- Unstable lie refers to a frequently changing fetal position in late pregnancy, usually after 37 weeks. It can be diagnosed through abdominal palpation. - The risk factors include fetal macrosomia, anomalies, and maternal factors like high parity, uterine abnormalities, and pelvic issues. - Management includes observation with the expectation of spontaneous version in many cases. Physical techniques and ultrasound can also be used. - Options are expectant monitoring, attempting external cephalic version in a medical facility, or elective c-section depending on the situation and ability to safely attempt vaginal delivery. Close monitoring is important with an unstable lie.

1. Unstable Lie
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2. Introduction
• Definition
– Unstable lie refers to the frequent changing of fetal lie and presentation in late
pregnancy usually after 37 weeks
– Diagnosis can be made by abdominal palpation using Leopold's maneuver by
appreciation of varying fetal lie
• The sensitivity of Leopold's maneuver for detection of a non-cephalic fetal
presentation (oblique, breech or transverse lie)at 35- 37 GA is about 70%
• Although the accuracy of detecting transverse lie by abdominal palpation is
likely to be greater than for breech presentation, the sensitivity for detecting
transverse lie and oblique lie by abdominal palpation is not known because the
incidence of this abnormal presentation is too low to conduct a robust study
• Incidence
– At delivery the incidence is about 1 in every 300 (0.33%)
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3. Risk factors
• Fetal
– Fetal macrosomia
– Fetal anomaly (tumors of the neck or sacrum, hydrocephaly, abdominal distension)
– Undiagnosed twins
• Maternal
– High parity
– Pendulous abdomen
– Placenta previa
– Polyhydramnios
– Pelvic inlet contracture
– Uterine abnormalities (e.g. bicornuate uterus or uterine fibroids)
– Distended maternal urinary bladder
– Poorly formed lower segment
– Wrong dates (i.e. more premature than appears)
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4. Management of unstable lie
• Management of unstable lie start with prenatal clinical
assessment involving
– reliability of the gestational age
– risk factor assessment
– Pelvic assessment
– ultrasound evaluation for fetal malformation, pelvic tumor,
placental and uterine anomaly

5. Options of management
1) Expectant with observation
• spontaneous version can occur in about 80% of case
• physical exercise like knee-elbow position for 10 minutes on occasion which
lead to conversion to longitudinal lie in 5-10%
• exclude possible cause of obstructed labor like tumor previa , contracted pelvis
• need for prompt admission in event of labor or rupture of membrane
• with daily evaluation of lie and presentation, if cephalic or breech is
maintained for > 48 hours discharge home with strict advice on danger sign
• evidence from the available literature recommends delaying admission until at
least 38 weeks and awaiting for spontaneous version

6. 2) Hospitalization with active management
• ECV trial – try in facility with emergency cesarean delivery if in case need arise
– if longitudinal lie is maintained , discharge with advice on danger sign
– If ECV fails or reverts, second attempt can be done at 38/39 weeks of GA
• Stabilizing Induction – at 39 weeks of GA
– In labor ward, ECV performed, conversion to longitudinal lie maintained and titrated oxytocin infusion
commenced to stimulate uterine contraction and amniotomy performed while an assistance stabilizes
the head and then labor monitored closely
– after rupturing membrane examine for cord presentation or prolapse ,fetal presentation
3) Elective CS: in the presence of
• contraindication for ECV trial
• failure of external cephalic version
• mechanical obstruction to vaginal delivery or other contraindication for vaginal delivery
• lack of expertise in external cephalic version
• other obstetrics indication for C/S
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