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Transverse fetal lie

Transverse fetal lie
Literature review current through: Jan 2024.
This topic last updated: Feb 01, 2023.

INTRODUCTION — Transverse lie refers to a fetal presentation in which the fetal longitudinal axis lies perpendicular to the long axis of the uterus. It can occur in either of two configurations:

The curvature of the fetal spine is oriented downward (also called "back down" or dorsoinferior), and the fetal shoulder presents at the cervix (figure 1).

The curvature of the fetal spine is oriented upward (also called "back up" or dorsosuperior), and the fetal small parts and umbilical cord present at the cervix.

(Note: Lie refers to the long axis of the fetus relative to the longitudinal axis of the uterus; the long axis of the fetus can be transverse to, oblique to, or parallel to [longitudinal lie] the longitudinal axis of the uterus. Presentation refers to the fetal part that directly overlies the pelvic inlet; it is usually cephalic [head] or breech [buttocks] but can be a shoulder, compound [eg, head and hand], or funic [umbilical cord]. Position is the relationship of a nominated site of the presenting part to a denominating location on the maternal pelvis [eg, right occiput anterior].)

PREVALENCE — Approximately 1 in 300 fetuses is in a transverse lie at delivery [1,2]. It is most common early in pregnancy [3].

NATURAL HISTORY — Transverse lie is unstable: Most fetuses in this lie early in pregnancy convert to a cephalic or breech presentation with advancing gestation.

In one report, 85 percent of 146 fetuses in transverse lie at 24 to 28 weeks of gestation converted to a longitudinal lie by term [4].

In another report of 29 fetuses in transverse lie at 37 weeks of gestation, 83 percent (24/29) spontaneously converted to a longitudinal lie when presenting in labor (cephalic [15/24], breech [9/24]) [5]. Transverse lie persisted in the remaining 17 percent (5/24) of pregnancies. Overall, the cesarean birth rate was 45 percent (13/29); indications were breech presentation in eight cases and transverse lie in five cases.

PATHOGENESIS AND RISK FACTORS — A number of theories have been proposed to explain fetal lie/presentation and the eventual longitudinal lie/cephalic presentation of most fetuses as pregnancy reaches term. Gravity and fetal comfort may play 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 less constrained by the size of the uterine cavity and is often in a noncephalic presentation. As pregnancy continues and the volume of amniotic fluid diminishes relative to fetal size, the fetus usually assumes a longitudinal lie with the greatest mass of the fetus (the buttocks and flexed thighs) at the fundus. The longitudinal lie presents a body axis posture along the line of gravity and with the least constriction to overall fetal movement.

Preterm gestation is the most common risk factor for transverse lie. Other risk factors include high parity, placenta previa, contracted pelvis, uterine anomalies or tumors, polyhydramnios, fetal anomaly, and multiple gestation [1,7,8]. The site of the placental implantation, uterine distortion by anatomic factors, and uterine distension associated with these risk factors modify the space within the uterine cavity and likely affect fetal lie by this mechanism.

COMPLICATIONS — Even though modern perinatal care has reduced much of the morbidity and mortality associated with transverse lie, these pregnancies are still at increased risk of maternal and perinatal morbidity as compared with pregnancies in which the fetus is in a longitudinal lie.

In resource-abundant countries, placenta previa, prolapse of the umbilical cord, fetal trauma, fetal anomalies, and preterm birth contribute to morbidity from transverse lie [5,9]. In resource-limited countries where ultrasound imaging, urgent cesarean birth, and neonatal intensive care are not readily available, the maternal and perinatal mortality/morbidity associated with transverse lie in labor can be high. Uterine rupture from prolonged labor in a transverse lie is a major reason for maternal/perinatal mortality and morbidity [10]. If labor is allowed to progress in the transverse lie, the shoulder will become impacted in the upper maternal pelvis, resulting in a pathologic uterine contraction ring, called the "Bandl ring," which produces a thin lower uterine segment that is prone to rupture [11]. A report from the Korle Bu Hospital in Accra, Ghana, described 152 patients in labor with transverse lie from 1996 to 1998: Pregnancy outcome included two maternal deaths due to sepsis and hemorrhage, 25 stillbirths, and 37 infants requiring hospital care [12]. Fetal/newborn complications included asphyxia, preterm birth, and septicemia.

CLINICAL MANIFESTATIONS AND DIAGNOSIS

Maternal symptoms – Not infrequently, the pregnant individual suspects transverse lie because of an abnormal configuration of their abdomen or discomfort due to the fetal head in their flank.

Clinical diagnosis – The clinical diagnosis can be made by abdominal palpation utilizing Leopold maneuvers (figure 2). Transverse lie should be suspected when the firm resistance typical of the fetal head is not appreciated upon palpation of the uterus above the symphysis pubis. Additional palpation will detect the fetal head in one of the mother's flanks, confirming the diagnosis. The location of the fetal back up or down is more difficult to determine, especially if the patient has obesity.

