Management of the fetus in transverse lie

Author
Watson A Bowes, Jr, MD
Section Editor
Charles J Lockwood, MD
Deputy Editor
Vanessa A Barss, MD

Disclosures

Last literature review version 19.3: Fri Sep 30 00:00:00 GMT 2011 | This topic last updated:
Mon Sep 13 00:00:00 GMT 2010 (More)

INTRODUCTION — The fetus is in a transverse lie when its longitudinal axis is

perpendicular to the long axis of the uterus. A transverse lie can occur in either of two
configurations:

 The curvature of the fetal spine is oriented upward (also called "back-up" or
dorsosuperior), in which case the fetal small parts present at the cervix.
 The curvature of the fetal spine is oriented downward (also called "back-down" or
dorsoinferior), such that the fetal shoulder presents at the cervix (figure 1).

INCIDENCE — Transverse fetal lie occurs in approximately one in 300 deliveries [1,2]. In
contrast, the fetus is often found in a transverse lie when ultrasound examination is performed
early in gestation [3].

NATURAL HISTORY — Most fetuses in transverse lie early in pregnancy convert to a

cephalic (or breech) presentation by term. The later in pregnancy the transverse lie is
diagnosed, the more likely it is to persist. This was illustrated in a series of 235 patients with
transverse fetal lie incidentally discovered by sonography at more than 20 weeks gestation
[4]. When the diagnosis was first made between 20 to 25 weeks of gestation, 2.6 percent
persisted as transverse lie at term. By comparison, when the diagnosis was first made at 36 to
40 weeks, 11.8 percent persisted to the time of delivery.

In another series of 29 patients with transverse lie at 37 weeks of gestation, 24 (83 percent)
spontaneously converted to a longitudinal lie and presented in labor with either a vertex (15)
or breech (9) presentation [5]. Transverse lie persisted in the five (17 percent) remaining
patients. Overall, the cesarean delivery rate was 13 of 29 (45 percent); indications were
breech in eight and transverse lie in five.

ETIOLOGY — A number of theories have been proposed to account for fetal position within
the uterus and the eventual cephalic presentation of most fetuses as pregnancy reaches term.

Gravity and fetal comfort are factors that have been suggested as playing important roles [6].
Early in pregnancy when the volume of amniotic fluid is relatively large in relation to the
volume of the fetus, the fetus is often found in a noncephalic presentation. As pregnancy
continues and the volume of amniotic fluid diminishes in relationship to fetal size, the fetus is
usually found in a longitudinal orientation with the greatest mass of the fetus (the buttocks
and flexed thighs) in the fundal area of the uterus. The longitudinal lie presents a body axis
posture along the line of gravity and with the least constriction to overall fetal movement.
Prematurity is the most common factor noted in any series of deliveries complicated by
transverse lie. Other clinical conditions associated with transverse lie include high parity,
placenta previa, contracted pelvis, uterine anomalies or tumors, polyhydramnios, fetal
anomaly, and multiple pregnancy [1,4,7]. The site of placental implantation, distortion of the
uterus by anatomical factors, and uterine distension modify the configuration of space within
the uterine cavity and likely affect fetal position by this mechanism.

COMPLICATIONS — In developing countries where placental imaging, urgent cesarean

delivery, and neonatal intensive care are not readily available, the maternal and perinatal
mortality/morbidity associated with transverse lie in labor can be high. As an example, a
report from the Korle Bu Hospital in Accra, Ghana described 152 patients in labor with
transverse lie (from 1996 to 1998) in whom there were two maternal deaths, 25 stillbirths,
and 37 infants requiring hospital care [8].

Even though modern perinatal care has reduced much of the morbidity and mortality
associated with this condition, these pregnancies are, nevertheless, at increased risk of
maternal and perinatal morbidity as compared to pregnancies in which the fetus is a cephalic
or breech presentation. In developed countries, placenta previa, prolapse of the umbilical
cord, fetal trauma, and prematurity contribute to morbidity from transverse lie [5,9]. In
developing regions, uterine rupture from prolonged labor in a transverse lie is also a major
reason for maternal/perinatal mortality and morbidity [10]. (See "Umbilical cord prolapse".)

CLINICAL MANIFESTATIONS AND DIAGNOSIS — Not infrequently, the gravida

suspects transverse lie because of an abnormal configuration of her abdomen or discomfort
associated with the position of the fetal head in her flank.

