Transverse lie
When the long axis of the fetus lies
perpendicularly to the maternal spine,
it is called transverse lie.
When the fetal axis is placed oblique
to the maternal spine then it is called
oblique lie
Incidence:
Shoulder presentation occurs in
approximately 1:300 pregnancies near
term.
Only 17% of these cases remain as a
transverse lie at the onset of labour; the
majority are multigravidae
Causes:
Maternal
Lax abdominal and uterine muscles: This
is the most common cause and is found in
Multigravidae, particularly those of high parity.
Uterine abnormality: A bicornuate or
subseptate uterus may result in a transverse lie
– as, more rarely, may a cervical or low uterine
fibroid.
Contracted pelvis: Rarely, this may prevent
the head from entering the pelvic brim.
Fetal:
Pre-term pregnancy: The amount of
amniotic fluid in relation to the fetus is greater,
allowing the fetus more mobility than at term.
Multiple pregnancy: There is a possibility of
polyhydramnios but the presence of more than
one fetus reduces the room for manoeuvre
when amounts of liquor are normal. It is the
second twin that more commonly adopts this
lie after birth of the first baby.
Polyhydramnios : The distended uterus is
globular and the fetus can move freely in the
excessive liquor.
Macerated fetus: Lack of muscle tone causes the
fetus to slump down into the lower pole of the
uterus.
Placenta praevia: This may prevent the head
from entering the pelvic brim.
Antenatal diagnosis
Inspection:
The uterus looks broader and often asymmetrical,
not maintaining the pyriform shape
On abdominal palpation
The fundal height is less than expected for the
period of gestation.
Fundal palpation: neither head nor breech is felt.
Lateral palpation: The mobile head is
found on one side of the abdomen and the
breech at a slightly higher level on the
other.
Pelvic grip: the lower pole of the uterus is
found empty during pregnancy but during
labour, it may be occupied by the shoulder
Auscultation:
FHS is heard easily below the
umbilicus in dorso anterior position.
FHS is located at a higher level of
umbilicus in dorso posterior position
Ultrasound
An ultrasound scan may be used to
confirm the lie and presentation.
On vaginal examination
This should not be performed without first
excluding placenta praevia.
During pregnancy, the presenting part
may not be felt. The membranes usually
rupture early because of the ill-fitting
presenting part, with a high risk of cord
prolapse.
During labour:
Elongated bag of membranes can be felt if it
does not rupture prematurely
The shoulder is identified by palpating
the acromion process
The scapula
The clavicle and axilla.
On occasion, the arm is found prolapsed
Determination of position:
The thumb of the prolapsed hand, when
supinated, points toward the head, the palm
corresponds to the ventral (abdominal) aspect.
The angle of the scapula, if felt, indicates the
position of the back.
The side to which the prolapsed arm belongs,
can be determined by shaking hands with the
fetus. If the right hand is required for this, the
prolapsed arm belongs to right side and vice-
versa
Possible outcome:
There is no mechanism for delivery of
a shoulder presentation.
If this persists in labour, delivery must
be by caesarean section to avoid
obstructed labour and subsequent
uterine rupture.
Management:
Antenatal
External cephalic version should be done in all cases
beyond 35 weeks
if version fails or is contraindicated:
The patient is to be admitted at 37th week because risk
of early rupture of the membranes and cord prolapse.
Elective CS is the preferred method of delivery.
Vaginal delivery for dead or congenital malformation
fetus
Intrapartum:
Early Labour:
ECV: if good amount of liquor amnii
and there is no contraindication.
Caesarean section: if version fails or is
contraindicated
Late labour:
Baby alive: No ECV in late labour
because of rupture of membrane and drainage
of liquor.
If the baby is mature and the fetal condition
is good, prefer for CS in all cases.
Internal version in singleton fetus: in modern
practice internal version is not recommended
except in the case of second twin.
Baby dead:
CS even in such cases
Destructive operation: Decapitation or
Eviscerationis to be done.
Complications:
Prolapsed cord
Prolapsed arm
Neglected shoulder presentation
Unstable lie
This is a condition where the
presentation of the fetus is constantly
changed even beyond 36th week of
pregnancy when it should have been
stabilised.
Causes:
Grand multipara with lack of uterine
tone and pendulous abdomen –
commonest
Hydramnios
Contracted pelvis
Placenta praevia
Pelvic tumour
Management:
Antenatal
At each antenatal visit, the presentation
and the lie are to be checked.
If there is no contraindication, ECV is to
be done to correct the malpresentation.
Hospitalization:
The patient is admitted at 37th week.
After admission, the investigation is directed to exclude
placenta praevia, contracted pelvis or congenital
malformation of the fetus with sonography
ECV is done after 37th weeks (if no contraindication)
Elective CS if complicating factors like:
Pre-eclampsia
Placenta praevia
Contracted pelvis etc
Compound Presentation
When a cephalic presentation is
complicated by the presence of a hand or a
foot or both alongside the head or presence
of one of one or both hands by the side of
the breech, it is called compound
presentation.
Common is head with hand
Rare is presence of head, hand and a foot.
Incidence:
About 1 in 600
Etiology:
Prematurity (commonest)
Contracted pelvis
Pelvic tumours
Multiple pregnancy
Macerated fetus
High head with premature or early rupture of the
membranes
Hydramnios
Fetal malformations
External cephalic version causing head and foot
presentation
Diagnosis:
When the cervical os is sufficiently dilated
limbs can be feel by the side of the
presenting parts especially after rupture of
the membranes
Management :
1. Following factors should be considered
for management;
Stage of labour
Maturity of the fetus
Singleton or twins
pelvic adequacy
Associated cord prolapse
2. If mature single fetus associated with
contracted pelvis or cord prolapse with
the fetus alive: CS should be done
3. In second stage of labour, the prolapsed
limb should be replaced, if necessary
under GA but should not try to replace
the limb early because it increases the
maternal and fetal risk
4. Internal version or breech extraction,
when CS facilities are not available
5. Destructive operation is indicated in
cases of obstructed labour with dead
fetus
6. Inform obstetrician/pediatrician and
prepare resuscitation.
7. Other observation and management
same as normal labour.
Thank You