The sensitivity of abdominal palpation for detecting noncephalic presentations (breech, oblique, or transverse lie) at 35 to 37 weeks of gestation is approximately 70 percent. Although abdominal palpation is more likely to correctly identify a transverse lie than a breech presentation, the sensitivity of abdominal examination for detecting transverse lie is not known because the prevalence of this abnormal presentation is too low to conduct a robust study [7].

Ultrasound confirmation – Ultrasound examination is used to confirm the diagnosis and determine the precise lie, presentation, and position of the fetus. In addition, a survey of uterine and fetal anatomy should be performed when transverse lie is identified to look for abnormalities or conditions associated with this unstable position, such as placenta previa (see 'Pathogenesis and risk factors' above). If transverse lie is suspected by abdominal palpation and placenta previa has not been excluded by ultrasound examination, a digital vaginal examination should not be performed until the absence of previa is ascertained.

MANAGEMENT OF DELIVERY — Most fetuses in transverse lie are delivered by cesarean birth. The route of birth depends on the clinical circumstances at the time the diagnosis is made. Important factors to consider include the positions of the placenta and umbilical cord, gestational age and viability, whether labor has begun or membranes have ruptured, and whether the transverse lie is a second twin.

Transverse lie, intact membranes, live fetus

Approach before onset of labor — When the diagnosis of a singleton fetus in transverse lie is made before the onset of labor and in the absence of contraindications to a vaginal birth, we perform external version (ECV) to cephalic presentation at 37+0 to 37+6 weeks of gestation, as amniotic fluid volume is maximal and uterine tone and fetal weight are less than later in gestation, which likely improves success rates. Also, if complications arise during an attempted ECV, emergency cesarean birth of a term infant can be accomplished.

If ECV is successful but the nonlongitudinal lie (ie, transverse, oblique) recurs, we reattempt ECV at 38+0 to 39+6 weeks of gestation. If again successful, we induce labor [9].

If ECV is declined or the first or repeat ECV is unsuccessful, then cesarean birth is performed at 39+0 to 39+6 weeks. If a funic presentation is identified, cesarean birth at term should be considered since cord prolapse can complicate labor [13]. (See "Umbilical cord prolapse", section on 'Pregnancies with funic (cord) presentation'.)

An alternative approach is to perform the initial ECV at 39+0 weeks, immediately followed by iatrogenic rupture of membranes and labor induction of the now cephalic presentation. This approach is likely associated with a higher risk of unsuccessful ECV but also reduces the risk of reversion to a nonlongitudinal lie and need for a repeat procedure. (See "External cephalic version", section on 'Nonlongitudinal lies'.)

The rationale for induction of labor rather than expectant management is that transverse lie is an unstable presentation that may have resulted from physical factors (eg, contracted pelvis, uterine anomalies or tumors, polyhydramnios, fetal anomaly) that persist after successful ECV, thus prompting spontaneous reversion. This is in contrast to successful ECV in breech presentation, where reversion to breech presentation is uncommon. (See "External cephalic version".)

Only one study has compared active management (ECV plus planned induction of labor at term) with expectant management of transverse lie [14]. Among the 102 patients managed actively, one prolapsed umbilical cord and no perinatal deaths occurred, while among the 50 patients managed expectantly, there were 10 cord prolapses, four arm prolapses, and one perinatal death related to delivery of a fetus with arm prolapse. Three other perinatal deaths in the expectant management group were associated with major congenital anomalies. The cesarean birth rate was lower among patients managed actively (11 versus 40 percent). Based on these limited data, it appears that active intervention at ≥38 weeks of gestation may result in fewer perinatal deaths and cord prolapse from spontaneous rupture of membranes compared with expectant management, and also offers the mother, who is often multiparous, a higher likelihood of vaginal birth. In a population-based study, the risk that a neonate born at 38 weeks of gestation by scheduled cesarean birth will develop respiratory morbidity of any severity was 3.5 percent, and the risk of neonatal death was less than 1 in 1500 [15]. These risks are less than the risk of prolapse of the umbilical cord or arm after 37 weeks, which may be as high as 28 percent in patients who are managed expectantly [14].

Approach in early labor — For patients in early labor with a singleton fetus in transverse lie, intact membranes, and a live fetus, we suggest ECV to cephalic presentation if there are no contraindications to ECV. (See "External cephalic version", section on 'Candidates'.)

If ECV is successful in converting to a longitudinal lie and the cervix is adequately dilated and the presenting part well-applied to the cervix, amniotomy is performed. In the only study of this approach, 12 patients in labor with a transverse lie were given tocolysis and then underwent ECV [16]. Successful version to a longitudinal presentation (nine cephalic, one breech) was achieved in 10 patients (83 percent), and 6 patients (50 percent) gave birth vaginally.

