O&G: Unstable lie for external cephalic version (ECV)

This is a case of a 30+ years old lady, G5P4 at 39+0 week period of gestation, electively admitted to ward for external cephalic version due to unstable lie.

The fun thing is we just had the CME for unstable lie last week, so some knowledge is still fresh in head, and it is excited to see some real cases after you have your theory discussion. So for unstable lie, patient need to be admitted for lie chart, and if it is a breech, an ECV would be performed. If ECV fails, then options like vaginal breech delivery or LSCS would be considered.

Unstable lie is only diagnosed when the patient is term. And this patient obviously has the most common risk factor which is high number of parity as this patient is a grandmultipara. However other risk factors need to be screened as well including placenta praevia, polyhydramnious, fetal anomalies or even pelvic tumours. And since this patient is admitted for ECV, there are other contraindications for ECV to be screened as well. 

The lie chart is plotted 4 times per day. When I first palpated the patient during my night shift, the baby was in breech presentation, where the head was slightly to the left hypochondriac region. I could really feel that the uterus is quite lax because of grandmultipara. But when my MOs palpated the abdomen the next morning, the baby already turned to oblique lie where the head was at the right hypochondriac region and the fetal back is superior.

Then we had to perform a CTG before the ECV to make sure the wellbeing of baby. After that tocolysis is given to make sure that the uterus not contracting while the procedure is ongoing. Tocolysis given here is IV salbutamol. I think some other centers give nifedipine. My MO mentioned in CME that when patient starts feeling tachycardic as the side effects, it means the medication is in effect then you can carry out the procedure.

I did not perform the ECV but I saw my MO doing. When I was in medical school, I thought it would be quite easy to just turn the baby around. But when I see it in real life, I think it requires a lot of strength. You need to put some gel or powder on the mother's abdomen then put some strength to really turn the baby. If I was asked to perform, I surely cannot perform because I was in post night shift and was already a little bit drowsy by that time haha.

Even though my MOs looked like she had given all her energy to turn the baby into cephalic, but she said it was quite easy as the uterus is kind of lax. Not sure I have to agree that it was an easy one or not because she looked really exhausted. Anyhow the procedure was a success in just a single attempt. But the problem came next, since I mentioned that the uterus is kind of lax, which means that the chances of baby turning back to abnormal lie is high, so they immediately VE the patient to see if the os is open or not.

Because if the cervical os has opened to a desirable length, then we can just ARM the patient and make the baby head engage, so the baby wont turn and float around like in outer space anymore. We would not want to end up cutting the patient even after ECV done because of recurrent unstable lie.

It turned out that the cervical os is 3cm and bishop score is somehow favourable, so we immediately transferred the patient to labour room for stabilising ARM. Stabilising ARM is like one person holding the baby in position then the other person performing the ARM. This is to ensure the head engage and not other part that comes out after you ARM.

But I did not follow the case to Labour room because I am heading back home to sleep. But I think everything went as planned and uneventfully because no LSCS case was posted that afternoon. 

That's all for this case. Thanks for reading.