PATIENT’S DATA:

Madam Norasikin Bt. Selamon, a 37 year old Malay lady, gravida 7 para 5+1,
currently at 40 weeks and 4 days of gestation. She couldn’t remember her last menstrual
period (LMP), the cycle is regular at 28-30 days and she is on contraception in the form
of injection for 3 years. Given revised date of delivery (REDD) was at 10 December
2009, based on scan at 18 weeks of gestation.
Date of Admission: 11 December 2009
Date of Clerking: 14 December 2009
Source of information: Patient

PRESENTING COMPLAINT:
She was referred from KK Ampang for unstable lie with one previous scar.

HISTORY OF PRESENTING COMPLAINT:

She suspected the pregnancy when she missed her menses for 3 months and went
to KK Ampang to confirm it and ultrasound was done. She had her booking there. At
booking, her blood pressure was 120/80, normal throughout pregnancy and her
haemoglobin level was 11.4 g/dL. She takes Obimin daily since 18 weeks of gestation. At
32 weeks of gestation, MGTT was done at KK Ampang suspected gestational diabetes
mellitus (GDM) due to excessive weight gain however the result was normal. On 37
weeks of gestation, she was referred from KK Ampang to Hospital Ampang due to
transverse lie for further management. However ultrasound was done and found that the
fetus in cephalic presentation. She was discharged after 2 days in the ward. At term she
still not in labour, no ‘show’ no leaking liquor no contraction. Once again she was
referred to Hospital Ampang for further management due to oblique lie. Fetal movement
is good.

SYSTEMIC REVIEW:
Cardiovascular system: There is no chest pain, palpitation, orthopnea and paroxysmal
nocturnal dyspnoea.

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Respiratory system: She had no cough, shortness of breath. No heamoptysis.
Gastrointestinal system: There is no alteration bowel habit, no vomiting, diarrhea and
hematemesis.
Genitourinary system: There was no dysuria and hematuria, no polydypsia, urgency,
swollen ankle or urinary incontinence.
Central Nervous System: There was no headache, blurred vision

PAST OBSTETRIC HISTORY:

She has 5 children with 4 boys and one girl and all of them are alive and well. All
of them were delivered vaginally (SVD) except for the last child she had emergency
lower segment cesarean section (EL LSCS) after failed induction of labour (IOL) three
times for pregnancy induced hypertension (PIH). She was diagnosed having PIH at the
end of pregnancy and only on antihypertensive drugs for 3 days until delivery. The birth
weight of her children range up from 3.59 kg to 3.1 kg. There is no history of premature
labour. She had complete miscarriage at 6-8 weeks of gestation in 2005, uncomplicated.
1) 1996 - FTSVD uneventful - 3.1kg
2)1997 - FTSVD uneventful -3.56kg
3) 1998 - FTSVD uneventful 3.1kg
4) 2001 - FTSVD uneventful 3.57kg - no shoulder dystocia
5) 2005 - Complete miscarriage at 6-8wks - uncomplicated
6) 2006 - LSCS 3.4kg- uncomplicated, but patient not told whether suitable for
Trial of Scar (TOS)

PAST GYNAECOLOGY HISTORY:

This is her first marriage. She had her menarche at 12 years old, regular cycle of
28-30 days and good flow lasting for 7 days. There is no menorrhagia, dyspareunia and
intermenstrual bleeding. No Pap smear and vaccination was done.

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PAST MEDICAL/SURGICAL HISTORY:
She had no history of diabetes mellitus, hypertension, heart diseases, asthma or
bleeding tendencies however she had history of cesarean section in 2006. There is no
known drug or anaesthetic allergies.

MEDICATION/DRUG HISTORY:

As far as she knows, she is not on any medication. She did not take any traditional
medication during her pregnancy. She only took the medication given by the doctor
stated earlier and she is not allergic to any drug.