Conversely, if ECV is unsuccessful in converting to a longitudinal lie, we perform a cesarean birth.

Approach in active labor — For patients who present in active labor with a singleton fetus in transverse lie, we perform a cesarean birth.

Transverse lie with ruptured membranes, live fetus

If membranes have ruptured and gestational age is ≥34 weeks, we perform a cesarean birth.

If the gestational age is <34 weeks, expectant management is a reasonable option as long as the ability to perform cesarean birth is promptly available, given the increased risk of cord prolapse.

However, in some circumstances (eg, infection, abruption, preterm labor) between 28 and 34 weeks, delivery rather than expectant management may result in a better neonatal outcome. In such settings, we suggest administering a course of antenatal corticosteroids and monitoring the mother and fetus continuously for 48 hours, with intervention if clinically indicated (eg, signs of infection, abnormal fetal heart rate tracing).

After completion of the course of corticosteroids, further management is decided on a case-by-case basis. We may deliver pregnancies with a funic presentation and a dilated cervix, particularly if we believe the patient might be in the latent phase of labor. Lack of local neonatal intensive care unit resources and 24-hour anesthesia availability if emergency delivery is required are other examples of situations where delivery may be preferable to expectant management.

We avoid ECV in patients with ruptured membranes, in agreement with most clinical guidelines [17]. Version is less likely to be successful and the risk of maternal and fetal complications is probably increased [18].

Transverse lie of second twin after delivery of first twin — After birth of the first twin, the second twin may assume a transverse lie, regardless of its original position in the uterus. In such cases:

We perform internal podalic version to breech presentation and then breech extraction of the formerly transverse second twin (figure 3A-B) [19]. This procedure is accomplished promptly after birth of the first twin while the cervix is fully dilated and the membranes of the undelivered twin are still intact [19]. The obstetrician should have experience with this maneuver because of the potential for fetal trauma in difficult cases.

ECV is an alternative approach that is familiar to more obstetricians. The ultrasound transducer is used both to monitor the procedure and assist with the version, as illustrated in the figure (figure 4) [20].

There are no prospective trials that provide high-quality comparative data demonstrating the relative merits of internal versus external version or cesarean birth for managing the birth of the second twin in transverse lie. Based on level of training and experience, the obstetrician should recommend the approach they are most comfortable with. (See "Twin pregnancy: Labor and delivery", section on 'Assessment'.)

Transverse lie with fetal demise or previable fetus

In cases of fetal demise or a previable fetus in transverse lie before labor or in early labor, we suggest ECV to achieve a longitudinal lie (cephalic or breech) regardless of membrane status, followed by induction of labor or augmentation, if appropriate.

If the fetus is in transverse lie during active labor, internal podalic version by an experienced practitioner is an option when the cervix becomes fully dilated, regardless of membrane status [21-23].

However, if the fetus is extremely small (<600 to 800 grams) and dead, the body may collapse and double up on itself (conduplicato corpore) during labor, thus allowing the head and thorax to simultaneously pass through the pelvis and deliver vaginally. This is unlikely to occur if the fetus is alive and at a viable gestational age [24]. If dystocia due to malpresentation occurs, we perform a cesarean birth.

Transverse lie with coexistent placenta previa or umbilical cord prolapse — A coexistent placenta previa or umbilical cord prolapse requires delivery by cesarean birth. (See "Placenta previa: Epidemiology, clinical features, diagnosis, morbidity and mortality" and "Placenta previa: Management" and "Umbilical cord prolapse".)

PROCEDURE FOR CESAREAN BIRTH

Dorsosuperior (back up) transverse lie — For the back up transverse lie in patients with a well-developed lower uterine segment, we make a low transverse hysterotomy using an accentuated curvilinear incision to reduce the risk of extension into the broad ligament. The surgeon standing on the same side as the fetal head then attempts to grasp the fetal feet and perform a footling breech extraction. If this is not readily achievable, a vertical incision is made to form an inverted-T.

In one series of 66 patients who underwent cesarean birth for transverse lie, 92 percent were successfully delivered through the low isthmic transverse uterine incision; conversion of this incision to an inverted-T was necessary in 5 cases (8 percent) [25]. Of note, 39 of the 66 fetuses (59 percent) were dorsosuperior and 27 (41 percent) were dorsoinferior; 20 were preterm with an overall mean gestational age of 33.9±2.5 weeks. The inverted-T was performed in four dorsosuperior presentations (one with ruptured membranes) and one dorsoinferior presentation with ruptured membranes.

A second report included 80 patients at term in whom cesarean birth for singleton fetuses in transverse lie was accomplished in 79 (99 percent) using a transverse curvilinear incision in the lower uterine segment, with no extensions of the hysterotomy [26]. Neonatal morbidity consisted of a fractured femur in one newborn and torticollis in another, and no serious maternal morbidity occurred related to the method of delivery. The number of dorsosuperior and dorsoinferior fetuses was not provided.

