Transverse lie

(shoulder presentation)
 Transverse, oblique Lie
“Shoulder Presentation”
Transverse lie occurs when the longitudinal axis
of the fetus lie perpendicular to the longitudinal
axis of the mother.
An oblique lie occurs when the long axis of the
fetal body crosses the long axis of the maternal
body at an angle close to 45 degrees.
Both results in shoulder presentation with an
incidence at term is about1:300 deliveries.
Transverse lie. Right acromiodorsoposterior position (RADP). The
shoulder of the fetus is to the mother's right, and the back is posterior.
CAUSES

Placenta Previa
Pelvic or uterine mass
Multiparty “pendulous abdomen”
Prematurity
Oligohydramnious
Polyhydramnious
Uterine abnormalities
Fetal abnormalities ,multiple pregnancy
 On abdominal examination:
SFH is less than expected for gestation 
The abdomen appears asymmetrical 
Broader uterus ,the fetal head or buttocks may be in 
the iliac fossa.
Empty lower uterine segment 
Transverse lie with shoulder presentation in the 
antenatal period corrects itself to longitudinal lie with
the onset of labour in most of the cases due to increased
muscular tone of the uterus.

if rupture of membranes take place with the fetus in the 

transverse lie, cord prolapse, shoulder presentation and
arm prolapse are likely possibilities with progressive
cervical dilatation.
 MANAGEMENT

Management of transverse lie depend on

the gestational age and the possible cause

- Proper clinical assessment history, examination

, investigation
- Search for the cause if any treat according to
the cause
A gentle version of the baby’s head may restore
the presentation to cephalic,if this does not occur
or the lie is unstable ,it is important to think of
possible uterine or fetal ceuses.
 - Caesarian section if labor start or at term
with persistent T.L.
If the membranes rupture & the fetus is still in the 
transverse lie, CS should be performed to avoid
injury to the fetus or the uterus.
Labour and spontaneous vaginal delivery is 
possible only in extreme preterm and macerated
fetuses
COMPLICATION

Increased Maternal complication

Obstructed labor
Rupture uterus
Operative intervention

Increased Fetal complication

Cord prolapse
Fetal trauma
Fetal death
Mal-position of
the fetal head
When the head is presented with vertex
posterior “OP” it will be deflexed and the
longitudinal diameters will be will change
to:
Sub-occipito frontal 10.5cm
Or
Occipito frontal 11.5cm
Occipito Posterior Position OP
Diagnosis
Antenatal
Diagnoses is important at least to rule out any
major causes which may be a contraindication to
leave the patient inter into labour

Suspicion during antenatal examinations raise when:

○ High head &large amount of head is palpable

abdominally
○ flattening of the abdomen below the umbilicus
○ fetal back is placed posterior &the limbs are felt
anteriorly
Occipito Posterior Position OP
Diagnosis During Labour
vaginal examination during labour :
For assessment of descent,flexion &position
○ High presenting part
○ Anterior fontanel felt near to the symphysis
○ Posterior fontanel felt near to the sacral
promontory
○ Frontal sutures and Frontal bones
Occipito Posterior Position OP
Possible Etiological causes
Maternal Fetal
Bicornoate uterus Prematurity
Septet uterus Multiple gestation
Fibroid Polyhydramnios
Pelvic tumor Oligohydramnios
Non gynaecoid pelvis Large Fetus
(Anthropoid) Large Fetal head
contracted pelvis Congenital Abnormalities
Cord around the neck
Neck tumer
○ Mechanism of labour in OP

Mechanism of labour is identical to OT &

anterior varieties
○ 75 % of the cases flexion increases &
the occipt rotates when it reaches the
pelvic floor from the posterior to anterior
position through 135º instead of 90º or
45º in OT &LOA positions and deliver as
OA &this long journey in rotation explains
the prolonged labour associated with this
position.
,
.

,
0

Mechanism of labor for right occiput

posterior position, anterior rotation.
○ Mechanism of labour in OP

○ 5 % of the cases deflexion persists or

increase & the pregma will be the part
which reaches the pelvic floor first &rotates
forwards causing a direct occipitoposterior
position and in some cases the presenting
part descends further &delivers as face to
pubis with high incidence of severe
perineal tears.

○ 20% will end as deep transverse arrest

of the head & needs C/S.
 MANAGEMENT OF OCCIPITO-
POSTERIOR POSITION IN LABOUR
The possible management for vaginal delivery 
1. Await spontaneous delivery &slow progress in 1st
stage may be treated with a titrated oxytocin
infusion &if satisfactory progress is not achieved
C/S is indicated.
2. Forceps delivery with the occiput directed
posterior for delay or fetal distress in the 2nd stage.
3.or forceps &vacum rotation of the occiput to the
anterior position and then delivery
*generous episiotomy is usually needed.