SlideShare a Scribd company logo
UNSTABLE LIE
AND
VERSION
Neethu ss
Second year MSc Nursing
UNSTABLE LIE
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.
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.
Complications
Cord entanglement is a possible risk.
Risk of cord prolapse is there once the
membranes rupture.
Perinatal death is high
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
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
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.
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.
VERSION
It is a manipulative
procedure designed to
change the lie or to bring the
comparatively favorable pole
to the lower pole of the
uterus.
TYPES
According to the methods employed:
 Spontaneous
  External
  Internal
 Bipolar
 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
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.
INDICATION
Breech presentation
Transverse lie/
oblique lie
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
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
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.
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
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.
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
“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.
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.
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.
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.
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
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.
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.
INTERNAL VERSION
Internal version is always a podalic version
and is almost always completed with the
extraction of the fetus.
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:
(1)Transverse lie with cervix fully dilated
(2)Cord prolapse with cervix fully dilated with transverse lie or head high up
and the baby is alive.
Conditions to be fulfilled
The cervix must be fully dilated
Liquor amnii must be adequate for intrauterine fetal
manipulation
Fetus must be living.
Contraindication
◦It must not be attempted in neglected
obstructed labor even if the baby is
living.
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.
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.
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.
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.
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%.
BIPOLAR VERSION
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.
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.
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; I2=94%). The pooled
complication rate was 6.1% (95% CI: 4.7 to 7.8; I2=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.
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; I2=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 (I2=70%) and foetal tachycardia (I2=53%)
Unstable lie

More Related Content

What's hot

Management of Preterm labor
 Management of Preterm labor Management of Preterm labor
Management of Preterm labor
sunil kumar daha
 
Transverse lie
Transverse lie Transverse lie
Transverse lie
Chandrima Karki
 
Malposition and malpresentations
Malposition and malpresentationsMalposition and malpresentations
Malposition and malpresentationsraj kumar
 
Management of Rh negative pregnancy
Management of Rh negative pregnancyManagement of Rh negative pregnancy
Management of Rh negative pregnancy
Chimezie Obi
 
Disorders of uterine contraction, precipitate labor, premature labor and prol...
Disorders of uterine contraction, precipitate labor, premature labor and prol...Disorders of uterine contraction, precipitate labor, premature labor and prol...
Disorders of uterine contraction, precipitate labor, premature labor and prol...
VANITASharma19
 
Occipito posterior position
Occipito posterior positionOccipito posterior position
Occipito posterior position
Priyanka Gohil
 
Face presentation
Face presentationFace presentation
Face presentationraj kumar
 
Cervical incompetence
Cervical incompetenceCervical incompetence
Cervical incompetence
Adil Muhammed
 
Obstructed labour
Obstructed labourObstructed labour
Obstructed labour
Naila Memon
 
Post term pregnancy
Post term pregnancyPost term pregnancy
Post term pregnancydrmcbansal
 
Obstructed labour
Obstructed labourObstructed labour
Obstructed labour
Priyanka Gohil
 
Face presentation
Face presentationFace presentation
Face presentation
Sudha Gayatri Konijeti
 
Inversion Of Uterus
Inversion Of UterusInversion Of Uterus
Inversion Of Uterus
Abhishek Joshi
 
Instrumental vaginaldelivery...
Instrumental  vaginaldelivery...Instrumental  vaginaldelivery...
Instrumental vaginaldelivery...
imanswati
 
Postdate pregnancy
Postdate pregnancyPostdate pregnancy
Postdate pregnancy
Aboubakr Elnashar
 
Cervical incompetence
Cervical incompetenceCervical incompetence
Cervical incompetence
Nikita Sharma
 
Breech presentation
Breech presentationBreech presentation
Breech presentation
Deepa Mishra
 
Uterine rupture
Uterine ruptureUterine rupture
Uterine rupture
Deepa Mishra
 

What's hot (20)

Management of Preterm labor
 Management of Preterm labor Management of Preterm labor
Management of Preterm labor
 
Transverse lie
Transverse lie Transverse lie
Transverse lie
 
Malposition and malpresentations
Malposition and malpresentationsMalposition and malpresentations
Malposition and malpresentations
 
Management of Rh negative pregnancy
Management of Rh negative pregnancyManagement of Rh negative pregnancy
Management of Rh negative pregnancy
 
Disorders of uterine contraction, precipitate labor, premature labor and prol...
Disorders of uterine contraction, precipitate labor, premature labor and prol...Disorders of uterine contraction, precipitate labor, premature labor and prol...
Disorders of uterine contraction, precipitate labor, premature labor and prol...
 
