Management of pregnancies with transverse lie.pptx

Management of pregnancies with transverse lie

1. TRANSVERSE LIE

2. When the long axis of the fetus lies perpendicular to the long axis of the centralized uterus or the maternal spine, the lie is said to be transverse. Presentation in transverse lie: Shoulder presentation Denominator : Acromion Position is determined by the direction of the back of the fetus: Dorsoanterior : most common(60%) Dorsoposterior Dorsosuperior Dorsoinferior Right or left position is determined by the fetal head, right being more common than left.

3. Incidence: 1 in 300 pregnancies at term Risk factors: Prematurity Multiparity Multifetal pregnancy Polyhydramnios Contracted pelvis Placenta previa Pelvic tumors Congenital malformation of the uterus Intrauterine death

4. Diagnosis: Abdominal Examination : Inspection : Uterine ovoid appears wide and often asymmetrical Palpation : Fundal height is less than the period of gestation. On fundal grip: none of the fetal pole is palpable. On lateral grip: head is palpable in one flank and breech in the other flank. On pelvic grip: lower pole of the uterus is found empty. Auscultation : In dorsosuperior position, FHS is heard along the fundus. In dorsoanterior and dorsoinferior position, FHS is heard below the umbilicus. In dorsoposterior position, FHS is heard with difficulty.

5. Per Vaginal Examination: 1. Presenting part is high up and the cervix is not well applied to the presenting part. 2. Elongated bag of membranes felt. 3. Premature rupture of membranes is often present. 4. Shoulder may be identified as the presenting part. 5. Grid iron feel due to the ribs and intercostal spaces may be there. 6. Hand prolapse with or without cord prolapse may be present. Ultrasound: confirmation of the diagnosis.

6. NEGLECTED SHOULDER : Includes the series of complications that arise out of shoulder presentation when the labor is left uncared. Premature rupture of membranes Escape of liquor Increased uterine contractions Impacted shoulder Tonic/vigorous uterine contractions Obstructed labour Maternal exhaustion Dehydration Ketoacidosis Uterine rupture Sepsis Shock Fetal distress Fetal demise

7. MANAGEMENT OF TRANSVERSE LIE DIAGNOSED IN ANTENATAL PERIOD FAILS SUCCESSFUL LSCS AT 38-39 WEEKS FOLLOW UP WEEKLY

8. MANAGEMENT OF TRANSVERSE LIE IN EARLY LABOUR MEMBRANES INTACT MEMBRANES ABSENT ATTEMPT EXTERNAL CEPHALIC VERSION FAILS LIQUOR PRESENT LIQUOR ABSENT ATTEMPT EXTERNAL CEPHALIC VERSION LSCS FAILS

9. MANAGEMENT OF TRANSVERSE LIE IN LATE LABOUR FETUS ALIVE FETUS DEAD LSCS LIQUOR ADEQUATE, CERVIX >7cm LIQUOR DRAINED, NO SIGNS OF OBSTRUCTION LIQUOR DRAINED, SIGNS OF OBSTRUCTION INTERNAL PODALIC VERSION AND BREECH EXTRACTION DECAPITATION LSCS

10. EXTERNAL CEPHALIC VERSION External Cephalic Version (ECV) is the manipulation of the fetus, through the maternal abdomen to a cephalic presentation. Timing : From 36 weeks onwards in nulliparous women From 37 weeks onwards in multiparous women Indications: Breech presentation Abnormal lie- transverse lie, oblique lie

11. Contraindications for External Cephalic Version : Absolute contraindications: Antepartum hemorrhage within the last 7 days Abnormal cardiotocography Major uterine anomaly Ruptured membranes Multiple pregnancy Any contraindication for vaginal delivery Relative contraindication: Small for gestational age fetus with abnormal doppler parameters Preeclampsia Oligohydramnios Major fetal anomaly Scarred uterus Unstable lie

12. Prerequisites: ECV should be carried out in a facility equipped to perform emergency cesarean section Proper counselling should be done Informed written consent should be taken Mild sedation like Phenergan may be given Cardiotocography and Ultrasound should be available Bladder should be emptied prior to the procedure Tocolytics like terbutaline, ritodrine, salbutamol can be used RCOG and ACOG recommend the use of tocolytics when an initial attempt at ECV without tocolysis has failed due to uterine contractions.

13. Procedure : 1. Ultrasound examination is done to confirm the presentation, for liquor, to rule out any congenital anomaly in fetus 2. Determine the two poles of the fetus 3. Both the poles of the fetus are held 4. Gentle and intermittent pressure is applied so that the fetus is turned in the direction of its face in order to maintain an attitude of flexion, known as “forward somersault” or “the forward roll” 5. This is done till the head comes to occupy the pelvic inlet and the podalic pole occupies the fundus. 6. Ultrasound is done post procedure to confirm the presentation 7. Fetal cardiotocography is done 8. Anti-D immunoglobulin is given in case of Rh negative mothers Success rate : 30-80%

14. Complications of ECV: Abruptio Placentae Premature rupture of membranes and premature labor pains Fetal Distress Feto -maternal hemorrhage and isoimmunization Rarely Uterine rupture, amniotic fluid embolism

15. THANK YOU