The diagnosis can be made by abdominal palpation utilizing Leopold's maneuvers (figure
2) [11]. Transverse lie should be suspected if firm resistance of the fetal head is not detected
above the symphysis pubis and can be diagnosed when further palpation confirms the
position of fetal head in one or the other of the mother's flanks. Location of the fetal back (up
or down) may be more difficult, especially if the patient is obese. Sensitivity for detecting
non-cephalic presentation (breech, oblique, or transverse lie) by abdominal palpation at 35 to
37 weeks of gestation is only 70 percent. Although the accuracy of detecting transverse lie by
abdominal palpation is likely to be greater than for breech presentation, the sensitivity for
detecting transverse lie by abdominal palpation is not known because the incidence of this
abnormal presentation is too low to conduct a robust study [4]. If transverse lie is suspected
by abdominal palpation, a vaginal examination should be postponed until placenta previa has
been excluded.

Ultrasound examination is used to confirm the diagnosis and determine the precise position
of the fetus. In addition, a survey of maternal pelvic and fetal anatomy should be performed
to look for abnormalities or conditions associated with transverse lie (see 'Etiology' above).

MANAGEMENT — Management of transverse lie depends upon the clinical circumstances

at the time the diagnosis is made. Important factors to consider include the position of the
placenta, length of gestation, viability of the fetus, whether labor has begun, and whether
membranes have ruptured.

Placenta previa — Patients with coexistent placenta previa must be delivered by cesarean.
(See "Clinical manifestations and diagnosis of placenta previa".)
Previable or dead fetus — If labor occurs with a previable fetus or dead fetus very early in
gestation, and placenta previa has been ruled out, vaginal delivery can be attempted. Collapse
of the fetal body (conduplicato corpore) allows delivery by this route in many cases. Internal
podalic version may also be considered (figure 3A-B) [12-14]. Such a delivery should be
attempted only by an obstetrician who has experience with this maneuver because of the risk
of uterine rupture.

Viable fetus — If pregnancy has reached the stage of fetal (newborn) viability, there are two
options:

 Cesarean delivery
 Version of the fetus to a longitudinal lie

Intrapartum or ruptured membranes — If labor has begun or membranes have ruptured,

cesarean delivery is generally recommended. However, if membranes are intact, version to
either a cephalic or breech presentation may be considered. The only report describing this
approach is a series of 12 patients in labor with a transverse lie who were managed with
external version under tocolysis [15]. Version to a longitudinal presentation was successful in
ten patients (nine cephalic, one breech). Six patients delivered vaginally and the remainder by
cesarean.

Antepartum — In situations in which the diagnosis is made prior to the onset of labor at or
near term (≥37 weeks of gestation), and in the absence of contraindications to a vaginal
delivery, one option is external version to cephalic presentation, followed by artificial rupture
of the membranes while the vertex is held in position, and induction of labor [9]. If the vertex
is high in the pelvis when membranes are to be ruptured, the procedure should be performed
in a delivery room and with needle punctures rather than an amniohook to control the flow of
amniotic fluid and reduce the risk of cord prolapse. The indication for induction of labor is
that successful external cephalic version of a transverse lie is frequently followed by
spontaneous reversion of the fetus to an unstable lie. This is in contrast to successful external
version in patients with a breech presentation, where reversion to breech presentation is
unusual. (See "External cephalic version".)

If the version is unsuccessful, a cesarean delivery should be performed.

Only one study has compared active management using external version plus elective
induction of labor at ≥37 weeks of gestation to expectant management [16]. Among 102
patients managed actively, there was one instance of prolapsed cord and no perinatal deaths,
while among 50 patients managed expectantly, there were 10 instances of cord prolapse and 4
perinatal deaths. The incidence of cesarean delivery was lower among women managed
actively (11 versus 40 percent). Therefore, based on the small amount of data available, it
appears that active intervention at ≥37 weeks of gestation will result in fewer perinatal deaths
from spontaneous rupture of membranes and cord prolapse than expectant management, and
also offers the mother, who is often a multiparous patient, a higher likelihood of vaginal
delivery. Based on data from a nationwide study in the Netherlands, the risk that an infant
born at 37 weeks of gestation by elective cesarean delivery will develop respiratory morbidity
of any severity is 6.8 percent, and the risk of neonatal death is less than 1 in 1500 [17]. These
risks are lower than the risk of prolapse of the umbilical cord leading to perinatal death after
37 weeks, which is 5 to 10 percent in patients who are managed expectantly [16].
Second twin — After delivery of the first twin, the second twin may assume a transverse lie,
regardless of its original position in the uterus. This situation can often be resolved
successfully with internal podalic version and total breech extraction (figure 3A-B) [18]. This
procedure should be accomplished promptly after delivery of the first twin while the cervix is
fully dilated and the membranes of the undelivered twin are still intact [5]. Such a delivery
should be attempted only by an obstetrician who has experience with this maneuver because
of the risks of uterine rupture and fetal trauma.