Occipito posterior position
Occipito posterior positionOccipito posterior position
Occipito posterior position
 
Face presentation
Face presentationFace presentation
Face presentation
 
Cervical incompetence
Cervical incompetenceCervical incompetence
Cervical incompetence
 
Obstructed labour
Obstructed labourObstructed labour
Obstructed labour
 
Post term pregnancy
Post term pregnancyPost term pregnancy
Post term pregnancy
 
Obstructed labour
Obstructed labourObstructed labour
Obstructed labour
 
Face presentation
Face presentationFace presentation
Face presentation
 
Inversion Of Uterus
Inversion Of UterusInversion Of Uterus
Inversion Of Uterus
 
Instrumental vaginaldelivery...
Instrumental  vaginaldelivery...Instrumental  vaginaldelivery...
Instrumental vaginaldelivery...
 
Fetal distres
Fetal distresFetal distres
Fetal distres
 
Postdate pregnancy
Postdate pregnancyPostdate pregnancy
Postdate pregnancy
 
Cervical incompetence
Cervical incompetenceCervical incompetence
Cervical incompetence
 
Breech presentation
Breech presentationBreech presentation
Breech presentation
 
Mal presentation
Mal presentationMal presentation
Mal presentation
 
Uterine rupture
Uterine ruptureUterine rupture
Uterine rupture
 

Similar to Unstable lie

BREECH DELIVERY.pptx
BREECH DELIVERY.pptxBREECH DELIVERY.pptx
BREECH DELIVERY.pptx
HarunMohamed7
 
Breech presentation
Breech presentationBreech presentation
Breech presentation
Ali S. Mayali
 
Version..
Version..Version..
Aetiology Classification and management of breech presentation.pptx
Aetiology Classification and management of breech presentation.pptxAetiology Classification and management of breech presentation.pptx
Aetiology Classification and management of breech presentation.pptx
PuiteaChhangte
 
Breech presentation
Breech presentation Breech presentation
Breech presentation
Rebecca Omozuapo
 
Breech presentation and delivery
Breech presentation and deliveryBreech presentation and delivery
Breech presentation and delivery
Natangwe Tangi
 
version-180530071824.pptx
version-180530071824.pptxversion-180530071824.pptx
version-180530071824.pptx
Subi Babu
 
version-180530071824.pptx
version-180530071824.pptxversion-180530071824.pptx
version-180530071824.pptx
Subi Babu
 
Transverse lie and unstable lie
Transverse lie and unstable lieTransverse lie and unstable lie
Transverse lie and unstable lie
MyatNoeSuuKyi1
 
Malpresentation and cord prolapse
Malpresentation and cord prolapseMalpresentation and cord prolapse
Malpresentation and cord prolapse
Abhilasha verma
 
Breech presentation
Breech presentationBreech presentation
Breech presentation
yuyuricci
 
BREECH PRESENTATION, TYPES, DELIVERY.pptx
BREECH PRESENTATION, TYPES, DELIVERY.pptxBREECH PRESENTATION, TYPES, DELIVERY.pptx
BREECH PRESENTATION, TYPES, DELIVERY.pptx
PhilemonChizororo
 
operative obstetrics emergency.pptx
operative obstetrics emergency.pptxoperative obstetrics emergency.pptx
operative obstetrics emergency.pptx
MesfinShifara
 
