TRANSVERSE LIE AND CORD PROLAPSE

Dr. Hem Nath SubediRESIDENT

COMS-TH, BHARATPUR , NEPAL

TRANSVERSE LIE

• When the long axis forms an acute angle, an oblique lie results. The latter is usually only transitory, because either a longitudinal or transverse lie commonly results when labor supervenes.

• The position is determined by the direction of the back, which is the denominator.

• 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.

POSITION

(1) Dorsoanterior, which is the commonest (60%). The flexor surface of the fetus is better adapted to the convexity of the maternal spine.

(2) Dorsoposterior(3) Dorsosuperior(4) Dorso-inferior.

• 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.

Etiology

• Abdominal Wall Relaxation From High Parity,• Preterm Fetus• Placenta Previa • Abnormal Uterine Anatomy, • Hydramnios• Contracted Pelvis.

DIAGNOSIS

ABDOMINAL EXAMINATIONInspection: The uterus

looks broader and often asymmetrical, not maintaining the pyriform shape.

Palpation: The fundal height is less than the period of amenorrhea.• Fundal grip—Fetal pole (breech or head) is not palpable.• Lateral grip

(a) Soft, broad and irregular breech is felt to one side of the midline and smooth, hard and Positions of transverse lie

(A) Dorsoanterior and (B) Dorsoposterior 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 irregular small parts are felt anteriorly in dorso-posterior.

• Pelvic grip—The lower pole of the uterus is found empty.

Auscultation: FHS is heard easily much below the umbilicus in dorso-anterior position. FHS is, however, located at a higher level and often indistinct in dorso-posterior position.

Ultrasonography and radiography confirms the diagnosis

VAGINAL EXAMINATIONDuring 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—acromion process, the scapula, the clavicle and axilla. The characteristic landmarks are the feeling of the ribs and intercostal spaces (grid iron feel).

On occasion, the arm is found prolapsed. It should be remembered that the findings of a prolapsed arm is confined not only to transverse lie but it may also be associated with compound presentation. Rarely, a leg may be prolapsed. Frequently, a loop of cord may be found alongside the arm.

Determination of position: The thumb of the prolapsed hand, when supinated, points toward the head, the palm corresponds to the ventral aspect. The angle of the scapula, if felt, indicates the position of the back. The side to which the prolapsed arm belongs, can be determined by shaking hands with the fetus. If the right hand is required for this, the prolapsed arm belongs to right side and vice-versa.

Course of labour

• UNFAVORABLE EVENTS– Cord prolapse– Hand prolapse– Obstructed labour– Fetal death– Neglected shoulder

• Ruptured uterus• Ketoacidosis (due to exhausted

labour)• Sepsis • Shock

• FAVORABLE EVENTS• The following are the favorable events that

may occur– (1) spontaneous rectification or version– (2) spontaneous evolution and – (3) spontaneous expulsion (conduplicato

corpore). These events are very rare and occur only when the

baby is premature or macerated.

Management of Labour

• External cephalic version should be done in all cases beyond 35 weeks provided there is no contraindication as mentioned in breech presentation .

• 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.

PATIENT SEEN IN LABOR: The principles in management are as outlined below:

• EARLY LABOR:External cephalic version: Provided there is good amount of liquor

amnii and there is no contraindication.• External cephalic version should be tried in all cases. Cesarean section is the preferred method of delivery if version fails

or is contraindicated. Difficulties are faced during cesarean section as the lower uterine segment is poorly developed. However, the fetus can be manipulated to a polar (cephalic/breech) presentation before entering the uterus and a low transverse incision may be made. Otherwise lower segment vertical incision may be made.

LATE LABOR:Baby alive—There is hardly any scope of external version in late labor because of

invariable rupture of the membranes and drainage of liquor. If the baby is mature and the fetal condition is good, it is preferable to do cesarean section in all cases.

Internal version—In a singleton fetus, the risk of internal version is high. Not only it might inflict injury to the uterus (rupture uterus) but also the fetal mortality is increased to the extent of about 50%. In modern obstetric practice, internal version is not recommended except in the case of second twin.

Baby dead—Cesarean section even in such cases, is much safer in the hands of those who are not conversant with destructive operations. If the obstetrician is conversant with destructive operation, decapitation or evisceration is to be done (see p. 587). Following destructive operation, the uterine cavity is to be explored to exclude rupture of the uterus. Internal version should not be done.