FAMILY HISTORY:
There is family history of multiple pregnancies but no family history of other
medical illnesses such as diabetes mellitus, hypertension, heart diseases, and asthma,
bleeding tendencies, breech and congenital abnormalities.

SOCIAL HISTORY:
She works as technician at MPAJ while her husband works as bodyguard. Her
family income is RM 4,000 monthly indicates that she from middle socioeconomic class.
She does not smoke or consume alcohol however she is a passive smoker.

PHYSICAL EXAMINATION:
General Examination
On inspection, the patient is alert, conscious with GCS 15/15 not in pain and not
in respiratory distress at that time lying on her bed. There is branula on her right hand
connected to Hartman solution. She is fairly hydrated and has obese body built. Her vital
signs were:
Blood Pressure – 130/80 mmHg
Pulse Rate - 80 beats/ minute, good volume and regular rhythm,
Temperature - 37 ˚C
There were no facies abnormalities, muscle wasting, scars or any other abnormalities.
There were also no signs of jaundice, pallor or cyanosis.

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Hand: Warm, no excessive sweating, capillary filling time was less than 2 seconds, no
finger clubbing, no Dupuytren contracture, no palmar erythema,
Eye: There are no signs of pallor on the conjunctiva and jaundice on the sclera.
Mouth: No central cyanosis, no gum bleeding and hydration was fair.
Neck: No anterior neck swelling was palpable, JVP not elevated
Lower limb: No ankle edema, calf tenderness and visible dilated vein.
Lymph nodes: No palpable lymph nodes detected.

Specific physical examination

[Abdomen]
Inspection: Abdomen is distended by gravis uterus as evidence by linea nigra and striae
gravidarum. There is suprapubic tranverse incision scar. The umbilicus is centrally
located and flat. Otherwise the abdomen is normal.
Palpation: On light palpation, the abdomen is soft, non tender. No scar tenderness. No
uterine contraction felt. On deep palpation, the fundal height correspondence to 40 weeks
of gestation. It measures 36 cm. There is single fetus in oblique lie with the fetal head at
left iliac fossa. Head is not engage and can still ballote the head. The amount of liquor is
adequate for this period. Expected birth weight is 2.8-3.0 kg.
Auscultation: Fetal heart sound was heard, fetal heart rate is 140 beats per minute,
regular rhythm.
Vaginal examination should be done to complete this examination.

[Breast]
Both breast are symmetrical bilaterally, no visible or palpable mass and dilated veins, no
nipple discharge.

Systemic examination
[Cardiovascular system]
The first and second heart sounds were present and normal. There were no murmur and
added heart sound.

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[Respiratory system]
Air entry equal bilaterally with vesicular breath sound. Vocal resonance was equal on
both sides.

CASE SUMMARY:
Madam N, a 37 year old Malay lady gravida 7 para 5+1 currently at 40 weeks and
4 days of gestation referred to Hospital Ampang due to unstable lie for further
management with one previous scar. On examination, there is no scar tenderness, fetal in
oblique lie with the fetal head at left iliac fossa. She had admitted to the ward for the last
4 days, her blood pressure is stable no uterine contraction felt and she was planned to
have elective lower segment cesarean section (EL LSCS).

PROVISIONAL DIAGNOSIS:
Unstable lie
Reason for: grandmultiparous, changes fetal lie after 36 weeks of gestation

DIFFERENTIAL DIAGNOSIS:
1. Macrosomic baby
Reasons for: maternal obesity, previous big babies
Reasons against: MGTT result normal
2. Polyhydramnios
Reasons for: identification of fetal part is difficult
Reasons against: fundal height correspondence to period of gestation

LABORATORY INVESTIGATIONS:
Date/Time Event Value: 11/12/2009
Full Blood Count (FBC)
Haemoglobin – 11.4 g/dL ABNORMAL (12.0- 18.0)
Haematocrit – 36.4% ABNORMAL (37.0- 51.0)
Platelet – 249 K/uL (140-440)

