Transverse Lie in Obstetrics

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Questions and Answers

What is defined as a transverse lie in relation to fetal position?

Transverse lie occurs when the long axis of the fetus is perpendicular to the maternal spine or uterine axis.

What is the incidence rate of transverse lie at birth?

The incidence of transverse lie is about 1 in 300 births.

List two common causes of transverse lie.

Multiparity and prematurity are common causes of transverse lie.

How do the fetal spine orientations differ in transverse lie positions?

In a transverse lie, the fetal spine can be oriented upward or downward, known as 'back up' or 'back down'. Signup and view all the answers

What key finding is observed upon inspection during abdominal examination for transverse lie?

The uterus appears broader and often asymmetrical, not maintaining a pyriform shape. Signup and view all the answers

What is a notable palpation finding in a lateral grip during diagnosis of transverse lie?

A soft, broad, and irregular breech is felt to one side, while a smooth, hard, globular head is felt on the other side. Signup and view all the answers

What is the relationship between transverse lie and congenital malformations of the uterus?

Congenital malformations such as arcuate or subseptate uterus can contribute to the occurrence of transverse lie. Signup and view all the answers

Why is the fundal height typically less than expected during transverse lie?

The fundal height is less because the fetal position does not align with the typical longitudinal lie, affecting measurement. Signup and view all the answers

What is the recommended approach for a transverse lie with intact membranes and a live fetus before labor?

Perform external cephalic version (ECV) at approximately 37 weeks of gestation. Signup and view all the answers

What should be done if the first ECV attempt is unsuccessful?

Attempt ECV again at 38 to 39 weeks of gestation, and if successful, induce labor. Signup and view all the answers

What is the intervention for a single fetus in transverse lie during active labor?

Perform a cesarean delivery. Signup and view all the answers

What is the implication of ruptured membranes for a fetus in transverse lie at 34 weeks or more?

Perform a cesarean delivery. Signup and view all the answers

What should be the management approach if the gestational age is less than 34 weeks and there are ruptured membranes?

Expectant management is reasonable with the ability to perform cesarean delivery ready. Signup and view all the answers

What technique is used for the transverse lie of the second twin after the delivery of the first twin?

Internal podalic version followed by breech extraction. Signup and view all the answers

In the case of fetal demise or a previable fetus, what is the recommended procedure before labor?

Perform ECV to achieve longitudinal lie followed by induction of labor or augmentation. Signup and view all the answers

What condition may occur during labor if the fetus is extremely small and dead?

The fetus may experience 'conduplicato corpore', allowing simultaneous passage through the pelvis. Signup and view all the answers

How is the fetal heart sound (F.H.S) in the dorso-anterior position compared to the dorso-posterior position?

In the dorso-anterior position, F.H.S is heard easily much below the umbilicus, while in the dorso-posterior position, it is located at a higher level and is often indistinct. Signup and view all the answers

What is the significance of the elongated bag of membranes during labor?

The elongated bag of membranes can indicate the presence of the presenting part at a high level, affecting identification during vaginal examination. Signup and view all the answers

What are some unfavorable events that can occur during labor?

Unfavorable events during labor include PROM (premature rupture of membranes), hand prolapse, cord prolapse, and obstructed labor. Signup and view all the answers

What does spontaneous rectification refer to in the context of fetal position during labor?

Spontaneous rectification refers to the alignment change of the fetus from an oblique to longitudinal lie with vertex presentation, often occurring when the baby is small and movable. Signup and view all the answers

Under what conditions can spontaneous evolution occur during labor?

Spontaneous evolution can occur when the arm prolapses, and the head lies on one iliac fossa, requiring strong uterine contractions to expel the fetus. Signup and view all the answers

Why is spontaneous expulsion considered extremely rare?

Spontaneous expulsion is extremely rare as it typically occurs only in cases of a premature or macerated fetus, often resulting in a unique delivery position. Signup and view all the answers

What role does a contracting uterus play during spontaneous rectification?

A contracting uterus can force the fetal head or breech lying in the iliac fossa to align with the brim, facilitating a safe delivery. Signup and view all the answers

What outcomes can result from maternal distress during labor?

