Transverse lie

Lecture on transverse lie (malpresentation)

1. Transverse lie Dr. chandrima karki Lecturer Obs /gyn kmcth

2. Objectives

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.

5. Position

6. Dorso -anterior Dorso -posterior

7. 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.

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

9. 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.

10. Diagnosis (contd..) Lateral grip 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 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.

11. 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.

12. 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

13. 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.

14. 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

15. Pathological retraction ring. Maternal distress Sepsis Rupture uterus

16. 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.

17. 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 .

18. 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.

19. 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.

20. Management

21. Thank you