Transverse Lie/ Shoulder Presentation: Causes, Diagnosis, Management

Transverse Lie/ Shoulder Presentation

The term is applied when the fetus lies with its long axis across that of the mother. In transverse lie, the shoulder usually presents. This is a very serious complication in obstetrics and the ratio is 1:300 cases near term. The incidence is greater in multiparae than in primigravidae. The breech is usually slightly higher on one side than on the other side. Back may be in anterior or posterior.

Causes:

Maternal:

·              Contracted pelvis – prevent engagement (rare)

·              Tumours – Fibroids (rare)

·              Grande multiparity – lax uterine and abdomen muscle s

·              Abnormal uterus – Bicornuate\ subseptate uterus

Fetal:

·              Multiple pregnancy – Twins.

·              Prematurity – Large amniotic volume & small fetus

·              Macerated fetus.

·              Placenta praevia – Hydrocephalus & gross abnormalit y

·              Polyhydramnios ,Anterior obliquity of the uterus

Positions

·              Dorsal Anterior – the fetus lies with the back to the front of the mother. Head could be to the left or right.

·              Dorsal Posterior – the fetus lies with the back to the back of the mother.

Diagnosis

During pregnancy

On inspection – Abdomen looks broad fundal height i s lower than normal

On Palpation

·              No presentation part either at the pelvis or in the fundus.

·              Fundal height lower than gestational age.

·              Head is felt on one side and the breech at the other side

On Auscultation

Fetal heart sound is head below the umbilicus

Ultrasound: May be used to confirm the lie & presentation.

In Labour

When membranes rupture the uterus appears more irregular, the uterus mould round the fetus making palpation to be difficult – shoulder may be wedged into the pelvic brim.

There may be prolapse of the arm, foot, cord or both foot and arm.

On Vaginal Examinations

Presenting part is very high – cord may prolapse – soft irregular mas may be felt.

Ribs may be felt, arm prolapse may occur. Sponteneous delivery becomes impossible except in macerated fetus when it is born doubled – up.

No mechanism for shoulder presentation. Placenta praevia must first be excluded before performing vaginal examination.

Management

In pregnancy:

Adequate prenatal care to diagnose the case antenatally. Causes should be investigated by Doctor. The position can be rectified or appropriate management is arranged prior to labour e.g. in case of contracted pelvis and placenta praevia elective C/S is done at term. If no contraindication external cephatic version is done at 34th week to longitudinal lie.

In Labour:

Inform Doctor immediately. In early labour and membranes intact external cephalic version could be done, followed by immediate rupture of membranes and close observation to ensure a longitudinal lie. In late labour with ruptured membranes internal podalic version is performed under general anaesthesia and the baby delivered by breech extraction. Caesarean section is the method of choice in cases of:

·              Failed external cephalic version.

·              When membranes are gone

·              Cord prolapse

·              Prolonged labour.

Immediate C/S is done weather fetus is alive or dead.

Danger

·              Early rupture of membranes leading to oedematous vulva

·              Cord prolapse and arm prolapse.

·              Obstructed labour

·              Ruptured uterus

·              Still birth

·              Infection.

Unstable Lie

This term is applied when the lie which should be stable as longitudinal at 36 weeks of pregnancy is found to vary from one examination to the other – breech, vertex or should er.

Causes

·              Any condition which increases mobility of the fetus in utero e.g.

o     Polyhydramnios, Fetal

o     Laxed uterine muscle as in grande multiparity.

·              Any condition that prevents the head from entering the pelvis e.g

a.           Contracted pelvis, placenta praevia

Management

·              Admit the woman to the hospital at 37th – 38th w eek of pregnancy till she delivers to avoid

Unsupervised onset of labour with transverse lie.

To receive essential and expert supervision – inves tigation to detect the cause – rule out placenta praevia.

·              Further attempts are made to correct the lie by external cephalic version.

·              At the 38th week or when labor starts membranes may be ruptured after making the lie longitudinal bearing in mind the risk of cord prolapse.

·              Intravenous oxytoxin drip is set up taking appropriate precaution especially in

·              multiparous patients.

·              Vigilant  supervision  is  important  in  labour  to  see  that  the

·              longitudinal lie is maintained throughout labour by thorough

·              abdominal examination at the onset of labour and at      frequent intervals. Fetal heart sound should be checked frequently for possible cord prolapse.

·              The bladder should be emptied 2hrly to aid descent of the presenting part.

·              Bowels should be emptied so as to facilitate and preserve longitudinal lie.

·              If the correction of the lie fails at term caesarean section is done. Labour is considered trial.

Complication

Same as transverse lie if labour commences in any lie other than longitudinal.

Compound Presentation

When a hand or foot lies alongside the head the presentation is said to be compound. Common with small pelvis or roomy pelvis – it may be head, hand, foot

Causes

·              Small fetus

·              Very roomy pelvis

Diagnosis

·              Usually made on V.E or

·              Seen at the vulva during labor.

Usually not a difficult encounter.

Management

First Stage:

Seek medical aid.

An attempt could be made to push the arm upwards over the baby’s face.

Second Stage

Midwife should hold the hand back pushing it over the baby’s face. Occasionally caesarean section may be necessary where there is average pelvis and average size baby.