Shoulder dystocia
Shoulder dystociaShoulder dystocia
Shoulder dystocia
Dr Zharifhussein
 
version.pdf ...version.pdf..content.pdf..
version.pdf ...version.pdf..content.pdf..version.pdf ...version.pdf..content.pdf..
version.pdf ...version.pdf..content.pdf..
sunnykharshandi1995
 
Obstetrical Emergencies.pptx
Obstetrical Emergencies.pptxObstetrical Emergencies.pptx
Obstetrical Emergencies.pptx
DhruvilPatel323414
 
CORD PROLAPSE AND CORD PRESENTATION.pptx
CORD PROLAPSE AND CORD PRESENTATION.pptxCORD PROLAPSE AND CORD PRESENTATION.pptx
CORD PROLAPSE AND CORD PRESENTATION.pptx
Deepti Kukreti
 
Cord prolapse & cord presentation
Cord prolapse & cord presentationCord prolapse & cord presentation
Cord prolapse & cord presentation
Jasmi Manu
 
MALPRESENTATION AND MALPOnnnnnSITION.ppt
MALPRESENTATION AND MALPOnnnnnSITION.pptMALPRESENTATION AND MALPOnnnnnSITION.ppt
MALPRESENTATION AND MALPOnnnnnSITION.ppt
imnetuy
 
Breech presentation
Breech presentationBreech presentation
Breech presentation
Noor alwiely
 

Similar to Unstable lie (20)

BREECH DELIVERY.pptx
BREECH DELIVERY.pptxBREECH DELIVERY.pptx
BREECH DELIVERY.pptx
 
Breech presentation
Breech presentationBreech presentation
Breech presentation
 
Version..
Version..Version..
Version..
 
Aetiology Classification and management of breech presentation.pptx
Aetiology Classification and management of breech presentation.pptxAetiology Classification and management of breech presentation.pptx
Aetiology Classification and management of breech presentation.pptx
 
Breech presentation
Breech presentation Breech presentation
Breech presentation
 
Breech presentation and delivery
Breech presentation and deliveryBreech presentation and delivery
Breech presentation and delivery
 
version-180530071824.pptx
version-180530071824.pptxversion-180530071824.pptx
version-180530071824.pptx
 
version-180530071824.pptx
version-180530071824.pptxversion-180530071824.pptx
version-180530071824.pptx
 
Transverse lie and unstable lie
Transverse lie and unstable lieTransverse lie and unstable lie
Transverse lie and unstable lie
 
Malpresentation and cord prolapse
Malpresentation and cord prolapseMalpresentation and cord prolapse
Malpresentation and cord prolapse
 
Breech presentation
Breech presentationBreech presentation
Breech presentation
 
BREECH PRESENTATION, TYPES, DELIVERY.pptx
BREECH PRESENTATION, TYPES, DELIVERY.pptxBREECH PRESENTATION, TYPES, DELIVERY.pptx
BREECH PRESENTATION, TYPES, DELIVERY.pptx
 
operative obstetrics emergency.pptx
operative obstetrics emergency.pptxoperative obstetrics emergency.pptx
operative obstetrics emergency.pptx
 
Shoulder dystocia
Shoulder dystociaShoulder dystocia
Shoulder dystocia
 
version.pdf ...version.pdf..content.pdf..
version.pdf ...version.pdf..content.pdf..version.pdf ...version.pdf..content.pdf..
version.pdf ...version.pdf..content.pdf..
 
Obstetrical Emergencies.pptx
Obstetrical Emergencies.pptxObstetrical Emergencies.pptx
Obstetrical Emergencies.pptx
 
CORD PROLAPSE AND CORD PRESENTATION.pptx
CORD PROLAPSE AND CORD PRESENTATION.pptxCORD PROLAPSE AND CORD PRESENTATION.pptx
CORD PROLAPSE AND CORD PRESENTATION.pptx
 
Cord prolapse & cord presentation
Cord prolapse & cord presentationCord prolapse & cord presentation
Cord prolapse & cord presentation
 
MALPRESENTATION AND MALPOnnnnnSITION.ppt
MALPRESENTATION AND MALPOnnnnnSITION.pptMALPRESENTATION AND MALPOnnnnnSITION.ppt
MALPRESENTATION AND MALPOnnnnnSITION.ppt
 
