Transverse lie

Transverse lieoblique lie

Dr HAIDER Al-Shamma’a

objectives

Able to define transverse and oblique lie
The student should be able to diagnose transverse , oblique lie
Should be able to list the causes .
Able to outline the management and justify it
Able to define unstable lie
Able to list the causes
Able to outline the management and can justify it

Objectives continue…

Able to identify fetal causes of abnormal labor
Able to outline the management with justification
The student should be able to diagnose cord prolaps
Able to apreciate the risks of cord prolaps
Able to manage the patient with cord prolaps


Transverse lie :- occurs when the longitudinal axis of the fetus is perpendicular to the longitudinal axis of the mother the presenting part is the shoulder ( also named shoulder presentation ).

Oblique lie :- when the head or the breech is slightly higher than the other side

Transverse lie

Oblique lie

the denominator is the back ( dorsum )

Dorso-anterior is more common than dorso-posterior

Incidence :- 1/250 – 1/500 deliveries

Right acromio-dorsoposterior

Causes of transverse lie

• Multiparity is the most common cause
• Prematurity
• Polyhydramnious
• Multiple pregnancy
• Contracted pelvis
• Placenta previa
• Fibroids of the lower segment
• Congenital abnormalities of the uterus as septate and arcuate uterus

Diagnosis of transverse lie

On abdominal examination:-
• The abdomen is asymmetrically distended
• Width more than length
• Fundal height less than expected
• Round heard mass at one iliac fossa , softer breech at the other fossa
• Absent presenting part ( pelvic grip feel empty lower segment


• On p/v examination:-
• Can not feel the presenting part (high)
• Bulging membranes or rupture membranes
• Fetal arm or umbilical cord may prolaps to the vagina

Abdom. Finding T. Lie

Hand prolaps

Mechanism of labor

No mechanism of labor due to very large dimensions of the fetus , in a neglected case lead to fetal death and rupture of the uterus and maternal death

Rarely in a small premature dead macerated fetus in a stout mother , the baby may fold on itself and deliver vaginally

Management of transverse lie

• Before labour :-
• Manage as breech do ECV *
• During early labor:-
• Before rupture membrane can try ECV
• 3. Advanced labor , failure of ECV or contraindicated ECV :-
• Cesarean section is the safest method even incase of a dead fetus (TLSCS or easier LVCS)


Rarely in advanced neglected case with no facilities of CS
Decapitation by hook or saw , then pull the hand to deliver the trunk then deliver the head by forceps
Cesarean section is safer

Unstable lie

When the fetus changes its axis every visit
Causes as t lie
Management :-ECV each visit after 36 weeks
((same contraindication as ECV of breech)
Admission to hospital at 36 weeks
ECV and induction of labor at 38 wks
Elective cs may be performed in selected cases

Fetal malformation causes difficult labor

Hydrocehalus
Diagnosed by U/S
During labor feel widely separated sutures
Big head cause obstructed labor rare in modern practice
Management : terminate pregnancy when the head reaching 9.5 cm by induction of labor or by CS (up to 12cm)
Advanced obstructed labor perforate the head and drain the CSF and deliver vaginally ( rare )

hydrocephalus

Anencephalus

Absent vault and brain , incompatible with life
May cause prolonged pregnancy(>42 wks)
due to irregular shape dilatation is difficult , may need cleidotomy

Anencephalus

anencephalus

Conjoined twins

Suspected if the twins maintain the same relation to each other
U/S can diagnose the connection
Cause obstructed labor and need CS even that may be difficult !!

Conjoined twins cephalopagus

Thoracopagus

Compound presentation

Head +hand
Head + foot
Give large and irregular presenting part with risk of cord prolaps
Management:-
Usually corrected spontaneously with progress of head descent
If persistent try to push limb up
CS may be needed

Cord prolaps

Descent of loop of cord through the cervix to the vagina or even outside the vagina when the membranes ruptures
Causes
• Malposition malpresentation
• Rupture of the membranes when the head is high

Diagnosis of cord prolaps

Feel soft cord felt below the fetus
Pulsation can be felt and this mean the fetus is alive
If No pulsation either dead or spasm


Consequences of cord prolaps
Thermal and tactile stimulation cause spasm that interfere with fetal oxygenation fetal hypoxia and death may occur in less than 30 min
Also cord compression between the presenting part and boney pelvis

Treatment of cord prolaps

Steep Trendlingberg position or knee chest position to dis-impact the fetus and reduce cord compression
Vaginal pack
Terminate pregnancy by the most rapid method before fetal death
(1st stage C/S) & ( 2nd stage : forceps , vacuum extractor or C/S which ever can deliver first)

Diagram of cord prolaps Mx

prolaps

Dead fetus alive fetus

Continue labor 1st stage 2nd stage
As no prolaps
CPD no CPD

C/S forceps / vacuum

Thank you