Unstable lie

unstable lie and version, types of version

1. Unstable lie and version Neethu ss Second year MSc Nursing

2. UNSTABLE LIE

3. UNSTABLE LIE This is a condition where the presentation of the fetus is constantly changed even beyond 36th week of pregnancy when it should have been stabilized.

4. CAUSES The causes are those which prevent the presenting part to remain fixed in the lower pole of the uterus. Such conditions are: Grand multipara with lack of uterine tone and pendulous abdomen— commonest cause Hydramnios Contracted pelvis Placenta previa Pelvic tumor.

5. Complications Cord entanglement is a possible risk. Risk of cord prolapse is there once the membranes rupture. Perinatal death is high

6. ANTENATAL At each antenatal visit, the presentation and the lie are to be checked. If there is no contraindication, external version is to be done to correct the malpresentation. MANAGEMENT

7. Hospitalization : The patient is to be admitted at 37th week. Premature or early rupture of the membranes with cord prolapse is the real danger with the lie remaining oblique. After admission, the investigation is directed to exclude placenta previa, contracted pelvis or congenital malformation of the fetus with the help of sonography for localization of the placenta

8. FORMULATION OF THE LINE OF TREATMENT: • Elective cesarean section is done in majority of the cases especially in the presence of complicating factors like pre-eclampsia, placenta previa, contracted pelvis, etc .

9. Stabilizing induction of labor: External cephalic version is done (if not contraindicated) after 37 weeks → oxytocin infusion is started to initiate effective uterine contractions. This is followed by low rupture of the membranes (amniotomy). Labor is monitored for successful vaginal delivery. This procedure may be done even after the spontaneous onset of labor.

10. version

11. It is a manipulative procedure designed to change the lie or to bring the comparatively favorable pole to the lower pole of the uterus.

12. TYPES According to the methods employed:  Spontaneous   External   Internal   Bipolar

13. Spontaneous: Version process occurs spontaneously. The incidence of spontaneous version in breech presentation is nearly 55% after 32 weeks and about 25% after 36 weeks. It is more common in multiparous women. External: The maneuver is done solely by external manipulation. Internal: The conversion is done principally by one hand introducing into the uterus and the other hand on the abdomen. Bipolar (Braxton-Hicks): The conversion is done introducing one or two fingers through the cervix and the other hand on the abdomen

14. When the cephalic pole is brought down to the lower pole of the uterus, it is called cephalic version and when the podalic pole is brought down, it is called podalic version.

15. INDICATION Breech presentation Transverse lie/ oblique lie

16. CONTRAINDICATIONS OF ECV Antepartum hemorrhage (placenta previa or abruption)— risk of placental separation Fetal causes—hyperextension of the head, large fetus (> 3.5 kg), congenital abnormalities (major), dead fetus, fetal compromise (IUGR) Multiple pregnancy Ruptured membranes—with drainage of liquor Known congenital malformation of the uterus Abnormal cardiotocography Contracted pelvis Previous cesarean delivery—risk of scar rupture Obstetric complications: Severe pre-eclampsia, obesity, elderly primigravida, bad obstetric history (BOH) Rhesus isoimmunization

17. The advantages of ECV at term By this time spontaneous version will occur in many cases If any complications occur during ECV prompt delivery could be done by cesarean section as the baby is at term. Success rate of ECV in general is 60%. Use of tocolytics (ritodrine) increases the success rate of ECV

18. Time of version ECV has been considered from 36 weeks onwards. While version in the early weeks is easy but chance of reversion is more. Late version may be difficult because of increasing size of the fetus and diminishing volume of liquor amnii . However, the use of uterine relaxant (tocolysis) has made the version at later weeks less difficult. It minimizes chance of reversion and should fetal complications develop, it can be effectively tackled by cesarean section. Hypertonus or irritable uterus can be overcome with the use of tocolytic drugs.

19. Benefits of ECV Reduces the incidence of breech presentation at term and of breech delivery Reduces the number of cesarean delivery Reduces maternal morbidity due to cesarean or vaginal breech delivery. Reduces the fetal hazards of vaginal breech delivery

20. Preliminaries The patient is asked to empty her bladder. She is to lie on her back with the shoulders slightly raised and the thighs slightly flexed. Abdomen is fully exposed. The presentation, position of the back and limbs are checked and FHR is auscultated.

21. PROCEDURES In breech presentation The maneuver is carried out after 36 weeks in the labor-delivery complex. Any one of the following tocolytic drugs (Terbutaline – 0.25 mg SC or Isoxsuprine 50–100 µg IV), if required, can be administered. Real time ultrasound examination is done to confirm the diagnosis and adequacy of amniotic flood volume. A reactive NST should precede the maneuver

22. “ Forward roll” movement . Step—I The breech is mobilized using both hands to one iliac fossa towards which the back of the fetus lies. The podalic pole is grasped by the right hand in a manner like that of Pawlik’s grip while the head is grasped by the left hand .

23. Step—II The pressure (firm but not forcible) is now exerted to the head and the breech in the opposite directions to keep the trunk well flexed which facilitates version. The pressure should be intermittent to push the head down towards the pelvis and the breech towards the fundus until the lie becomes transverse. The FHR is once more to be checked.

24. Step—III: The hand is now changed one after the other to hold the fetal poles to prevent crossing of the hand. The intermittent pressure is exerted till the head is brought to the lower pole of the uterus.

