Lecture on transverse lie (malpresentation)

1. TRANSVERSE LIE
DR. CHANDRIMA KARKI
LECTURER
OBS/GYN
KMCTH

2. OBJECTIVES
Objectives
• Definition
• Different Positions
• Incidence
• Etiology
• Diagnosis
• Complications
• Management

3. What is LIE???

4. DEFINITION
• When the long axis of the fetus lies perpendicular to the maternal
spine or centralized uterine axis, it is called transverse lie.

6. POSITION
Dorso-
anterior
commonest
(60%).
The flexor surface of the
fetus is better adapted to
the convexity of the
maternal spine.
Dorso-
posterior
Extensor surface of the
fetus is better adapted to
the convexity of maternal
spine
Dorso-
superior
The curvature of the
fetal spine is oriented
upward (also called
"back up")
the fetal small parts
and umbilical cord
present at the cervix.
Dorso-
inferior:
The curvature of the fetal
spine is oriented downward
(also called "back down")
the fetal shoulder presents
at the cervix

7. DORSO-ANTERIOR DORSO-POSTERIOR

8. INCIDENCE
• The incidence is about 1 in 300 births.
• It is common in premature and macerated fetuses, 5 times
more common in multiparous than primigravidae.

9. ETIOLOGY
• Multiparity
• Prematurity: commonest cause
• Twins
• Hydramnios
• Contracted pelvis
• Placenta previa
• Pelvic tumors
• Congenital malformation of the uterus – arcuate or subseptate
• Intrauterine death

10. DIAGNOSIS
ABDOMINAL EXAMINATION
• Inspection:
• the uterus looks broader and
often asymmetrical, not
maintaining the pyriform shape
• Palpation:
• The fundal height is less than
the period of gestation
• Fundal grip – fetal pole (breech
or head) is not palpable.

11. DIAGNOSIS (CONTD..)
• Lateral grip
A. Soft, broad and irregular breech is felt to one side of the midline and
smooth, hard and globular head is felt on the other side.
The head is usually placed at a lower level on one iliac fossa
B. The back is felt anteriorly across the long axis in dorso-anterior or the
irregular small parts are felt anteriorly in dorso-posterior.
• Pelvic grip – lower pole of the uterus is found empty.

12. DIAGNOSIS (CONTD..)
Auscultation
• F.H.S. is heard easily much below the umbilicus
in dorso-anterior position.
• F.H.S. is, however, located at a higher level and
often indistinct in dorso-posterior position.
• Sonar/X-ray: Ultrasonography or radiography
confirms the diagnosis.

13. DIAGNOSIS (CONTD..)
Vaginal Examination
• During pregnancy
Presenting part is so high that is cannot be identified properly
but one can feel some soft parts.
• During labour –
 Elongated bag of the membranes
 Shoulder is identified by palpating the following parts –
acromion process, the scapula, the clavicle and axilla.
 A prolapsed arm

14. CLINICAL COURSE OF LABOUR
• There is no mechanism of labour in transverse lie and an
average size baby fails to pass through an average size
pelvis.

15. Unfavourable events
(most common)
• PROM
• Hand prolapse with or without
a loop of cord.
• Cord prolapse
• Ascending infection from the
lower genital tract.
• Obstructed labour

16. • Pathological retraction ring.
• Maternal distress
• Sepsis
• Rupture uterus

17. Favourable events
(very rare)
• Spontaneous rectification or version
• Spontaneous evolution
• Spontaneous expulsion (conduplicato corpore).
These events are very rare and occur only when the
baby is premature or macerated.

18. • Spontaneous rectification or version
• It usually occurs in early labour with good amount of liquor
and the baby is small and movable.
• Contracting uterus forces the head or the breech lying in the
iliac fossa to lie in alignment to the brim.
• Thus, the lie may be changed from oblique to longitudinal
with vertex presentation, when it is called rectification or
with breech presentation when it is called version.
• It is more frequent in multiparae.

19. • Spontaneous evolution:
• The arm is usually prolapsed; the head lies on one iliac
fossa; the trunk and the breech are forced into the cavity;
the neck is markedly elongated.
• Breech and the trunk are expelled first followed by delivery
of the head.
• This requires very strong uterine contractions.

20. • Spontaneous expulsion:
• It is extremely rare and occurs only in
premature and macerated fetus.
• Fetus is expelled doubled up, with chest and
abdomen apposed.
• The head and the feet are delivered last.

21. MANAGEMENT
Transverse lie with intact membrane
and live fetus
Approach before onset of labor
• In absence of C/I for vaginal delivery perform ECV at approx. 37
weeks of gestation
• If recurs, attempt ECV at 38 to 39 weeks of gestation  if
successful induce labor.
• If ECV declined or first or repeat ECV unsuccessful, then
cesarean delivery is performed at 38+0 to 39+6 weeks.

22. Approach in early labor
Single fetus in transverse lie, intact membranes and
a live fetus  ECV to cephalic presentation if there
are no C/I to ECV.
If successful with cervix adequately dilated and vertex
well applied to the cervix, amniotomy is performed.
If ECV in unsuccessful  cesarean delivery

23. Approach in active labor
Perform a cesarean delivery

24. Transverse lie with ruptured
membranes, live fetus
Gestational age is >/=34 weeks,
perform cesarean delivery
Gestational age < 34 weeks- expectant management is
reasonable as long as the ability to perform cesarean delivery
promptly is available given the increased risk of cord prolapse.
Between 28- 34 weeks– delivery rather than expectant management may
result in a better neonatal outcome, with a course of antenatal corticosteroids.

25. Transverse lie of
second twin after
delivery of first
twin
Internal podalic version to
breech presentation
followed by breech
extraction.

26. Transverse lie with fetal
demise or previable fetus
Before labor or early labor – ECV to
achieve longitudinal lie regardless of
membrane status, followed by IOL /
augmentation.
In active phase of labor  Internal
podalic version by experienced
practitioner.
If the fetus is extremely small and dead- the body
may collapse and double up on itself (conduplicato
corpore) during labor, thus allowing head and
thorax to simultaneously pass through the pelvis
and deliver vaginally.

27. Thank
you