Management Of Unstable Lie 2

MANAGEMENT OF UNSTABLE LIE BY DR T.K. NYENGIDIKI

PRENATAL ASSESSMENT 

CLINICAL

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INVESTIGATIONAL -Ultrasonological -Radiological -

PRENATAL ASSESSMENTCLINICAL PRENATAL HISTORY -Reliability of gestational assessment -Relevant family History PAST OBSTETRIC HISTORY -significant polyhydramnios-cause -abdominopelvic tumors PELVIC EXAMINATION -Pelvic shape,capacity, tumors etc -Must have excluded presence of placenta previa.

INVESTIGATIONS Real time ultrasound scan - fetal malformations,pelvic tumors,placenta uterine malformations. Radiological -No place in the presence of above. -X ray Gross fetal malformations/pelvic size and shape.

MANAGEMENT PRENATAL PERIOD

INTRAPARTUM PERIOD

POSTNATAL PERIOD

Prenatal management NON – INTERVENTION INTERVENTION Non –intervention  Spontanous version- 80% of cases  Exclude possible causes of obstructed labour  Advice on the risk associated with unstable lie  Need for prompt admission in the event of mb rupture /labour  Physical exercises-knee-elbow position for 10mins on a no of occasions 5-10% of longitudinal lie  Individualization of treatment in this enviroment.

INTERVENTION Hospitalization from 37weeks -Daily observation of fetal lie ,presentation -provides opportunity for correction of lie -provides immediate clinical assistance in the event of labour/mb rupture. -facilitates urgent mgt in the event of a non longitudinal lie, fetal distress, cord presentation and prolapse.

INTERVENTION EXPECTANT -Admitted -Daily examination of lie -Cephalic/breech is maintained >48 hours -Discharge home to report when in labour .ACTIVE -external cephalic version -Stabilising induction -Elective Cesarean section at 38/39 weeks.

ACTIVE MANAGEMENT EXTERNAL CEPHALIC VERSION. -Procedure done in a facility for emergency C/section -Longitudinal lie is maintained -discharge patient -Rhesus negative mothers- Anti D immunoglobulin prophylaxis at/before. -If unsuscessful patient to remain on admission. -Success rate of version antenatally 40-65%

STABILIZING INDUCTION Performed immediately after admission or within days or weeks FIRST METHOD In labour ward, ECV performed conversion to longitudinal lie and maintained. Titrated oxytocin infusion commenced to stimulate contractions. Aim of achieving of contractions within 10 minutes Low water amniotomy is performed while an assistance stabilises the head. Monitor labour normally SECOND METHOD Perform an ECV Stimulate uterine contractions with titrated oxytocin infusion Perform Hind water rupture using a Drew-Smythe catheter Reduces the risk of cord prolapse Other methods of stimulation of uterine contraction include Prostalglandins but unpredictable.

ELECTIVE CESAREAN SECTION Advocated in the presence of: - contraindication to external cephalic version - Failure of external version -Mechanical obstruction to vaginal delivery

INTRAPARTUM MANAGEMENT When the membranes rupture or labour occurs -Longitudinal lie Examine for fetal presentation exclude cord prolapse conduct a normal labour -Non-longitudinal lie -Determine state of fetus -Vaginal examination to exclude mechanical obstruction , assess cervical dilatation and exclude cord prolapse. -Perform ECV in between contractions or under intravenous tocolytic administration. -Success -Allow labour -Unsuccessful -Emergency cesarean section.

INTRAPARTUM CONT. Cord presentation /prolapse -Partially dilated cervix/ Non longitudinal lie- C/section -Fully dilated longitudinal lie - Assisted vaginal delivery

POSTNATAL No specific management advice if vaginal delivery or lower segment C/section Classical C/section - Advice of future pregnancy outcome/delivery is given.