Transverse Lie - Face - Brow Presentation PDF

TRANSVERSE LIE Dr. Melad  Definition Different Positions Incidence Objectiv Etiology Diagnosis es Complications Management What is LIE???  DEFINITION When the long axis of the fe...

TRANSVERSE LIE Dr. Melad  Definition Different Positions Incidence Objectiv Etiology Diagnosis es Complications Management What is LIE???  DEFINITION When the long axis of the fetus lies perpendicular to the maternal spine or centralized uterine axis, it is called transverse lie.  POSITION The flexor surface of the fetus Doors- co1mnonest is better adapted to the anterior (60%). convexity of the maternal spine. Doors- Extensor surface of the fetus is better posterior adapted to the convexity of maternal Spine The curvature of the the fetal small Doors- fetal spine is oriented parts and umbilical superior upward (also called "back up") cord present at the cervix. The curvature of the fetal the fetal Doors- spine is oriented shoulder inferior downward (also called "back down") presents at the cervix DORSO-ANTERIOR DORSO-POSTERIOR  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.  ETIOLOGY Multiparity Prematurity: commonest cause Twins Hydramnios Contracted pelvis Placenta previa Pelvic tumors Intrauterine death Congenital malformation of the uterus - arcuate or subseptate  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.  DIAGNOSIS (CONTD..) Lateral grip A. 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. B. The back is felt anteriorly across the long axis in dorso- anterior or the  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.  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.  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.  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  Pathological retraction ring. Maternal distress Sepsis Rupture uterus  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.  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.  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.  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.  MANAGEMENT Transverse lie with intact membrane and live fetus Approach before onset of labor In absence of C/1 for vaginal delivery perform ECV at approx. 37 weeks of gestation If recurs, attempt ECV at 38 to 39 weeks of gestation if successful induce labor. If ECV declined or first or repeat ECV unsuccessful, then cesarean deliver is erformed at 38+0 to 39+6 weeks. Approach in early labor Single fetus in transverse lie, intact membranes and a live fetus ECV to cephalic presentation if there are no C/I to ECV. If successful with cervix adequately dilated and vertex well applied to the cervix, amniotomy is performed If ECV in unsuccessful cesarean delivery Approach in active labor Perform a cesarean delivery  Transverse lie with ruptured membranes, live fetus Gestational age is >/=34 weeks, perform cesarean delivery Gestational age < 34 weeks- expectant management is reasonable as long as the ability to perform cesarean delivery promptly is available given the increased risk of cord prolapse. Between 28- 34 weeks- delivery rather than expectant management may result in a better neonatal outcome, with a course of antenatal corticosteroids. Transverse lie of second twin after delivery of first twin Internal podalic version to breech presentation followed by breech extraction. Transverse lie with fetal demise or previable fetus Before labor or early labor - ECV to achieve longitudinal lie regardless of membrane status, followed by IOL / au mentation. In active phase of labor Internal podalic version by experienced practitioner If the fetus is extremely small and dead- the body may collapse and double up on itself (conduplicato corpore) during labor, thus allowing head and thorax to simultaneously pass through the pelvis and deliver vaginally.