Cord prolapse

There are three clinical types of abnormal descent of the umbilical cord by the side of the presenting part. All these are placed under the heading cord prolapse.

Occult prolapse—The cord is placed by the side of the presenting part and is not felt by the fingers on internal examination.

Cord presentation—The cord is slipped down below the presenting part and is felt lying in the intact bag of membranes.

Cord prolapse—The cord is lying inside the vagina or outside the vulva following rupture of the membranes

• INCIDENCE: The incidence of cord prolapse is about 1 in 300 deliveries. It is mostly confined to parous women.

• Incidence is reduced with the increased use of elective CS in noncephalic presentations.

ETIOLOGYThe following are the associated factors:

– Malpresentations—the commonest being transverse (5–10%) and breech (3%) especially with flexed legs or footling and compound (10%) presentation

– Contracted pelvis,– Prematurity– Twins– Hydramnios– Placental factor—minor degree placenta praevia with marginal

insertion of the cord or long cord– Iatrogenic—low rupture of the membranes, manual rotation of the

head, ECV, IPV– Stabilizing induction

DIAGNOSIS: • Occult prolapse—is difficult to diagnose. The possibility

should be suspected if there is persistence of variable deceleration of fetal heart rate pattern detected on continuous electronic fetal monitoring.

• Cord presentation—The diagnosis is made by feeling the pulsation of the cord through the intact membranes.

• Cord prolapse—The cord is palpated directly by the fingers and its pulsation can be felt if the fetus is alive. Cord pulsation may cease during uterine contraction which, however, returns after the contraction passes off.

Management Cord presentation: The aim is to preserve the membranes and to

expedite the delivery. Once the diagnosis is made, no attempt should be made to replace the cord, as it is not only ineffective but the membranes inevitably rupture leading to prolapse of the cord.

If immediate vaginal delivery is not possible or contraindicated, cesarean section is the best method of delivery. During the time of preparing the patient for operative delivery, she is kept in exaggerated Sims’ position to minimise cord compression.

A rare occasion is a multipara with longitudinal lie having good uterine contractions with the cervix three-fourth (7–8 cm) dilated, without any evidence of fetal distress. Watchful expectancy can be adopted till full dilatation of the cervix, when the delivery can be completed by forceps or breech extraction.

CORD PROLAPSE: Management protocol is to be guided by: (1) Baby living or dead (2) Maturity of the baby(3) Degree of dilatation of the cervix.

BABY LIVING: I. Definitive treatment: • Cesarean section is the best treatment when the baby is sufficiently mature and is alive. Just

prior to making the abdominal incision, the fetal heart should be auscultated once more to avoid unnecessary section on a dead baby. The operation should be done quickly upto the delivery of the baby.

II. Immediate safe vaginal delivery is possible: • If the head is engaged, delivery is to be completed by forceps. Ventouse may not be ideal in

such circumstances as it takes a longer time. • If breech, the delivery is to be completed by breech extraction and in transverse lie, it should be

completed by internal version followed by breech extraction. The same also applies in cases where the head is not engaged in second baby of twins.

III. Immediate safe vaginal delivery is not possible: First aid management: The aim is to minimize pressure on the cord till such time when the patient is prepared for assisted delivery or is transferred to an equipped hospital. If an oxytocin infusion is on, this should be stopped. At this time intravenous fluid and O2 by face mask is given.

• Bladder filling has been done to raise the presenting part off the compressed cord till such time that patient has delivered (either by CS or vaginally). Bladder is filled with 400–750 mL of normal saline with a Foley’s catheter, the balloon is inflated and the catheter is clamped. Bladder is emptied before cesarean delivery.

• To lift the presenting part off the cord, by Woman in labour wiht cord prolapse the gloved fingers introduced into the vagina. The fingers should be placed inside the vagina till definitive treatment is instituted.

• Postural treatment—exaggerated and elevated Sims’ position with a pillow or wedge under the hip or thigh; Trendelenburg or knee-chest position has been traditionally mentioned but may be tiring and irksome to the patient.

• To replace the cord into the vagina to minimize vasospasm due to irritation.

BABY DEAD: Labor is allowed to proceed awaiting spontaneous delivery.

• Thank you