25. A reactive NST should be obtained after completing the procedure. There may be undue bradycardia due to head compression which is expected to settle down by 10 minutes. If however fetal bradycardia persists, the possibility of cord entanglement should be kept in mind and in such cases reversion may have to be considered. The patient is to be observed for about 30 minutes : (1) To allow the FHR to settle down to normal (2) To note for any vaginal bleeding or evidence of premature rupture of the membranes.

26. Instructions  The patient is advised for follow up to check the corrected position To report to the physician if there is vaginal bleeding or escape of liquor amnii or labor starts Rh-negative nonimmunized women must be protected by intramuscular administration of 100 µg anti-D gamma globulin

27. External version in transverse lie The version is much easier than in breech. The association of placenta previa or congenital malformation of the uterus should be excluded.

28. External podalic version The external podalic version may be done in cases when the external cephalic version fails in transverse lie in case of the second baby of twins.

29. INTERNAL VERSION Internal version is always a podalic version and is almost always completed with the extraction of the fetus.

30. INDICATIONS Internal version is hardly indicated in a singleton pregnancy in present day obstetric practice. Its only indication being the transverse lie in case of the second baby of twins. However, it may be employed in singleton pregnancy to expedite delivery in adverse conditions where the cesarean section facilities are lacking. Such conditions are: Transverse lie with cervix fully dilated Cord prolapse with cervix fully dilated with transverse lie or head high up and the baby is alive .

31. Conditions to be fulfilled The cervix must be fully dilated Liquor amnii must be adequate for intrauterine fetal manipulation Fetus must be living.

32. Contraindication It must not be attempted in neglected obstructed labor even if the baby is living.

33. PROCEDURES Assessment of the lie, presentation and FHR is made by an experienced obstetrician by abdominal palpation, vaginal examination and/or transabdominal ultrasound examination. Close (continuous) FHR monitoring is essential. Internal version should be done under general or epidual anesthesia.

34. Step—I: Patient is placed in dorsal lithotomy position. Antiseptic cleaning draping and catheterization are done. Introduction of the hand—If the podalic pole of the fetus is on the left side of the mother, the right hand is to be introduced and vice versa. The hand is to be introduced in a cone shaped manner. It is then pushed up into the uterine cavity keeping the back of the hand against the uterine wall until the hand reaches the podalic pole.

35. Step—II: The hand is to pass up to the breech and then along the thigh until a foot is grasped. The identification of the foot is done by palpation of the heel. It is advantageous to grasp the first foot which one encounters. Step—III: While the leg is brought down by a steady traction, the cephalic pole is pushed up using the external hand.

36. Step—IV: After one leg is brought down, there is no difficulty to deliver the other leg. The delivery is usually completed with breech extraction during uterine contractions. Step—V: Routine exploration of the uterovaginal canal to exclude rupture of the uterus or any other injury.

37. Complications Maternal risk includes placental abruption, rupture of the uterus and increased morbidity. The fetal risk includes asphyxia, cord prolapse and intracranial hemorrhage apart from all hazards of breech delivery leading to a high perinatal mortality of about 50%.

38. BIPOLAR VERSION

39. The bipolar version named after Braxton-Hicks is an obsolete maneuver in present day obstetric practice. However, it may be a life saving procedure at places, specially in the rural areas of the developing countries, where it is not possible to transport the patient with placenta previa to an equipped medical center. Its chief indication is lesser degree of placenta previa when the fetus is dead, deformed or previable.

40. The cervix must be at least two fingers dilated to facilitate manipulation by pushing up of the head to one iliac fossa and to grasp one leg at the ankle. Simultaneous manipulation by the external hand facilitates the procedure. Bringing down of one leg facilitates compression over the placenta and thereby stops the bleeding Fundal pressure to assist the process of vaginal delivery should not be used. It results in pelvic hematoma formation, orthopedic and neurological complications .

41. External cephalic version-related risks: a meta-analysis K Grootscholten , M Kok , SG Oei , BW Mol, and JA van der Pos Eighty-four studies (12,955 cephalic version procedures), including 57 cohort studies, 15 randomised controlled trials and 10 case-control studies, were included in the review. Forty-seven studies collected outcome data prospectively, 45 studies recruited participants consecutively and 70 studies used tocolytics. The success rate for external cephalic version ranged from 16 to 100% (pooled success rate 58%, 95% confidence interval (CI): 56 to 57; I 2 =94%). The pooled complication rate was 6.1% (95% CI: 4.7 to 7.8; I 2 =92%). Subgroup analyses for all complications failed to show any significant effects of study quality. Pooled odds ratios for each individual complication type were also reported, but only analyses related to the outcome of external cephalic version have been reported in this abstract.

42. Vaginal bleeding was significantly less likely after a successful external cephalic version as compared with an unsuccessful attempt (odds ratio 0.33, 95% CI: 0.14 to 0.82; four studies; I 2 =0%). There were no statistically significant differences between a successful and an unsuccessful outcome of external cephalic version, in terms of the odds of stillbirth (eight studies), placental abruption (six studies), cord prolapse (three studies), abnormal cardiotocography post-intervention ( foetal bradycardia, 10 studies; foetal tachycardia, two studies), foeto -maternal transfusion (two studies) or ruptured membranes (three studies). No significant heterogeneity was evident for any of the pooled analyses, with the exception of foetal bradycardia (I 2 =70%) and foetal tachycardia (I 2 =53%)