Breech presentation
Breech presentationBreech presentation
Breech presentation
 

More from Neethu Satheesan

Breast complications
Breast complicationsBreast complications
Breast complications
Neethu Satheesan
 
Contracted pelvis
Contracted pelvisContracted pelvis
Contracted pelvis
Neethu Satheesan
 
Destructive operations
Destructive operationsDestructive operations
Destructive operations
Neethu Satheesan
 
Collective bargaining
Collective bargainingCollective bargaining
Collective bargaining
Neethu Satheesan
 
Vaginitis
VaginitisVaginitis
Vaginitis
Neethu Satheesan
 
Assessment of postnatal women
Assessment of postnatal womenAssessment of postnatal women
Assessment of postnatal women
Neethu Satheesan
 
Total parenteral nutrition
Total parenteral nutritionTotal parenteral nutrition
Total parenteral nutrition
Neethu Satheesan
 

More from Neethu Satheesan (7)

Breast complications
Breast complicationsBreast complications
Breast complications
 
Contracted pelvis
Contracted pelvisContracted pelvis
Contracted pelvis
 
Destructive operations
Destructive operationsDestructive operations
Destructive operations
 
Collective bargaining
Collective bargainingCollective bargaining
Collective bargaining
 
Vaginitis
VaginitisVaginitis
Vaginitis
 
Assessment of postnatal women
Assessment of postnatal womenAssessment of postnatal women
Assessment of postnatal women
 
Total parenteral nutrition
Total parenteral nutritionTotal parenteral nutrition
Total parenteral nutrition
 

Recently uploaded

Surgical Site Infections, pathophysiology, and prevention.pptx
Surgical Site Infections, pathophysiology, and prevention.pptxSurgical Site Infections, pathophysiology, and prevention.pptx
Surgical Site Infections, pathophysiology, and prevention.pptx
jval Landero
 
The POPPY STUDY (Preconception to post-partum cardiovascular function in prim...
The POPPY STUDY (Preconception to post-partum cardiovascular function in prim...The POPPY STUDY (Preconception to post-partum cardiovascular function in prim...
The POPPY STUDY (Preconception to post-partum cardiovascular function in prim...
Catherine Liao
 
Prix Galien International 2024 Forum Program
Prix Galien International 2024 Forum ProgramPrix Galien International 2024 Forum Program
Prix Galien International 2024 Forum Program
Levi Shapiro
 
Physiology of Special Chemical Sensation of Taste
Physiology of Special Chemical Sensation of TastePhysiology of Special Chemical Sensation of Taste
Physiology of Special Chemical Sensation of Taste
MedicoseAcademics
 
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdf
ARTIFICIAL INTELLIGENCE IN  HEALTHCARE.pdfARTIFICIAL INTELLIGENCE IN  HEALTHCARE.pdf
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdf
Anujkumaranit
 
micro teaching on communication m.sc nursing.pdf
micro teaching on communication m.sc nursing.pdfmicro teaching on communication m.sc nursing.pdf
micro teaching on communication m.sc nursing.pdf
Anurag Sharma
 
Antiulcer drugs Advance Pharmacology .pptx
Antiulcer drugs Advance Pharmacology .pptxAntiulcer drugs Advance Pharmacology .pptx
Antiulcer drugs Advance Pharmacology .pptx
Rohit chaurpagar
 
ARTHROLOGY PPT NCISM SYLLABUS AYURVEDA STUDENTS
ARTHROLOGY PPT NCISM SYLLABUS AYURVEDA STUDENTSARTHROLOGY PPT NCISM SYLLABUS AYURVEDA STUDENTS
ARTHROLOGY PPT NCISM SYLLABUS AYURVEDA STUDENTS
Dr. Vinay Pareek
 
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journey
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness JourneyTom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journey
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journey
greendigital
 
Ophthalmology Clinical Tests for OSCE exam
Ophthalmology Clinical Tests for OSCE examOphthalmology Clinical Tests for OSCE exam
Ophthalmology Clinical Tests for OSCE exam
KafrELShiekh University
 