Dorsoinferior (back down) transverse lie — The dorsoinferior (back down) transverse lie is more difficult to deliver than the back up transverse lie because the fetal feet are difficult to grasp. If the fetal membranes are intact, we perform an intraabdominal version to convert the transverse lie to a cephalic or breech presentation before making the hysterotomy, thus facilitating delivery through the low segment accentuated curvilinear transverse uterine incision [27].

For the version, one hand is placed on the fetal head and the other hand is placed on the buttocks. The fetal pole that will become the presenting part is very gently manipulated toward the pelvic inlet while the other pole is guided in the opposite direction. Although either cephalic or podalic version can be performed, we have found that breech extraction is technically easier in the setting of a floating fetal vertex presentation. After the version has been completed, an assistant holds the fetus in the longitudinal position so it will not revert to its original position (figure 5A-B), the hysterotomy is made, and the fetus is delivered.

Some experts recommend a vertical uterine incision for the back down transverse lie [11], which is also a reasonable approach. We believe a vertical hysterotomy, even if mostly confined to the lower segment, is less desirable than a transverse incision as it may increase the risk of uterine rupture in a subsequent pregnancy, but it may be necessary if the lower uterine segment is poorly developed. As described in the series above, all 26 dorsoinferior fetuses with intact membranes were successfully delivered through a low transverse incision [25]. If the fetus is large, especially if membranes are ruptured and the shoulder is impacted in the birth canal, a classical incision may be necessary [11].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Labor".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topic (see "Patient education: External cephalic version (The Basics)")

SUMMARY AND RECOMMENDATIONS

Diagnosis – 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). (See 'Introduction' above.)

Prognosis – Most fetuses in transverse lie early in pregnancy convert to a cephalic (or breech) presentation by term. (See 'Natural history' above.)

In resource-abundant regions, prolapse of the umbilical cord, fetal trauma, and preterm birth are the major adverse outcomes associated with transverse lie. In resource-limited regions, uterine rupture from prolonged labor in a transverse lie is also a major cause of maternal/perinatal mortality and morbidity. (See 'Complications' above.)

Management

Antepartum – For patients with transverse lie prior to the onset of labor and in the absence of contraindications to a vaginal birth, we perform external version to cephalic presentation at approximately 37+0 to 37+6 weeks of gestation. If the transverse lie recurs, we reattempt external cephalic version at 38+0 to 39+6 weeks of gestation. If successful, we induce labor. If unsuccessful, we perform a cesarean delivery at 39+0 to 39+6 weeks of gestation. (See 'Approach before onset of labor' above.)

Early labor with intact membranes – For patients in early labor with a singleton fetus in transverse lie and intact membranes, we attempt external version to cephalic presentation. If successfully converted to a longitudinal lie and the cervix is adequately dilated and the vertex well-applied to the cervix, amniotomy is performed. (See 'Approach in early labor' above.)

Active labor or ruptured membranes – For patients with a transverse lie in active labor or with ruptured membranes, we perform a cesarean birth. (See 'Approach in active labor' above and 'Transverse lie with ruptured membranes, live fetus' above.)

Second twin – For patients with a transverse lie of the second twin after delivery of the first twin, we perform internal version to breech presentation and breech extraction of the nonvertex second twin. External version is also a reasonable approach. (See 'Transverse lie of second twin after delivery of first twin' above.)

Late fetal demise – For patients with a fetal demise in transverse lie before labor or in early labor, we perform external version to achieve a longitudinal lie followed by induction of labor or augmentation, if appropriate. If the fetus is in transverse lie during active labor, internal podalic version by an experienced practitioner is an option in the second stage. If dystocia due to malpresentation occurs, we perform cesarean birth. (See 'Transverse lie with fetal demise or previable fetus' above.)

Previable fetus or early fetal demise – If labor occurs with a previable fetus or dead fetus very early in gestation and placenta previa has been ruled out, vaginal birth can be attempted as the small, collapsed fetal body can often pass through the birth canal. (See 'Transverse lie with fetal demise or previable fetus' above.)

Cesarean birth

-For the dorsosuperior (back up) transverse lie at cesarean birth, we perform a low transverse accentuated curvilinear uterine incision and extract the fetus as a footling breech. (See 'Dorsosuperior (back up) transverse lie' above.)

-For the dorsoinferior (back down) transverse lie at cesarean delivery, we perform an intraabdominal version to convert the transverse lie to a breech presentation before making the hysterotomy, if membranes are intact. We perform a low transverse accentuated curvilinear uterine incision and extract the fetus as a footling breech. (See 'Dorsoinferior (back down) transverse lie' above.)

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