INTRODUCTION:

The normal process of parturition relies in part, on the physical relationships between the fetus and maternal bony outlet. Fetal lie refers to the relationship between the long axis of the fetus with respect to the long axis of the mother. The possibilities include a longitudinal lie, a transverse lie, and, on occasion, an oblique lie.¹

In an oblique lie, the fetal long axis is at an angle to the bony inlet, and no palpable fetal part generally is presenting. This lie usually is transitory and occurs during fetal conversion between other lies. In the meantime, an oblique lie is actually better news than a transverse lie.²

It is perhaps surprising that late in pregnancy and in labour only the occasional foetus presents other than as a longitudinal lie. In mid-pregnancy, transverse and oblique lies occur relatively frequently, but the majority correct themselves spontaneously before term. Fetal lie other than longitudinal at term may predispose to prolapse of cord or fetal arm and uterine rupture. Local guidelines recommend admission at 37+0 (RCOG guidelines after 37+6 weeks) but give no specific recommendations regarding further management.³

The incidence of oblique lie a fetus may assume at term pregnancy is about 1 in 100 which is also referred to as nonaxial. Grand multiparae, previous caesarean section, previous transverse lie, placenta praevia, pelvic tumors most commonly cervical fibroids may displace the fetal head from the pelvic cavity, disproportion, multifetal gestation and prematurity are some of the common aetiological factor which contribute for abnormal lie at term pregnancy.⁴ Abnormal lie and late spontaneous podalic version account for a very small percentage (less than 1%,).⁵

Several methods can be used to identify fetal position in utero. These include radiography, ultrasonography, internal vaginal examination and abdominal palpation. Although being highly accurate and popular in the 1950s, the use of radiography is now rarely used in pregnancy due to the known harmful effects to the fetus of prolonged exposure to radiation. Ultrasonography provides the same level of accuracy as radiography but without the effects of radiation. However, it is costly, requires expensive equipment and is therefore not available in all clinical settings especially in developing country like India. Internal vaginal examination can be used to identify fetal position and presentation. However this method relies on the dilatation of the cervix and descent of the presenting part so is only reliable when the woman is in established labour. Abdominal palpation is non-invasive, involves no expensive equipment so can be undertaken in any setting, does not subject the woman or fetus to any ultrasound or radiation, and can be done at any point in the latter months of pregnancy or intrapartum. It therefore remains the popular and ubiquitous test for identifying fetal position and presentation in the gravid woman.⁶

Abdominal palpation is accurate in identifying position and presentation, especially if carried out by an experienced health professional. In Australia, it is recommended that all health professionals providing antenatal care be experienced in palpation of the pregnant abdomen including identification of the position and presenting part. While the positive effects of abdominal palpation are difficult to quantify, no risks have been identified and it provides a point of engagement with the mother and fetus.⁷

Where there is any doubt as to the position and presenting part, obstetric ultrasound should be used to confirm the palpation findings. Overdependence and abuse of ultrasound remains a problem and it should be emphasized that ultrasound is to complement and not a substitute to clinical judgment. The effects of ultrasound on the low-risk pregnancy need to be evaluated. Midwives need to be research-based in their clinical practice and question the overuse of technology, such as the ultrasonography, in cases where it is not warranted.⁸However; there has been scant research into the accuracy of abdominal palpation to identify fetal lie.⁹

Competency of abdominal palpation is an essential part of modern midwifery practice. Despite this, My Mak and Wong found that although midwives had positive attitudes and moderate employment of abdominal palpation, but they felt that their knowledge and confidence of the practice was inadequate.¹⁰

In 2008 Antenatal Care guideline, the National Institute for Health and Clinical Excellence (NICE) recommend that fetal position and presentation should be assessed by abdominal palpation at 36 weeks or later, when presentation is likely to influence the plans for the birth. Routine assessment of presentation by abdominal palpation should not be offered before 36 weeks because it is not always accurate and may be uncomfortable.¹¹

Much information can be gained by measurement and palpation of the pregnant abdomen, including fetal position, growth and presentation. As these examinations require no equipment other than a measuring tape, they are very helpful in any setting. However, they also require much experience in order to develop the skill necessary to provide reliable information. ⁶

This case report looks at how the art of midwifery is used as a cost effective method in screening the antenatal women at labour along with the use of sophisticated technology. The use of the ultrasonography is an example of how overuse of such technology can have detrimental effects, not only for the midwife but also for the woman in labour. While this technology has made a great impact in midwifery nursing.