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdf
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfMANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdf
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdf
Jim Jacob Roy
 
Phone Us ❤85270-49040❤ #ℂall #gIRLS In Surat By Surat @ℂall @Girls Hotel With...
Phone Us ❤85270-49040❤ #ℂall #gIRLS In Surat By Surat @ℂall @Girls Hotel With...Phone Us ❤85270-49040❤ #ℂall #gIRLS In Surat By Surat @ℂall @Girls Hotel With...
Phone Us ❤85270-49040❤ #ℂall #gIRLS In Surat By Surat @ℂall @Girls Hotel With...
Savita Shen $i11
 
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...
kevinkariuki227
 
heat stroke and heat exhaustion in children
heat stroke and heat exhaustion in childrenheat stroke and heat exhaustion in children
heat stroke and heat exhaustion in children
SumeraAhmad5
 
THOA 2.ppt Human Organ Transplantation Act
THOA 2.ppt Human Organ Transplantation ActTHOA 2.ppt Human Organ Transplantation Act
THOA 2.ppt Human Organ Transplantation Act
DrSathishMS1
 
The hemodynamic and autonomic determinants of elevated blood pressure in obes...
The hemodynamic and autonomic determinants of elevated blood pressure in obes...The hemodynamic and autonomic determinants of elevated blood pressure in obes...
The hemodynamic and autonomic determinants of elevated blood pressure in obes...
Catherine Liao
 
For Better Surat #ℂall #Girl Service ❤85270-49040❤ Surat #ℂall #Girls
For Better Surat #ℂall #Girl Service ❤85270-49040❤ Surat #ℂall #GirlsFor Better Surat #ℂall #Girl Service ❤85270-49040❤ Surat #ℂall #Girls
For Better Surat #ℂall #Girl Service ❤85270-49040❤ Surat #ℂall #Girls
Savita Shen $i11
 
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists  Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists
Saeid Safari
 
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...
VarunMahajani
 
Evaluation of antidepressant activity of clitoris ternatea in animals
Evaluation of antidepressant activity of clitoris ternatea in animalsEvaluation of antidepressant activity of clitoris ternatea in animals
Evaluation of antidepressant activity of clitoris ternatea in animals
Shweta
 

Recently uploaded (20)

Surgical Site Infections, pathophysiology, and prevention.pptx
Surgical Site Infections, pathophysiology, and prevention.pptxSurgical Site Infections, pathophysiology, and prevention.pptx
Surgical Site Infections, pathophysiology, and prevention.pptx
 
The POPPY STUDY (Preconception to post-partum cardiovascular function in prim...
The POPPY STUDY (Preconception to post-partum cardiovascular function in prim...The POPPY STUDY (Preconception to post-partum cardiovascular function in prim...
The POPPY STUDY (Preconception to post-partum cardiovascular function in prim...
 
Prix Galien International 2024 Forum Program
Prix Galien International 2024 Forum ProgramPrix Galien International 2024 Forum Program
Prix Galien International 2024 Forum Program
 
Physiology of Special Chemical Sensation of Taste
Physiology of Special Chemical Sensation of TastePhysiology of Special Chemical Sensation of Taste
Physiology of Special Chemical Sensation of Taste
 
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdf
ARTIFICIAL INTELLIGENCE IN  HEALTHCARE.pdfARTIFICIAL INTELLIGENCE IN  HEALTHCARE.pdf
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdf
 
micro teaching on communication m.sc nursing.pdf
micro teaching on communication m.sc nursing.pdfmicro teaching on communication m.sc nursing.pdf
micro teaching on communication m.sc nursing.pdf
 
Antiulcer drugs Advance Pharmacology .pptx
Antiulcer drugs Advance Pharmacology .pptxAntiulcer drugs Advance Pharmacology .pptx
Antiulcer drugs Advance Pharmacology .pptx
 
