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

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.

17. INDICATION
Breech presentation
Transverse lie/
oblique lie

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.

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.

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%.

44. BIPOLAR VERSION

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%)