1. Transverse lie and oblique lie cord presentation and prolapse
Dr. Asmaa Al Sanjary
Lecturer in Obs./gyn.

2. Transverse lie and oblique lie:
The baby lie with it’s long axis transverse or oblique in the uterus.
Occurs once in 500 labours.

4. Position : The fetus may lie in either iliac fossa ,
with the back sloping obliquely across
the pelvic brim, the breech occupies higher level in the opposite direction of the abdomen.
Two positions are described:
Dorsoanterior
Dorsoposterior

5. Aetiology: Multiparity. Prematurity. Polyhydramnios.
Multiple pregnancy.
Contracted pelvis,placenta previa ,fibroid.
Uterine malformation.

6. Diagnosis: Abdominal examination:
Uterus appears asymmetrical ,broader and lessthan expected for gestational age.
palpation reveals hard head at one iliac
fossa and softer breech one the other
side. no presenting part is felt over the
brim with the back is felt anteriorely in
dorsoanterior and fetal parts in dorso-
posterior.

7. Vaginal examination:
In early labour the presenting part is high can’t be reached ,membranes may rupture early.
When the cervix become dilated an arm or a loop of cord may prolapse.
Diagnosis of shoulder presentation
depends on recognition of acromion
process ,scapula and adjacent ribs.

8. Cource of labour: There is no true mechanism of labour
Untreated case will ends in obstructed
labour ,rupture of uterus and fetal death.
Delivery not occurs until the fetus is macerated or premature. (doubled up)

9. Treatment :
Caesarean section should be performed in persistant transverse lie presentation.
Internal podalic version in delivery of second twin (transverse lie).
External cephalic version may be tried in selected cases before labour or in early labour .
In advanced labour or in case of ruptured
membrane C.S. IS SAFER EVEN IN A CASE OF
FETAL DEATH.

10. Unstable lie
Is a term used when the fetal lie and presentation is repeatedly changed after 36 weeks of pregnancy .
The lie being variable between longitudinal, transverse and oblique.
By 36 week the fetus usually adopt stable lie and presentation which will be unchanged until the onset of labour.
Incidence is 0.1% -1% .

11. Risks of unstable lie : PROM. Cord presentation and cord prolapse.
Compound presentation.
Uterine rupture.
fetal distress and death.

12. Causes of unstable lie:
Multiparty.
Polyhydramnios.
Multiple pregnancy .
Fetal anomaly
Placenta previa .
Pelvic tumour as fibroid,ovarian cyst.
Uterine anomaly.
Contracted pelvis or fetal macrosomia.

13. Management : Clinical assessment : History. Examination :
-abdominal examination to exclude polyhydramnios .
Determine the lie and presentation.
-Pelvic examination : assess the capacity of the Pelvis,
tumour in the pelvis (after excluding placenta
previa).
Investigation :
-US : for diagnosis of the lie and presentation and
exclusion of the underlying cause.
-X ray :no place if US is available.

14. Management options for delivery :
No intervention : the lie will become
longitudinal in >80% of cases before the
onset of labour. (as out patient or
admitted in the hospital till spont.version)

15. Active:
External cephalic version,then induction
of labour and low amniotomy.
To induce controlled release of liquor use the
Drew-smythe catheter with it’s stylet inside to
puncture the amniotic membrane and allows
controlled release of liquor.
Elective C.S. at weeks gestation
with version to longitudinal lie during laprotomy
if there is contraindication to external cephalic
version or fails or contraindication to vaginal
delivery.

16. Cord presentation : Cord prolapse :
Cord presentation : is when the cord
presented in the birth canal over the cervix with intact membrane .
Cord prolapse :when the cord prolapsed out of cervix after the sac is ruptured.
Incidence once in deliveries.

17. Aetiology: Presenting part does not fill the lower segment.
Prematurity.
Multiparty.
Operative maneuvers. (amniotomy)
Abnormality of the cord. (long, low placental
insertion)
Fetal hypotension .(cord is not turgid as in
abruptio placentae)

18. Diagnosis: Coils of cord may be felt in the fore waters.
If pulsating present distinction is easy .
Cord compression is possible if the liquor is
scanty especially if the head presents.
When the membrane have ruptured the cord prolapse into the vagina and may protrude out of the vulva.
Absence of the pulsation in the umbilical cord
is unreliable as evidence of fetal death .

20. Anticipation:
All patients should come to the hospital early in labour (in 25% of cases occurs before admission).
Comes once they notice a leaking liquor even if no contraction.
Those women at risk (hydramnio ,unstable or oblique lie, malposition , malpresentation ,CPD ,) should be admitted electively in late pregnancy.

21. Every patient for amniotomy is a potential
candidate for C.S., look for the level of the
presenting part before surgical induction, if
high then stimulate contraction before
amniotomy and exclude cord prolapse by
pelvic examination .
Fetal heart external monitoring may suggest
cord complication even before rupture of the
membranes.

22. MANAGEMENT :
Fetus a live and sufficiently mature the ideal is immediate delivery by C.S.
While waiting for C.S. postural treatment involves :
The cord should be replaced within the warm,
moist vagina ,so preventing vasospasm.
Placing fingers in the vagina lifting the
presenting part.
Placing patient in trendelenberg’s position
or Knee elbow position .
Full the bladder with ml of saline ,used when the patient transported for some distance .

23. Rare exception: When the cervix is fully dilated. Multipara.
Longitudinal lie.
Normal fetal heart
Choose between C.S. or rapid delivery by
vacuum or forceps .
Virtually in all cases of cord prolapse C.S. to be
preferred treatment .

24. In cases of fetal death (absent fetal heart) cord prolapse can be ignored .
Prognosis
Prompt diagnosis at amniotomy and a short
diagnosis to delivery interval result into low fetal
mortality .
Mortality is 5.5% if delivery was effected with in
10 minutes.
C.S. is preferred Because of lower perinatal
mortality even in cases approaching full
dilatation cervix.

25. Thank you