EBM POMR

Diagnosis:
GIIIP2002 UK 37-38 minggu/Tunggal/ Hidup/ Intrauterin/
letak lintang/ usia> 35 tahun/lilitantalipusat/TBJ
4000gram/ UPD N
Definition: The fetus is in a transverse lie when its longitudinal
axis is perpendicular to the long axis of the uterus. A
transverse lie can occur in either of two configurations:
o The curvature of the fetal spine is oriented upward (also
called "back-up" or dorsosuperior), in which case the
fetal small parts present at the cervix.
o The curvature of the fetal spine is oriented downward
(also called "back-down" or dorsoinferior), such that the
fetal shoulder presents at the cervix
The diagnosis can be made by abdominal palpation utilizing
Leopold's maneuvers. Transverse lie should be suspected if
firm resistance of the fetal head is not detected above the
symphysis pubis and can be diagnosed when further palpation
confirms the position of fetal head in one or the other of the
mother's flanks. Ultrasound examination is used to confirm
the diagnosis and determine the precise position of the fetus.
In addition, a survey of maternal pelvic and fetal anatomy
should be performed to look for abnormalities or conditions
associated with transverse lie.
(Management of the fetus in transverse lie, 2011)
Many of the risk factors associated with pregnancy are more
harmful when the expectant mother is over 35. According to
an extensive, register-based study carried out at the
University of Eastern Finland, the risks associated with
overweight, smoking, gestational diabetes and pre-eclampsia
are higher in advanced maternal age than in younger
 expectant mothers(New evidence on risks of advanced
maternal age, 2015)
A nuchal cord (or Cord-Around-the Neck (CAN)) occurs when
the umbilical cord becomes wrapped around the fetal neck
360 degrees.(Cord around the neck syndrome, 2012)

Planning:
I. Diagnosis : NST
A NST may be performed if:
The baby is not moving as frequently as usual
Overdue
There is any reason to suspect the placenta is not
functioning adequately
You are high risk for any other reason
The test can indicate if the baby is not receiving
enough oxygen because of placental or umbilical cord
problems; it can also indicate other types of fetal
distress (http://americanpregnancy.org/prenatal-
testing/non-stress-test/)

II. Terapi : pro SC

(Evidence level IV)
One 2013 conference poster reporting the management of
57 women admitted with unstable lie in pregnancy
(Szaboova) was identified. 54% were admitted before 38
weeks. The lie permanently stabilised to cephalic without
intervention in 28%. The most common mode of delivery
was caesarean section (75%) at a median gestation of 39+1
weeks (IQR 39 to 39+6). Half of the cases of elective
caesarean section had a cephalic presentation at delivery
and none of these had an absolute indication for operative
delivery. The authors conclude: "If there are no other
contraindications to vaginal delivery, it is prudent to wait
 until 41-42 weeks to allow spontaneous version and
possible vaginal delivery."(Royal College of Obstetricians
and Gynaecologists 2016)
If pregnancy has reached the stage of fetal (newborn)
viability, there are two options:
o Cesarean delivery
o Version of the fetus to a longitudinal lie(Management
of the fetus in transverse lie, 2011)
It is important to note that although there may
be little research evidence to back up some
contraindications, some care providers may use their
expert opinion to recommend against a version in
certain circumstances. A care provider may
anticipate a difficult version, a low likelihood of
success, or perhaps that the benefits do not outweigh
the risks. For example, a care provider may not want
to perform a version on someone with very low
amniotic fluid because that increases the difficulty of
the procedure. Other care providers might not want
to perform a version if the baby has the umbilical
cord wrapped around the neck. Although there is no
solid research on these topics, the care providers
clinical opinion may be that the procedure may be
too difficult, or that the risks of the procedure
outweigh the benefits.(Evidence level IV)
If the lie is not longitudinal and cannot be corrected
> Caesarean section (Clinical Guideline: South Australian
Perinatal Practice Guidelines unstable lie of the fetus,
2014)