Transverse lie , Cord and complex presentations By Dr. Hazem Abdelghaffar Lecturer of OB/GYN Sohag 2013 SHOULDER PRESENTATION (TRANSVERSE LIE): Definition: The long axis of the fetus crosses that of the mother with the head on one side and the breech on the opposite side of the middle line. Incidence: About 1/200 (0.5%). Etiology: Any condition which changes the shape of the uterus, pelvis or the fetus or prevents engagement or allows free mobility of the fetus favours transverse lie as: 1- Laxity of the abdominal and uterine muscles in multipara ( the commonest cause in general and the commonest cause in multipara) 2- Contracted pelvis ( accounts for most cases in primigravidae) 3- Placenta previa You should not conduct pelvic exam. For a case of transverse lie unless you have excluded placenta previa by ultrasonic exam. 4- Polyhydramnios. 5- Multiple pregnancy. 6- Prematurity. 7- Intrauterine fetal death. 8- Congenital malformation of the uterus as bicornuate, subseptate or arcuate. 9- Tumors of the uterus as fibroid. Positions: The scapula is the denominator. There are 4 positions depending on the position of the back and direction of the head: 1st: left scapuloanterior: back anterior and head to the left. 2nd: right scapuloanterior. 3rd: right scapuloposterior. 4th: left scapuloposterior. Scapuloanterior is more common than scapuloposterior as in the former the concavity of the front of the fetus fits into the convexity of the maternal spine. Mechanism of labor: There is no mechanism and the labor is obstructed. Rarely, one of the following may occur early in labor before rupture of membranes: Spontaneous rectification: into vertex. Spontaneous version: into breech. In extremely rare conditions, if the fetus is very small, the pelvis is very wide and the uterine contraction is strong one of the following may occur: Spontaneous expulsion: the fetus is folded like the letter V and expelled. Spontaneous evolution: the head is retained above the pelvic brim, the neck greatly elongated; the breech descends followed by the trunk and the aftercoming head. Diagnosis: (A) During pregnancy: (1) Inspection: The abdomen is broader from side to side. (2) Palpation: Fundal level: Lower than level expected from the period of amenorrhea. Fundal grip: Neither head nor breech are felt in the fundus (empty). Umbilical grip: The head is felt on one side and the breech on the other. The head is usually at a lower level that is in one iliac region. Pelvic grip: Neither head nor breech is felt (empty). (3) Auscultation: FHS at the side of umbilicus towards the head. (4) Ultrasonography : Confirm the diagnosis. Exclude any abnormality in the fetus or in the pelvis. (B) During labor: Vaginal examination: revealed: (1) Slow dilatation of the cervix, protruding membranes, presenting part is high and premature rupture of membranes with prolapsed arm or cord is common (2) When the cervix is sufficiently dilated especially after rupture of membranes feel the scapula, the acromin, the clavicle, the ribs and the axilla (the region of the shoulder) (3) If prolapse of the arm occurs, the dorsum of the prolapsed supinated arm points to the back and the thumb to the head. Management: (A) During pregnancy: Do external cephalic version and re examine the patient after one week to be sure that the malpresentation dose not recur. In shoulder presentation, external version can be done up to the end of pregnancy and even early in labor provided that the membranes are intact. (B) During labor: (1) In contracted pelvis placenta previa, previous CS: do caesarean section. (2) Early in labor and membranes intact, try external cephalic version. If succeeded rupture the membranes and apply abdominal binder. If external version fails, wait for further dilatation of the cervix so long as the membranes are intact. (3) If the membranes are ruptured and the cervix is not sufficiently dilated, we do caesarean section which is the safest procedure for both the mother and the fetus. Internal podalic version Its place nowadays is restricted to a second twin and should be conducted under general anesthesia. (4) Internal podalic version is done when the cervix is fully dilated, sufficient amount of liquor is present, the uterus is not tonically retracted and there is no contracted pelvis. Internal podalic version is followed by breech extraction. (5) Caesarean section is indicated in: Contracted pelvis. artially dilated cervix with rupture of membrane prolapsed pulsating cord or fetal distress. Elderly primigravida. n the rare cases of neglected shoulder with living baby. (6) Management of neglected shoulder: It means shoulder presentation that is neglected during labor till the picture of imminent rupture uterus appears, (the shoulder is impacted, the labor is obstructed, the membranes are long ruptured, the liquor is drained, the uterus is tonically retracted i.e. patient is presented with picture of impending rupture of the uterus). Internal podalic version is contraindicated here as it may cause rupture uterus. Management: Caesarean section whether the fetus is living or dead. Decapitation of a dead fetus is not used in modern obstetric. Maternal risks: (1) Prolonged labor and exhaustion, obstructed labor with its complications occur in neglected cases. (2) Lacerations of genital tract (spontaneous and operative). (3) Postpartum hemorrhage. (4) Infection. Fetal risks: Mortality is high due to: (1) Asphyxia. (2) Prolapse of the cord. (3) Operative trauma. CORD PRESENTATION AND PROLAPSE: Definition: Cord presentation is the condition in which coils of the umbilical cord can be felt below the presenting part through the intact bag of waters . Prolapse of the cord is descent of the cord before the presenting part through the cervix into the vagina, after rupture of the membranes Incidence: Prolapse of the cord occurs in 1:150 of malpresentations. The condition is rare in normal vertex presentations Etiology: The condition is favored by an abnormally long cord, and by a low implantation of the placenta. The primary cause is any condition which interferes with adaptation of the presenting part to the lower uterine segment or the pelvic brim. These conditions include contracted pelvis especially flat pelves, malpresentations especially transverse, breech, and occipitoposterior. Premature rupture of the membranes, especially in cases of hydramnios, twins, and multipara with nonengagement of head. The cord may prolapse during intrauterine manipulations as artificial rupture of the membranes and version. Diagnosis: Prolapse of the cord should be anticipated in every malpresentation, and, therefore, a prophylactic measure not to be forgotten is to perform a vaginal examination immediately after rupture of the membranes. The condition should also be suspected when the foetal heart rate shows unusual changes after uterine