Abnormal Lie: - Abnormal Lie Consists of Two Types: Transverse Lie Oblique Lie

Abnormal Lie
• Abnormal lie consists of two types:

Transverse lie
Oblique lie
Transverse Lie
• Definition: This position is where the baby's
head is on one side of the mother's body and the
feet on the other, rather than having the head
close to the cervix or close to the heart.
• The fetus is in a transverse lie when its
longitudinal axis is perpendicular to the long axis
of the uterus.
• When the long axis of the fetus lies
perpendicularly to the maternal spine or
centralized uterine axis, it is called transverse
lie.
Cont.
• The baby can also be slightly at an angle, but
still more sideways, than up or down.
• This side ways position in the uterus is more
common earlier in pregnancy when the baby has
space to move around freely.
• Very few babies are in this position at term.
Position of the Fetus
• The position is determined by the direction of the
back, which is the denominator.
• The position may be:
 Dorso-anterior,which is the commonest (60%) .
 Dorso- posterior
 Dorso- superior, which is rare.
 Dorso- inferior , which is rare.
• In dorso- posterior, the chance of fetal extension
is common with increased risk of arm prolapsed.
Incidence
• Transverse fetal lie occurs in
approximately one in 300 deliveries.
• In contrast, the fetus is often found in a
transverse lie when ultrasound
examination is performed early in
gestation
• Most fetuses in transverse lie early in
pregnancy convert to a cephalic (or
breech) presentation by term.
Incidence Cont.
• The later in pregnancy the transverse lie is
diagnosed, the more likely it is to persist.
• This was illustrated in a series of 235 patients
with transverse fetal lie incidentally discovered by
sonography at more than 20 weeks gestation.
• When the diagnosis was first made between 20
to 25 weeks of gestation, 2.6 percent persisted as
transverse lie at term.
• By comparison, when the diagnosis was first
made at 36 to 40 weeks, 11.8 percent persisted
to the time of delivery.
Incidence Cont.
• In another series of 29 patients with transverse lie
at 37 weeks of gestation, 24 (83 percent)
spontaneously converted to a longitudinal lie and
presented in labor with either a vertex (15) or
breech (9) presentation.
• Transverse lie persisted in the five (17 percent)
remaining patients. Overall, the cesarean delivery
rate was 13 of 29 (45 percent); indications were
breech in eight and transverse lie in five.
Etiology
• Multiparity:- lax and pendulous abdomen,
imperfect uterine tone.
• Prematurity
• Twins
• Hydramnios: poly or oligo hydromnios
• Contracted pelvis
• Placenta previa
• Pelvic tumours
• Placenta previa
• Congenital malformation of the uterus
• Intrauterine death.
Diagnosis
• Abdominal examination
 Inspection: uterus looks broader and often
asymmetrical.
 Palpation:
 The fundal height is less than the period of
gestation.
 Fundal grief: Fetal pole (breech or head) is not
palpable.
 Lateral grief: Soft, irregular breech is felt to one
side and hard, globular head is felt on the other
side.
Diagnosis
 Pelvic grief: the lower pole of the uterus is found
empty. This however, is evident only during
pregnancy, but during labour,it may be occupied by
the shoulder.
 Auscultation: FHS is heard easily much below the
umbilicus in dorso anterior position. It is located at
higher level in dorso posterior position.
• Ultrasonography
• Vaginal examination:
 During pregnancy: the presenting parts is so high
that it cannot be identified properly but one can feel
some soft parts.
Cont.
 During labour: elongated bag of the membranes
can be felt if membrane is not rupture. The
shoulder is identified or palpated. On occasion
the arm is found prolapsed. A prolapsed arm is
confined not only to transverse lie but it may also
be associated with compound presentation.
What Are the Risks?
• A transverse pregnancy is rarely fatal to the
mother, especially in countries where there is
modern medical care.
• In underdeveloped countries where there is
inadequate medical care, this condition can be
fatal for both the mother and fetus because there
is no availability of C-section.
• In this country, however, a transverse lie could be
fatal to the fetus if the woman goes into labor and
breaks her water, allowing the fetal [umbilical]
cord to come out and be compressed.
Cont.
• "In general, women are able to make it to the
hospital so that the fetus can either be turned or be
delivered by Cesarean section.“
• "In modern obstetrics, a fatal outcome should not
happen.However, if labor continues, this can result
in obstructed labor, which can have serious
complications for the mother and baby.
• In regards to the baby, the cord can protrude first
and become occluded, which can result in oxygen
deprivation and brain damage, and possible death
to the baby. This is usually only seen in third world
countries."
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 event (most common).
o Premature rupture of the membranes.
o Hand of the correspounding shoulder may be
prolapsed with or without a loop of cord.
o There is chances of ascending infection.
o Shoulder becomes impacted into pelvis and
prolapsed arm become swollen and cyanosed.
o Gradually feature of obstructed labour.
Cont.
• Favourable event (very rare) :The following is
the favourable events that may occur:
 Spontaneous rectification or version.
 Spontaneous evolution
 Spontaneous expulsion.
• However these events are very rare and occurs
only when the baby is premature or macerated.
Prognosis
• In well supervised pregnancy and labour,
the maternal and fetal outlook is not much
unfavourable with the extended use of
caesarean section.
• However increase maternal morbidity
following early rupture of the membranes
and increased operative delivery, is
inevitable.
Management
 Antenatal
• External cephalic version beyond 35 weeks if there is
not contraindication.
• If your baby is in a transverse lie at term, a cesarean
section may be recommended if the baby doesn't turn.
• If version fail or 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 caesarean section is the preferred method of
delivery.
Cont.
• Vaginal delivery may be allowed in dead or
congenitally malformed (small size) fetus.The
labour must be under supervision. When the
baby can be deliver by internal version or
destructive operation.
 Labour : in early labour :
• If the patient is in early labour and the
membranes are intact,attempt external version.
• If external version is successful,proceed with
normal child birth.
• If external version is fail or contraindicated,
deliver by caesarean section.
Cont.
• Monitor for signs of cord prolapse.If the cord is
prolapsed deliver by caesarean section.
• In late labour:
• Baby alive: If the baby is mature and fetal condition
is good, it is preferable to do caesarean section in
all cases.
• Baby death: Caesarean section is much safer if the
hand is not conversant with destructive operation.
• Internal version: in modern obstetric practice
internal version is not recommended except in the
case of second twin.
Complication
• Impacted shoulder
• Obstructed labour
• Rupture uterus with clinical evidence of
dehydration,keto acidosis,shock and
sepsis.
References
• http://www.uptodate.com/patients/content/topic.d
o?topicKey=~VImVIdPU6aveZP_
• http://pregnancy.about.com/od/breechbabies/g/tr
ansverselie.htm
• D.C. Dutta,Text Book of Obstetrics, sixth edition
2004, Central
• Integrated Management of Pregnancy and Child
birth (IMPAC), Managing Complication in
pregnancy and Childbirth,WHO,2005.

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Abnormal Lie

• Abnormal lie consists of two types:

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