7.6 Transverse lie and shoulder presentation

A transverse lie constitutes an absolute foeto-pelvic disproportion, and vaginal delivery is impossible.

This is an obstetric emergency, because labour is obstructed and there is a risk of uterine rupture and foetal distress.

7.6.1 Diagnosis

– The uterus is very wide: the transverse axis is virtually equivalent to the longitudinal axis; fundal height is less than 30 cm near term.
– On examination: head in one side, breech in the other (Figures 7.1a and 7.1b). Vaginal examination reveals a nearly empty true pelvis or a shoulder with—sometimes—an arm prolapsing from the vagina (Figure 7.1c).

Figures 7.1 - Transverse lie and shoulder presentation

7.6.2 Possible causes

– Grand multiparity
– Uterine malformation
– Twin pregnancy
– Prematurity
– Placenta praevia
– Foeto-pelvic disproportion

7.6.3 Management

This diagnosis should be made before labour begins, at the final prenatal visit before the birth.

At the end of pregnancy

Singleton pregnancy

– External version 4 to 6 weeks before delivery, in a CEmONC facility (Section 7.7).
– If this fails, delivery should be carried out by caesarean section, either planned or at the beginning of labour (Chapter 1, Section 1.3.2).

Twin pregnancy

– External version is contra-indicated.
– If the first twin is in a transverse lie (unusual): schedule a caesarean section.
– If the second twin is in a transverse lie: there is no strict indication for caesarean section, but plan delivery in a CEmONC facility so that it can be performed if necessary. Deliver the first twin and then, depending on the experience of the operator, perform external and/or internal version on the second twin.

During labour, in a CEmONC facility

The foetus is alive and the membranes intact

– Gentle external version, between two contractions, as early as possible, then proceed as with normal delivery.
– If this fails: caesarean section.

The foetus is alive and the membranes ruptured

– Complete dilation:
• Multipara with relaxed uterus and mobile foetus, and an experienced operator: internal version and total breech extraction.
• Primipara, or tight uterus, or immobile foetus, or engaged arm, or scarred uterus or insufficiently-experienced operator: caesarean section.

– Incomplete dilation: caesarean section.
Caesarean section can be difficult due to uterine retraction. Vertical hysterotomy is preferable. To do the extraction, get hold of a foot in the fundus (equivalent to a total breech extraction, but by caesarean section).

The foetus is dead

Embryotomy for transverse lie (Chapter 9, Section 9.7.7).

During labour, in remote settings where surgery is not available

The foetus is alive and the membranes intact

Try to refer the patient to a CEmONC facility. Otherwise:
– Attempt external version as early as possible.
– If this fails, wait for complete dilation.
– In order to perform version under the proper conditions, perform general or spinal anaesthesia, depending on what is possible.
– Perform an external version (Section 7.7) combined with an internal version (Section 7.8), perhaps using various positions (Trendelenburg or knee-chest).

The foetus is alive and the membranes ruptured

Try to refer the patient to a CEmONC facility. Otherwise:

– Complete dilation:
• Put the woman into the knee-chest position.
• Between contractions, push the foetus back and try to engage his head.
• Vacuum extraction (Chapter 5, Section 5.6.1) and symphysiotomy (Chapter 5, Section 5.7) at the slightest difficulty.

– Incomplete dilation: Trendelenburg position and watchful waiting until complete dilation.

The foetus is dead

Try to refer the patient, even if referral takes some time.
Otherwise, embryotomy for transverse lie (Chapter 9, Section 9.7.7).