Maternal distress can lead to unfavorable labor outcomes such as sepsis or even rupture of the uterus. Signup and view all the answers

Study Notes

Transverse Lie

Definition: The long axis of the fetus is perpendicular to the maternal spine or central uterine axis.
Positions: Anterior (most common), Posterior, Superior, Inferior. The positions relate to the fetal surface that is facing the maternal spine (flexor or extensor).
Incidence: Approximately 1 in 300 births. More common in premature and macerated fetuses, and 5 times more common in mothers who have had multiple pregnancies compared to first-time mothers.
Etiology: Multiparity (common cause), twins, contracted pelvis, pelvic tumors, congenital malformations of the uterus (arcuate or subseptate), prematurity, hydramnios, placenta previa, intrauterine death.
Diagnosis:
- Inspection: Broad and asymmetrical uterus, deviating from a typical pyriform shape.
- Palpation: Fundal height is usually less than expected for gestational age. Fetal parts (breech or head) are not palpable in the fundal grip.
- Lateral grip: Soft, broad irregular breech felt on one side, hard globular head on the opposite side. The head is usually lower positioned on one iliac fossa. The back is felt running across the long axis anteriorly in dorso-anterior or dorso-posterior locations.
- Auscultation: Fetal heart sounds (FHS) easily heard lower down from the umbilicus in dors-anterior positions. FHS are higher and often indistinct in the dorso-posterior position.
- Ultrasound or X-ray confirms diagnosis.
  - During pregnancy: Presenting parts may be high and soft parts are felt.
  - During labor: Elongated membranes (shoulder located by acromion process, scapula, clavicle and axilla), prolapsed arm.
Clinical Course of Labor: No typical labor mechanism in transverse lie. Average size baby often cannot pass through average size pelvis.
Unfavorable Events:
- PROM (Premature rupture of membranes).
- Hand prolapse (with or without loop of cord).
- Cord prolapse.
- Ascending infection.
- Obstructed labor.
- Pathological retraction ring.
- Maternal distress.
- Sepsis.
- Uterine rupture.
Favorable Events (Very Rare):
- Spontaneous rectification or version.
  - Occurs in early labor with adequate water and movable, small baby.
  - Contractions shift fetus for longitudinal position.
  - Rectification or version occurs based on the fetal presentation (head or breech).
  - More common in multiparous pregnancies.
- Spontaneous evolution.
  - The head lies on an iliac fossa, trunk and breech force into cavity, neck elongated.
  - Breech and trunk delivered followed by head. Requires strong uterine contractions.
- Spontaneous expulsion
  - Extremely rare in premature or macerated fetuses.
  - Fetus delivered doubled up (chest and abdomen apposed). Head and feet delivered last.
Management:
- Intact membranes, live fetus: Approach before onset of labor: ECV (external cephalic version) at ~37 weeks. If ECV successful, induce labor. If unsuccessful or declined, Cesarean (~38-39 weeks).
- Early labor: ECV to achieve longitudinal lie. If successful with enough cervical dilation, allow vaginal delivery. If ECV unsuccessful, Cesarean.
- Active labor: Cesarean delivery.
- Rupture of membranes, live fetus (gestational age >34 weeks): Cesarean delivery.
 - Gestational age <34 weeks: Expectant management is reasonable (with possibility of performing cesarean if problems arise).
- Transverse lie of second twin after delivery of first twin: Internal podalic version and breech extraction.
- Fetal demise/previable fetus (before or early labor): ECV to achieve longitudinal presentation (for delivery options). In active labor: Internal podalic version or delivery in a way that is appropriate for the circumstances.

Brow Presentation

Definition: Fetal head is hyperextended. Fetal face is the presenting part lying between orbital ridges and chin.
Associated with: abnormal positions of the fetus and complications during labor and delivery and potential for injury to the fetus.

Face Presentation

Definition: Fetal head and neck hyperextended, causing the occiput to present behind the back; the fetal face is the presenting part.

Anteroposterior Diameters of the Fetal Skull

Table showing various AP diameters of the fetal skull, the attitude, and the presenting part (e.g., vertex, brow, face).

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Description

This quiz covers the definition, positions, incidence, and etiology of transverse lie in obstetrics. Learn about how it is diagnosed and the implications of this fetal position on pregnancy. Ideal for medical students and healthcare professionals aiming to deepen their understanding of fetal positions.