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Date/Time Event Value: 13/12/2009
ABO Group
Blood group – O
Rhesus group – D positive
Antibody Screen
Antibody screening result – Antibodies not detected

MANAGEMENTS:

Intrapartum management
Vaginal and pelvic assessment
 Establish presentation
 Exclude cord presentation
 Assess cervical dilatation
If the lie is longitudinal
 Normal labour management
If the lie is not longitudinal
 Consider external version to correct lie
 Stabilise lie by controlled ARM followed by oxytocin (in theatre if necessary)
If the lie is not longitudinal and cannot be corrected
 Caesarean section if persist until 41 weeks of gestation

Postpartum management

1. Allow discharge
2. Discharge with hematinics and analgesic
3. TCA 6 weeks at local clinic for post natal review/pap smear and contraceptive advice
4. TCA stat if experience excessive per vaginal bleeding/fever or abdominal pain
5. Advice patient for LSCS and bitubal ligation (BTL) for next pregnancy

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 DISCUSSION:

1. Unstable lie is a condition in which the lie of fetus changes from time to time within 24
hours after 36th week of pregnancy.
2. Lie of fetus is defined as the relationship between the longitudinal axis of the fetus to
the longitudinal axis of the maternal uterus.
3. In this case, the reason why the lie remains unstable is because of conditions that allow
for more than normal space in the uterine cavity for the fetus to move about. These
include a lax abdominal wall and uterus since that this patient is grandmultiparous.
4. She also had risk of gestational diabetes mellitus (GDM) due to excessive weight gain
and previous history of big babies with the birth weight range up from 3.1 kg to 3.59
kg. MGTT was done and the result is normal.
5. All patients with unstable lie after 36 weeks should be admitted. This is because the
mother might go into spontaneous labour at any time. If the lie of the fetus happens to
be oblique or transverse at that moment in time, umbilical cord prolapsed might occur.
6. Furthermore, if she delays her admission, obstructed labour may already have occurred.
7. Definition:
Lie - the relationship of the long axis of the fetus to that of the mother.
Oblique lie - a situation in which the long axis of the fetal body crosses that of the
maternal body at an angle close to 45 degrees. [1]
8. Oblique lie is associated with multiparity, abdominal laxity, uterine and fetal anomalies,
shortening of the longitudinal axis of uterus by fundal or low-lying placenta and
conditions that prevent the engagement of the presenting part such as pelvic tumours and
a small pelvic inlet. [2]
9. For optimum foetal survival internal version and extraction is best reserved for the
following circumstances:
(a) Cases with a good obstetric history.
(b) A moderate sized foetus.
(c) Where the foetus is alive, the cervix should be sufficiently dilated for delivery
to be effected almost immediately after the internal version. [3]

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10. The cause of foetal instability must be sought before the onset of labour and appropriate
treatment instituted, and it is likely that in the presence of a living foetus of moderate
size the best interests of both mother and baby will be served by caesarean section.
Caesarean section will probably be the chosen method of delivery under the following
circumstances of unstable lie:
(1) Primigravidae.
(2) Multigravidae with dystocia.
(3) Placenta praevia.
(4) Prolapse of cord.
(5) Cervix not dilated.
(6) Uterine malformation.
(7) Premature rupture of membranes. [3]

REFERENCES:

[1] Dorland’s Medical Dictionary. Copyright 2007. An Elsevier publication.

[2] Justus Hofmeyr, G.J. Breech presentation and abnormal lie in late pregnancy. A

Guide to Effective Care in pregnancy and childbirth (Chapter 22) 185, 192-193.

[3] G. BANCROFT-LIVINGSTON, H. GORDON (1967) Unstable lie in pregnancy and

in labour. Postgrad. med. J. (February 1967) 43, 92-96.

[4] WOOD, E.C. & FOSTER, F.M.C. (1959) Oblique and transverse foetal lie. J. Obstet.

Gynaec.Brit.Cwlth 66, 75.