contractions with no explainable cause. This necessitates frequent recording of the foetal heart sounds to ensure early diagnosis. The presenting loop of the cord can be detected during vaginal examination as a soft ropy structure which pulsates unless the child is dead. After rupture of the membranes there is no difficulty in recognizing a prolapsed loop of the cord present in the vagina or outside the vulva. The condition of the fetus should be determined as a part of the diagnosis. The foetal heart sounds should be estimated for their strength, rate and regularity. Therefore, the cord should be felt between two fingers and the pulsations recorded between two uterine contractions. It should be remembered that the pulsations may cease entirely during a uterine contraction and that they may not be appreciable although the foetal heart may continue to beat for some time. Prognosis: There is practically no danger for the mother except from operative interference carried out for the sake of the child. As long as the membranes are intact there is no special danger to the fetus. The danger arises after the membranes rupture when the cord becomes compressed between the presenting part and the cervical rim. This results in asphyxia from interference with the foetal circulation. The cord is more likely to be compressed in vertex presentation with the cord anterior to the head, in primipara, and when the cervix is not fully dilated. The foetal mortality is very high reaching over 50%. The following factors influence the prognosis: 1. The presentation. In breech and transverse presentations the risk of compression is less than in cephalic presentation. 2. Type of pelvic contraction. Prognosis is worse in cases of generally contracted pelvis than in a flat pelvis as in the latter the prolapsed loop may escape pressure by slipping into one of the bays to either side of the sacral promontory. 3. Extent of the prolapsed loop. A small loop can be more easily replaced and kept up, while on the other hand it is more readily overlooked 4. Age and parity of the patient. The condition is more dangerous in the primipara, especially elderly. 5. The positions of the cord, anterior prolapse in more dangerous than posterior or lateral prolapse 6. The earlier the diagnosis the better the prognosis. Booked cases have a better chance than emergency cases. Management: The choice of treatment is governed by the following factors: 1. Condition of the child. 2. Degree of cervical dilatation. 3. Presentation of the fetus. 4. Age and parity of the mother. 5. Associated complications such as placenta previa or contracted pelvis. A. Cord Presentation: a) With the cervix only partially dilated, the membranes should be preserved intact as long as possible. Postural treatment is recommended to relieve the cord of compression by assuming either the knee chest position, Sim's position, or the Trendelenburg position. In Sim's position, a pillow beneath the lower buttock helps the cord to gravitate towards the fundus. If the postural treatment succeeds in returning the cord above the presenting part, the attendant should push the presenting part well down into the brim and apply an abdominal binder. Postural treatment also serves to lessen the risk of premature rupture of the membranes until the cervix is well dilated. b) When the cervix is fully dilated, immediate delivery is indicated by forceps or internal podalic version after rupture of the membranes. c) Coexisting pelvic deformity or contraction indicates delivery by Caesarean section. B. Prolapse of Cord: If the child is dead as determined by cessation of pulsation in the cord in the interval between contractions, no active treatment should be adopted and the case is left to terminate spontaneously, except if correction of a mal presentation is required, or if the condition of the mother calls for early intervention. If the child is alive, the main factors determining the choice of treatment are the degree of dilatation of the cervix and the type of presentation. Cervix partially dilated: Caesarean section in such cases offers the best chances for the child. Reposition of the cord, both manually or instrumentally, is a waste of valuable time and only succeeds in a small proportion of cases. Reposition is indicated if section cannot be performed quickly as when the patient is at a distance from the hospital. The cord should be sterilized before reposition by painting with an antiseptic as mercurochrome. In cases of breech it is useful to bring down a leg after reposition. b) Cervix fully or nearly fully dilated: In cephalic presentations if the head is engaged it is extracted by forceps without need for reposition. If the head is high or the position transverse or complex internal podalic version with breech extraction should be performed. In breech presentation breech extraction is carried out without delay. Indications for Caesarean Section in Prolapse of the Cord: 1. Partially dilated cervix. 2. Elderly primipara. 3. Coexisting abnormality of the pelvis. 4. Associated complications such as placenta previa, large fetus, and brow and mentoposterior positions. Trendelenburg position of the mother, the administration of oxygen, and the presence of an assistant holding the infant's presenting part out of the pelvis until the operating room can be prepared, are factors which are often helpful in preserving the fetal life until delivery. COMPLEX PRESENTATION: Definition: Prolapse of one or more of the foetal limbs beside the presenting head. Most commonly the arm presents with the head and occasionally both hands or a hand and a foot may present with the head. Incidence: The condition occurs in about one in 800 labors. Etiology: The etiological factors here are in general similar to those that predispose to prolapse of the cord, mainly those conditions in which the head does not fit the maternal pelvic inlet as in contracted pelvis and Cephalopelvic disproportion or cases where the head is small in relation to a large pelvis. Other predisposing factors are hydramnios, multiparity, twins floating head, sudden escape of the liquor amnii as in artificial rupture of the membranes before engagement of the head. Diagnosis: The condition is only diagnosed on vaginal examination. It is essential to differentiate the condition by careful palpation from cases of transverse presentation with prolapse of an arm, and from footling presentation in cases of breech. Because both have the same etiological factors, a prolapsed cord should always be excluded in cases of complex presentation. Management: With a small baby the head may engage and labor may progress normally. Usually, however, the prolapsed limb interferes with progress of the head in the second stage. In such cases the limb should be replaced and forceps applied to the head. Thank You
"transverse lie final "