-Longitudinal lieExamine for fetal presentation Examine for fetal presentation exclude cord prolapseexclude cord prolapseconduct a normal labourconduct a normal labour

-Non-longitudinal lie-Non-longitudinal lie-Determine state of fetus -Determine state of fetus -Vaginal examination to exclude mechanical obstruction , -Vaginal examination to exclude mechanical obstruction , assess cervical dilatation and exclude cord prolapse.assess cervical dilatation and exclude cord prolapse.-Perform ECV in between contractions or under -Perform ECV in between contractions or under intravenous tocolytic administration.intravenous tocolytic administration.

-Success-Success -Allow labour-Allow labour-Unsuccessful-Unsuccessful -Emergency cesarean -Emergency cesarean

section.section.

INTRAPARTUM CONT.INTRAPARTUM CONT.

Cord presentation /prolapseCord presentation /prolapse

-Partially dilated cervix/ Non -Partially dilated cervix/ Non longitudinal lie- C/section longitudinal lie- C/section

-Fully dilated longitudinal lie - -Fully dilated longitudinal lie - Assisted Assisted

vaginal deliveryvaginal delivery

POSTNATALPOSTNATAL

No specific management advice if vaginal No specific management advice if vaginal delivery or lower segment C/sectiondelivery or lower segment C/section

Classical C/section - Advice of future Classical C/section - Advice of future pregnancy outcome/delivery is given.pregnancy outcome/delivery is given.