Transverse And oblique lie

Transverse&oblique lie

The fetus may lie with its long axis transverse or oblique in the uterus,when the point of the shoulder is usually the presenting part with potential risk of cord or hand or foot prolapse following rupture of membranes.In the abscence of antenatal care shoulder presentation occur once in 500 labours.

Causes

1-multiparity with lax uterus
&abdominal wall
2-In premature labour
3-polyhydramnios
4-multiple pregnancy
5-in conditions of anything prevent engagement of fetal head as contracted pelvis,placenta previa or pelvic tumour
6-uterine malformations as arcuate or subseptate uterus

Diagnosis

Abdominal examination:
The uterus appear asymmetrical&is broader than usual with fundus lower than expected for date.On palpation the hard round head is felt in one iliac fossa with the softer breech on the opposite side,no presenting part is felt over the pelvic brim.In the center of abdomen the back will be felt in dorsoanterior position&small parts in dorsoposterior position.Fetal heart sounds are heard just below umbilicus.

Vaginal examination

At the beginning of labour the presenting part is high.During labour the membranes may ruptures early &when cervix is dilated arm or loop of cord or foot may prolapse.
Diagnosis of shoulder presentation depends on recognition of acromion process,scapula&adjacent ribs.


Course of labour
Afetus lie obliquely or transversly cannot be born naturally unless it is macerated or very premature when the body is delivered doubled up.
In untreated cases will end in obstructed labour&fetal death with risk of ruptured uterus.

Management

During pregnancy:
Gentle external version may be used to correct the malpresentation.
During labour:
In early labour it may be corrected by external by external version if the membranes are intact,in many women the fetus correct its position spontaneously in early labour.

If an oblique or transverse lie persists in labour caesarean section is performed which is safer than intrnal podalic version which was previously commonly done immediately after rupturing of membranes.
Later in labour when shoulder become impacted c/s is the safest procedure even if the fetus is dead.

Decapitation is an alternative which was formerly recommended;after division of the neck of the fetus which can be done with heavy scissors the trunk can be delivered by traction on the prolapsed arm&the head then delivered with forceps

Unstable lie

This refers to the fetus which frequently changes its axis from transverse to longitudinal to oblique

Causes

-polyhydramnios
-multipara woman
-placenta previa
-pelvic tumours
-pelvic contraction


Management
If there is no contraindication for normal vaginal delivery,gentle external version used to correct the presentation whenever the patient is examined.patients should be warned to come to hospital immediately when starting labour.Patients who live far away from hospital admitted from 38 weeks .

In multiparous woman an unstable lie will often correct itself in early labour.If it is not practical to await for spontaneous onset of labour or if there is obstetric indication for delivery,induction is decided.After correction of the fetal lie to longitudinal starting with syntocinon infusion &delay amniotomy until there are uterine contractions&the head had settled into the pelvic brim.

Umbilical cord accidents

Definition
Umbilical cord presentation:Is the presence of asegment of umbilical cord at the cervical os as the presenting part with intact membranes.
Umbilical cord prolapse:Is present when the membranes have ruptured&the segment of cord may be at any level from upper vagina to outside the intoitus,this occur in about 1 in 500 deliveries.

The stage preceding cord presentation is the presence of cord beside the presenting part&may manifest as variable decelerations of the fetal heart due to cord compression.

Causes:

1-It is more common when the presenting part does not fit well into lower uterine segment as in malpresentation like in breech,shoulder,brow or face presentation or occipitoposterior position.

2-If the head is high above pelvic brimas in pelvic contraction

3-in premature or small fetus
4-multiple pregnancy
5-if the cord is unduly long
6-cord insertioninto placenta which is partially sited in the lower segment as type1or 2 placenta previa.


Diagnosis
Presentation of the umbilical cord can be felt through the intact back of membranes&pulsation of its vessels can be recognized.
In prolapse of the cord the diagnosis is easy as loop of cord is felt in the vagina or may even present at the vulva which is felt to know if pulsation is present,but sometimes pulsations are abscent&the baby still alive because the cord is compressed so fetal heart should be heard through the abdomen.

Whenever presentation or prolapse of the cord is diagnosed,the degree of dilatation of the cervix&the presentation should be noted.

Management

A-If the fetus is alive:the treatment is immediate delivery;
1-If the cervix is not fully dilated delivery will be by caesarean section,while preparations for c/s are being made;steps should be taken to relieve pressure on the cord,which include:

Position the patient in knee-chest position

Maintain digital pressure to push the presenting part as far out of the pelvic cavity
Sometimes passing urinary catheter &filling the bladder through it with normal seline
Replace the exposed cord in the vagina to keep it warm&prevent vasospasm

At the same time the assisstant should:

Establish I-V access with cannula
Take blood for haemoglobin level&cross-match
Give an H2 receptor agonist&/or antacid

2-If the cervix is fully dilated:

If it is cephalic presentation&there is no other complications as contracted pelvis,immediate delivery with forceps or vacuum is performed when the head is descending with the contractions.
In breech presentation:in multiparous woman with no other contraindications breech extraction is done,otherwise c/s is indicated.
Any other malpresentation c/s is indicated.


B-If the fetus is dead&the lie is longitudinal&there is no contraindication normal vaginal delivery should be anticipated which may require oxytocin infusion&/or analgesia

Prognosis

The prognosis for the fetus is poor,still birth or neonatal death occurs in about 20% of cases,especially in cephalic presentation&if the prolapse occur far away from hospital.
For the mother descend of the cord often calls for speedy delivery by forceps or c/s&these procedures increase the risk of mother to some extent.