Shoulder Presentation (Transverse lie)

Subject: Midwifery II (Theory)

Overview

A transverse lay occurs when the fetus's long axis crosses the long axis of the uterus. In either situation, the shoulder frequently appears over the cervical opening during labor, and so both are referred to as shoulder presentation. If a transverse lie is found in early labor while the membranes are still intact, the obstetrician and pediatrician should be notified of a possible cesarean section. If the external version is successful, a controlled membrane rupture should be performed. When the cord prolapses, the membranes have ruptured, and labor has been ongoing for several hours, an emergency cesarean section must be performed.

A transverse lie occurs when the fetus sits with its long axis across the long axis of the uterus. However, the fetus axis is more typically situated oblique to the maternal spine, resulting in an oblique lying.

In any of these conditions, the shoulder usually appears above the cervical opening during labor, and so both are referred to as shoulder presentation.

Cause

Maternal Factors

  • Multiparity
  • Uterine abnormality
  • Contracted pelvis
  • Pelvic tumors

Fetal Factors

  • Prematurity
  • Multiple pregnancies
  • Polyhydramnios
  • Intra -uterine death/ macerated fetus
  • Placenta previa

Management

  1. If a transverse lying is discovered during early labor while the membranes are still intact, the obstetrician and pediatrician should be notified of a possible cesarean section.
  2. If the external version is successful, a controlled rupture of the membrane should be performed.
  3. If the membranes have already ruptured, a PV exam must be performed right away to detect potential cord prolapse.
  4. An immediate cesarean section is required when:
    - the cord has prolapsed.
    - the membranes have already ruptured.
    - the external version has failed.
    - labor has already begun for several hours.
  5. Shoulder impaction causes obstructed labor if the fetus is already dead. To remove the fetus, a destructive operation should be performed. Following the operation, the uterine cavity will be probed to rule out uterine rupture.
  6. In present practice, whether the fetus is alive or dead, persistent transfer lying in labor is delivered with cesarean section.

References

  • onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2009.02376.x/pdf
  • Tuitui, Roshani, and S. N. Dr. Suwal. Manual of Midwifery II (Intrapartum Care). Bhotahity, Kathmandu: Vidyarthi Pustak Bhandar, 2014.
  • www.uptodate.com/contents/transverse-fetal-lie
  • http://www.fpnotebook.com/ob/Ld/ShldrPrsntn.htm 
Things to remember
  • A transverse lie occurs when the fetus sits with its long axis across the long axis of the uterus.
  • However, the fetus axis is more typically situated oblique to the maternal spine, resulting in an oblique lying.
  • In any of these conditions, the shoulder usually appears above the cervical opening during labor, and so both are referred to as shoulder presentation.
  • Cause Shoulder manifestations include multiparity, uterine abnormalities, contracted pelvis, prematurity, intra-uterine death/macerated fetus, and other conditions. If a transverse lying is discovered during early labor while the membranes are still intact, the obstetrician and pediatrician should be notified of a possible cesarean section.
  • If the external version is successful, a controlled rupture of the membrane should be performed.
  • When the cord prolapses, the membranes have ruptured, and labor has been ongoing for several hours, an emergency cesarean section must be performed.
Questions and Answers

A transverse lying occurs when the fetus crosses the uterine long axis with its long axis. However, the fetal axis is more frequently positioned oblique to the maternal spine, which is known as an oblique lie.

Both conditions are referred to collectively as shoulder presentation because during labor, the shoulder typically presents over the cervical opening.

 

Cause

Maternal

  • Multiparity,
  • Uterine abnormality,
  • Contracted pelvis,
  • Pelvic tumors.

Fetal Factors

  • Prematurity,
  • Multiple pregnancy,
  • Polyhydramnios,
  • Intra -uterine death/ macerated fetus,
  • Placenta previa.

Management

  • If a transverse lie is detected in early labour while the membranes are still intact, obstetrician and pediatrician should be informed for possible caesarean section.
  • An attempt is done for external version if this is success , a controlled rupture of membrane should be done.
  • If membranes have already ruptured PV exam must perform immediately to detect possible cord prolapse.
  • Immediate caesarean section must be performed when:
    • The cord prolapse,
    • The membranes are already ruptured,
    • External version is unsuccessful,
    • Labour has already been in progress for some hours.
  • If a fetus is already dead , shoulder impaction leads to obstructed labour. Destructive operation should do to remove the fetus. After operation, the uterine cavity is to be explored to exclude rupture of the uterus
  • In modern practice, persistent transfer lie in labour is delivered by caesarean section whether the fetus is alive or dead.

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