From the Research
For a patient with an unstable lie at 39 weeks, I recommend a planned cesarean delivery. This approach prioritizes the safety of both the mother and the baby, minimizing the risk of complications such as cord prolapse or malpresentation that can arise from an unstable fetal position during labor [ 1 ]. The timing of the cesarean should be scheduled promptly, ideally within the next few days, to avoid the increased risks associated with spontaneous labor [ 2 ].
Key Considerations
- Prior to the cesarean, the patient should undergo continuous fetal monitoring if there are concerns about fetal well-being or if there's a risk of cord prolapse, particularly if membranes rupture [ 3 ].
- The patient should be thoroughly counseled about the risks and benefits of cesarean delivery versus attempting vaginal birth, including potential complications of each approach [ 1 ].
- If the patient strongly desires a trial of labor, this would require close monitoring in a facility equipped for emergency cesarean delivery, though this approach carries higher risks [ 2 ].
- External cephalic version is not typically recommended at this stage with unstable lie as success rates are low and risks are increased [ 2 ].
Underlying Factors
The unstable lie likely results from factors such as abnormal uterine shape, placental position, polyhydramnios, or fetal anomalies, which should be evaluated to inform management [ 2 ]. Understanding these underlying factors can help in making an informed decision about the mode of delivery and in preparing for any potential complications.
Management Approach
Given the potential for serious complications, a proactive approach is warranted. The most recent and highest quality study [ 1 ] emphasizes the importance of urgent delivery, typically via cesarean, in cases where there's a risk of umbilical cord prolapse, highlighting the need for prompt action to ensure the best outcomes for both mother and baby.