CASE REPORT:

A 39 year old pregnant woman with 9 months of amenorrhea presented to the outpatient department of Obstetrics and Gynaecology unit on 20^th November, 2015. She was G₂P₁with one living issue. In her previous pregnancy she delivered a normal healthy male child by an uncomplicated vaginal delivery 12 years back. Her recent pregnancy was spontaneous conception and confirmed through urine test at home (using preg- kit). Her last menstrual period was on 12.02.15.

Through the past history collected it came to knowledge that the patient was a booked case in local district hospital and wanted to see in that hospital in view of long travel distances to attend tertiary hospital at Gangtok. Her current pregnancy was spontaneous conception and there was no family history of multiple pregnancy or child with congenital abnormality. She had two ante-natal checkups in first trimester and was regularly taking folic acid tablets.

In second trimester she took two doses of tetanus toxoid injection and had undergone her first ultrasonography done at 24 weeks of gestation. The ultrasonography showed single live gestation in-utero in transverse lie with normal parameters corresponding to 22 weeks 6 days. Appropriate counseling was done and she was advised for regular follow up in same hospital .The patient didn’t smoke and there was no history that suggested congenital infection or exposure to toxins or self-medication. She was having the history of nausea and vomiting during pregnancy.

In her 3^rd trimester at 36 weeks on 4/11/15 she came to the hospital for routine checkup and ultrasonography of her abdomen was done for fetal wellbeing which showed single live gestation in-utero with Oblique breech with normal parameters corresponding to 35 weeks 6 days with oligohydramnios. Appropriate counseling was done and was advised to come after one week.

Eight days later the patient had decreased fetal movement and she went to the local primary health center and where midwives performed an abdominal palpation and noted oblique lie of the fetus. She was counseled and advised to attend tertiary hospital; however she ignored the advice of the doctor. She was advised to attend the same hospital at 38 completed weeks of gestation with labor pain.

The patient again came for a follow up in same hospital on 18/11/15 with mild labour pain at 39 weeks of gestation and was admitted in antenatal ward .On 18/11/15 during inspection the abdomen was term size and fetal movement was present. Per vaginal examination showed os 1cm dilated with 40 % cervical effacement and bag of membrane was present and she was prescribed with tablet misoprostol. On 19/11/15, her vaginal examination didn’t show any further progress of the labour hence she was referred to attend tertiary hospital.

General examination was unremarkable at the time of admission to tertiary hospital. Her routine laboratory examinations were within normal limits. Patient height was 152 cm and weight 56 kg, vitals were normal, no signs of pallor. Obstetrical examination revealed height of her fundus at 32cm, abdominal girth 85 cm and fetal heart rate was 136 beats/ min regular and clear. Abdominal palpation was performed to see the maternal and fetal wellbeing.

Clinical examination of patient revealed uterus was broader than long suggestive of either transverse or oblique lie. No signs of infection, any scar and herniation were found. Linea niagra was prominent, straie gravidarum was present, fetal movement was visible. Further it revealed with fundal grip palpation that smooth hard globular mass was palpated at the upper left lateral aspect of the abdomen and in lateral grip at left lateral side smooth curved like curvature was identified which further revealed that the long axis of the fetal body crosses that of the maternal body at an angle close to 45 degree. Nothing was prominent and on right lateral grip nothing was identified. In pelvic grip there was no presenting part for engagement which was suggestive of oblique or transverse lie.

Pelvic examination revealed cervix 3cm dilated and 50% effaced with intact membrane. Presenting part was at -3 station. Although the presenting part was higher up hence there was no further improvement in cervical dilatation. Since the Oblique lie is usually transitory therefore it was decided to augment her labour with injection Epidosin and injection Oxytocin and her final diagnosis was confirmed with ultrasonography which showed single live fetus in-utero with Oblique breech with oligohydramnios. After one hour of interventions her labour progress was assessed which was found to non progressive with fetal distress and meconium stained liquor.

The obstetrician chose to perform a caesarean section to avoid any obstetric complication. The paediatric team was informed about the situation and the parents were given advice and counseled with regard to the poor prognosis of the labour. An emergency cesarean section was performed in view of persistent oblique lie with meconium stained liquor with non progress of labour on 21^st November, 2015. At cesarean section the baby delivered was a healthy male 3.4 kg with Apgar score of 6/10 and 9/10 at one and 5 minutes respectively.

The baby cried at birth and meconium stained liquor was present for which gastric lavage was done. The physical examination of the baby did not reveal any congenital anomalies. The new-born was immediately transferred to the sick newborn care unit.

Postoperatively both the mother and the baby had uneventful recovery and were discharged on 4^th day in a healthy state. The patient was advised for postnatal checkup at 6 weeks. The baby was thoroughly examined by pediatrician and has been perfectly normal. Immunization was done as per national immunization schedule.