ARTHROLOGY PPT NCISM SYLLABUS AYURVEDA STUDENTS
ARTHROLOGY PPT NCISM SYLLABUS AYURVEDA STUDENTSARTHROLOGY PPT NCISM SYLLABUS AYURVEDA STUDENTS
ARTHROLOGY PPT NCISM SYLLABUS AYURVEDA STUDENTS
 
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journey
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness JourneyTom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journey
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journey
 
Ophthalmology Clinical Tests for OSCE exam
Ophthalmology Clinical Tests for OSCE examOphthalmology Clinical Tests for OSCE exam
Ophthalmology Clinical Tests for OSCE exam
 
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdf
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfMANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdf
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdf
 
Phone Us ❤85270-49040❤ #ℂall #gIRLS In Surat By Surat @ℂall @Girls Hotel With...
Phone Us ❤85270-49040❤ #ℂall #gIRLS In Surat By Surat @ℂall @Girls Hotel With...Phone Us ❤85270-49040❤ #ℂall #gIRLS In Surat By Surat @ℂall @Girls Hotel With...
Phone Us ❤85270-49040❤ #ℂall #gIRLS In Surat By Surat @ℂall @Girls Hotel With...
 
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...
 
heat stroke and heat exhaustion in children
heat stroke and heat exhaustion in childrenheat stroke and heat exhaustion in children
heat stroke and heat exhaustion in children
 
THOA 2.ppt Human Organ Transplantation Act
THOA 2.ppt Human Organ Transplantation ActTHOA 2.ppt Human Organ Transplantation Act
THOA 2.ppt Human Organ Transplantation Act
 
The hemodynamic and autonomic determinants of elevated blood pressure in obes...
The hemodynamic and autonomic determinants of elevated blood pressure in obes...The hemodynamic and autonomic determinants of elevated blood pressure in obes...
The hemodynamic and autonomic determinants of elevated blood pressure in obes...
 
For Better Surat #ℂall #Girl Service ❤85270-49040❤ Surat #ℂall #Girls
For Better Surat #ℂall #Girl Service ❤85270-49040❤ Surat #ℂall #GirlsFor Better Surat #ℂall #Girl Service ❤85270-49040❤ Surat #ℂall #Girls
For Better Surat #ℂall #Girl Service ❤85270-49040❤ Surat #ℂall #Girls
 
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists  Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists
 
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...
 
Evaluation of antidepressant activity of clitoris ternatea in animals
Evaluation of antidepressant activity of clitoris ternatea in animalsEvaluation of antidepressant activity of clitoris ternatea in animals
Evaluation of antidepressant activity of clitoris ternatea in animals
 

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.
  • 11.
  • 12. It is a manipulative procedure designed to change the lie or to bring the comparatively favorable pole to the lower pole of the uterus.
  • 13. TYPES According to the methods employed:  Spontaneous   External   Internal  Bipolar
  • 14.  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
  • 15. 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.
  • 16.
  • 18. 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
  • 19. 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
  • 20. 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.
  • 21. 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
  • 22. 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.
  • 23. 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
  • 24. “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.
  • 25. 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.
  • 26. 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.
  • 27.
  • 28.
  • 29. 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.
  • 30. 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
  • 31. 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.
  • 32. 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.
  • 33. INTERNAL VERSION Internal version is always a podalic version and is almost always completed with the extraction of the fetus.
  • 34. 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: (1)Transverse lie with cervix fully dilated (2)Cord prolapse with cervix fully dilated with transverse lie or head high up and the baby is alive.
  • 35. Conditions to be fulfilled The cervix must be fully dilated Liquor amnii must be adequate for intrauterine fetal manipulation Fetus must be living.
  • 36. Contraindication ◦It must not be attempted in neglected obstructed labor even if the baby is living.
  • 37.
  • 38. 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.
  • 39. 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.
  • 40. 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.
  • 41. 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.
  • 42. 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%.
  • 43.
  • 45. 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.
  • 46. 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.
  • 47. 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; I2=94%). The pooled complication rate was 6.1% (95% CI: 4.7 to 7.8; I2=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.
  • 48. 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; I2=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 (I2=70%) and foetal tachycardia (I2=53%)