Transverse Lie

When the long axis of the fetus lies perpendicularly to the maternal spine or centralized
uterine axis, it is called transverse lie. But more commonly, the fetal axis is placed
oblique to the maternal spine and is then called oblique lie. In a transverse lie, the
shoulder is usually positioned over the pelvic inlet. The head occupies one iliac fossa, and
the breech the other. This creates a shoulder presentation in which the side of the mother
on which the acromion rests determines the designation of the lie as right or left acromial.
And because in either position the back may be directed anteriorly or posteriorly,
superiorly or inferiorly, it is customary to distinguish varieties as dorsoanterior and
dorsoposterior. In dorsoposterior, chance of fetal extension is common with increased
risk of arm prolapse. According to the position of the head, the fetal position is termed
right or left, the left one being commoner than the right.

The incidence is about 1 in 200births. It is common in premature and maceratedfetuses, 5

times more common in multiparae thanprimigravidae. Transverse lie in twin pregnancy is
found in 40% of cases.
Etiology
The causes are :

Abdominal wall relaxation from high parity (4/> deliveries)

Preterm fetus
Placenta previa
Abnormal uterine anatomy (arcuate / subseptate)

Hydramnios
Contracted pelvis
Twins
Pelvic tumors
Intrauterine death

A relaxed and pendulous abdomen allows the uterus to fall forward, deflecting the long
axis of the fetus away from the axis of the birth canal and into an oblique or transverse
position.

Diagnosis
Abdominal examination
Inspection: The uterus looks broader and often asymmetrical.
Palpation: The abdomen is unusually wide, whereas the uterine fundus extends to only
slightly above the umbilicus. No fetal pole is detected in the fundus, and the
ballottable head is found in one iliac fossa and the breech in the other. The position of
the back is readily identifiable. When the back is anterior a hard resistance plane
extends across the front of the abdomen. When it is posterior, irregular nodulations
representing fetal small parts are felt through the abdominal wall.
Auscultation: Fetal heard sound is heard easily much below the umbilicus in
dorsoanterior position. FHS is, however, located at a higher level and often indistinct
in dorsoposterior position.
Ultrasonography or radiography confirms the diagnosis

Vaginal examination

During pregnancy: The presenting part is so high that it cannot be identified

properly but one can feel some soft parts.

During labor: Elongated bag of the membranes can be felt if it does not rupture
prematurely. The shoulder is identified by palpating the following parts are
acromion process, the scapula, the clavicle and axilla. The characteristic
landmarks are the feeling of the ribs and intercostal spaces.

Mechanism of Labor
Antenatal: External cephalic version should be done in all cases beyond 35 weeks
provided there is no contraindication. If the lie fails to stabilize even at 36th week, the
case is to be managed as outlined in unstable lie.
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 is very much there. Elective cesarean section is the
preferred method of delivery.

Vaginal delivery may be allowed in a dead or congenitally malformed (small size) fetus.
The labor may be allowed to continue under supervision till full dilatation of the cervix,
when the baby can be delivered by internal version.
Spontaneous delivery of a fully developed newborn is impossible with a persistent
transverse lie. After rupture of the membranes, if labor continues, the fetal shoulder is
forced into the pelvis, and the corresponding arm frequently prolapses. After some
descent, the shoulder is arrested by the margins of the pelvic inlet, with the head in one
iliac fossa and the breech in the other. As labor continues, the shoulder is impacted firmly
in the upper part of the pelvis. The uterus then contracts vigorously in an unsuccessful
attempt to overcome the obstacle. With time, a retraction ring rises increasingly higher
and becomes more marked. With this neglected transverse lie, the uterus will eventually

rupture.

If the fetus is small (< 800 g) and the pelvis is large, spontaneous delivery is
possible despite persistence of the abnormal lie. The fetus is compressed with the head
forced against its abdomen. A portion of the thoracic wall below the shoulder thus
becomes the most dependent part, appearing at the vulva. The head and thorax then pass
through the pelvic cavity at the same time.
Active labor in a woman with a transverse lie is usually an indication for
cesarean delivery. Before labor or early in labor, with the membranes intact, attempts at
external version are worthwhile in the absence of other complications. If the fetal head
can be maneuvered by abdominal manipulation into the pelvis, it should be held there
during the next several contractions in an attempt to fix the head in the pelvis.
With cesarean delivery, because neither the feet nor the head of the fetus occupies the
lower uterine segment, a low transverse incision into the uterus may lead to difficult fetal
extraction. This is especially true of dorsoanterior presentations. Therefore, a vertical
incision is typically indicated.
External Cephalic Version

ECV has been considered from 36 weeks onwards. While version in the early weeks is
easy but chance of reversion is more. Late version may be difficult because of increasing
size of the fetus and diminishing volume of liquor amnii. However, the use of uterine
relaxant (tocolysis) has made the version at later weeks less difficult. It minimizes chance
of reversion and should fetal complications develop, it can be effectively tackled by
cesarean section. Hypertonus or irritable uterus can be overcome with the use of tocolytic
drugs.
Contraindications :
-

Antepartum hemorrhage (placenta previa/ abrution): risk of placental separation

Fetal causes : hyperextension of the head, large fetus (>3,5 kg), congenital

abnormalities, dead fetus, fetal compromise (IUGR)

Multiple pregnancy
Ruptured membranes
Congenital malformation of the uterus
Abnormal cardiotocography
Contracted pelvis
Previous cesarean delivery : risk of scar rupture
Obstetric complications : severe pre eclampsia, obesity, elderly primigravida, bad

obstetric history
Rhesus isoimmunization

Causes of failure of version:

-

Breech with extended legs : early engagement of presenting part and difficult to

flex the trunk because of splinting action of the limbs

Scanty liquor or big size baby
Mechanical : obesity, increased tone of the abdominal muscles and irritable uterus
Short cord
Uterine malformations : septate or bicornuate

The dangers of version are:

-

Premature onset of labor

Premature rupture of the membranes
Placental separation and bleeding
Entanglement of the cord round the fetal part or formation of a true knot leading

to impairment of fetal circulation and fetal death

Increased chance of feto-maternal bleed
Amniotic fluid embolism