DISCUSSION

Non progress of labour with its dangerous sequelae is gradually disappearing as a result of improvement in antenatal and intrapartum care. Unfortunately the problem continues unabated in rural areas of developing countries. It is a major cause of perinatal and maternal mortality, besides being responsible for considerable morbidity including uterine rupture and obstetric fistulae. Poverty, ignorance, inefficient health care delivery and communication systems with poor knowledge, skills, scarcity of peripheral health staff, lacunae in care at referral including nonexistent facilities for antenatal admission, all contribute.¹²

Even the most effective currently available antenatal care cannot predict accurately which woman will remain normal and which will develop complications. But by appropriate prenatal care, risk screening and early referral, it is possible to predict some and also minimize the sequelae of complications. Increased awareness and training of appropriate community health staff should prevent non progress of labour and its complications. The commonest cause of non progress of labour in our paper was oblique lie, which was diagnosed in local health care center and was referred to tertiary care center at an appropriate time.¹³

The main risk of an oblique lie is in association with preterm rupture of the membranes and cord prolapse. When diagnosed the state of the cervix should be checked. If the cervix is dilated, the patient should be admitted to hospital. If, however, the cervix is closed and the membranes are intact the patient may be reviewed on a regular basis. If the abnormal lie persists or constantly reoccurs, the woman should be admitted to hospital by the 38th week and if the patient's cervix is favorable then artificial rupture of the membrane can be performed. However in our case the mother was diagnosed in oblique lie antenatally in her late last trimester and was admitted after her labour pain started at 38^th week of gestation with intact bag of membrane to avoid prolonged hospital stay and financial burden.¹⁴

The risks associated with oligohydramnios often depend on the gestation of the pregnancy. Oligohydramnios or reduced volume of amniotic fluid poses challenge to obstetrician, when it is diagnosed before term. Oligohydramnios can develop in any trimester, although it is more common in third trimester. It can occur at any time during pregnancy, but it is most common during the last trimester. In our case she was detected with oligohydramnios at third trimester.¹⁵

One of the common causes for low amniotic fluid is leaking or rupture of membranes due to a tear in the membrane where there is gush of fluid or a slow constant trickle of fluid. Premature rupture of membranes (PROM) can also result in low amniotic fluid levels. In our case she was detected with low amniotic fluid due to rupture membrane after 38^th week of gestation. ¹⁶

Decrease in amniotic fluid volume or Oligohydramnios has been correlated with increased risk of intrauterine growth retardation, meconium aspiration syndrome, severe birth asphyxia, low APGAR scores and congenital abnormities. Oligohydramnios is also associated with maternal morbidity in form of increased rates of induction and/ or operative interference. Due to intrapartum complication and high rate of perinatal morbidity and mortality, rates of caesarean section are rising. In our case her labour was augmented with prostaglandin and oxytocin but it was non progressive due to abnormal lie hence to prevent the further obstetric complications, caesarean section was performed on her.¹⁷

Because abdominal palpation is already a standard part of antenatal care, presentation is easily and inexpensively assessed in the community.¹⁸ Most of us examining the pregnant abdomen sometimes have the impression that we can determine presentation with great certainty, sometimes not. However, we still do not know whether this ‘‘certain feeling’’ is illusory. Until we know whether confidence is linked to a higher sensitivity and specificity, it seems wise to follow the authors’ advice and arrange ultrasound scanning for all consenting women at 36 weeks late in labour.¹⁹ From this we concluded that the maneuvers used by experienced midwives and clinician can be effective as a screening tool for fetal lie and presentation, particularly in settings where ultrasound may not be readily available.

CONCLUSION:

There has been an increasing emphasis on the use of technology for the assessment and evaluation of women during the antepartum and intrapartum periods. As a result, "hands-on" skills, such as abdominal palpation receive less emphasis in educational programs and practice. Are nurse-midwifery educational programs turning the focus of their curriculum too frequently toward high-risk pregnancy and away from the normal pregnancy? There is a need to balance nurse-midwifery education, to consider the needs of all pregnant women while incorporating advances in technology appropriately. It is time to reflect on our competence in this area of practice and decide whether we have "art" in the heart of our midwifery practice.

ACKNOWLEDGMENTS:

We thank Dr Ritu Nath Deokota, Head of the Department, Department of Obstetrics and Gynaecology, STNM Hospital, Sikkim for his support to conduct the case study and publish this case report.

CONFLICT OF INTEREST:

The authors have no conflict of interest.

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Received on 01.01.2016 Modified on 27.01.2016

Asian J. Nur. Edu. and Research. 2016; 6(2): 255-259.

DOI: 10.5958/2349-2996.2016.00049.5