An alternative maneuver is external cephalic version using ultrasound to monitor the

procedure and the ultrasound transducer to assist with the version, as illustrated in the figure
(figure 4) [19].

There are no prospective trials that have conclusively determined the relative merits of
internal versus external version for dealing with the second twin. (See "Twin pregnancy:
Labor and delivery".)

Cesarean delivery — The dorsosuperior (back up) transverse lie may be delivered as a
footling breech through a low transverse incision in a well developed lower uterine segment.
Most authorities believe that the low transverse incision cannot safely accommodate the
delivery of a dorsoinferior (or back down) transverse lie due to potential technical difficulties
associated with extraction of the fetus [20]. The dorsoinferior position, in contrast to the
dorsosuperior (back up) position, does not allow the obstetrician to easily grasp the fetal feet
and effect a footling breech extraction. Consequently, a vertical incision in the uterus is
usually employed in these cases and when the lower uterine segment is poorly developed,
such as with many preterm gestations.

On the other hand, a few case series have reported successful delivery with low isthmic
transverse uterine incisions. The authors used this approach for both dorsoinferior and
dorsosuperior fetuses.

 In one series of 66 patients who underwent cesarean delivery for transverse fetal lie,
92 percent were successfully delivered through the low transverse incision;
conversion of this incision into an inverted-T was necessary in 8 percent of cases [21].
Of note, 27 of the 66 fetuses were dorsoinferior and 20 were preterm with an overall
mean gestational age of 33.9 ±2.5 weeks.
 A second report included 80 term patients in which cesarean delivery for singleton
fetuses in transverse lie was accomplished in 79 using a transverse lower uterine
incision, with no extensions of the uterine wound [22]. Neonatal morbidity consisted
of a fractured femur in one infant and torticollis in another, and there was no serious
maternal morbidity related to the method of delivery.

If the fetal membranes are intact at the time the cesarean delivery is performed, intra-
abdominal version of the fetus can convert the transverse lie to a cephalic or breech
presentation allowing delivery through a low-segment transverse incision (figure 5A-B) [23].
A vertical incision in the uterus, even if it is for the most part confined to the lower segment,
is less desirable as it increases the risk of uterine rupture in a subsequent pregnancy. (See
"Choosing the route of delivery after cesarean birth".)

SUMMARY AND RECOMMENDATIONS

  The fetus is in a transverse lie when its longitudinal axis is perpendicular to the long
axis of the uterus. The back may face toward or away from the cervix (called 'back
down' and 'back up' transverse lie, respectively).
 Most fetuses in transverse lie early in pregnancy convert to a cephalic (or breech)
presentation by term.
 In developed countries, placenta previa, prolapse of the umbilical cord, fetal trauma,
and prematurity are the major complications of transverse lie. In developing regions,
uterine rupture from prolonged labor in a transverse lie is also a major cause of
maternal/perinatal mortality and morbidity.
 When transverse lie is diagnosed prior to the onset of labor at or near term (≥37 weeks
gestation), and in the absence of contraindications to a vaginal delivery, we suggest
external version to cephalic presentation, followed by artificial rupture of the
membranes while the vertex is held in position, and induction of labor.
 If labor has begun or membranes have ruptured, we suggest cesarean delivery. We
suggest delivery through a low transverse incision for the dorsosuperior (back up)
position. Delivery of the dorsoinferior (back down) position can also be accomplished
through a low-transverse incision by performing intra-abdominal version of the fetus.
 If labor occurs with a previable fetus or dead fetus very early in gestation, and
placenta previa has been ruled out, vaginal delivery can be attempted as the small,
collapsed fetal body can often pass through the birth canal.

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