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A CLINICAL STUDY OF OUTCOME OF LABOUR IN TRANSVERSE LIE

Transverse lie complicates approximately 0.5% of birth and may result in neglected or impacted shoulder presentation leading to obstructed labour, rupture uterus and postpartum haemorrhage which may result in death of the mother, if not adequately managed in labour. A prospective observational study done in VIMS Bellary, Karnataka, aim of the study was to know the maternal and fetal outcome, to study caesarean rate, maternal and neonatal complications following caesarean. Objective of the study is to analyse the various modes of outcome of transverse lie to know the fetal and maternal mortality and morbidity, to improve the conditions which decreases these rates and guide us for better management of these cases. Out of 6116 deliveries100 cases were transverse lie during 2year period from April 1999 to January 2001. Out of 100 cases, 76 were caesarean sections, 48 were live births, 7 were neonatal deaths, 45 were still births. Maternal morbidity was 2 cases required subtotal hysterectomy. There were no maternal deaths. Elective caesarean section should be advised in all booked cases with transverse lie at term, after ruling out congenital anomalies of the fetus by anomaly scan.


INTRODUCTION:
Transverse lie complicates approximately 0.5% of births 1 and may result in neglected or impacted shoulder presentation leading to obstructed labour, rupture uterus and postpartum haemorrhage which may result in death of the mother, if not adequately managed in labour. Due to improper antenatal care there is high incidence of undiagnosed malpresentation in labour, and moreover due to inadequate transport facilities there is delay in approaching at the tertiary health Centre. These complicated, undiagnosed cases of transverse lie report to the hospital in advanced labour and by this time it is not always possible to salvage their babies and even some times these mothers also.
Aetiology of transverse liearematernal factors likepolyhydramnios causing an increased ratio of fluid to fetus, something preventing the engagement of the head in the pelvis, placenta praevia,fibroids, contracted pelvis, abnormal shape of uterus (subseptate or arcuate uterus), grand multiparity (5+), fetal factors like prematurity, second twin. 2,3 Ourstudy was to know the maternal and fetal outcome, to study caesarean rate, maternal and neonatal complications following caesarean in transverse lie.

MATERIALS AND METHODS:
A prospective observational study done in VIMS Bellary, Karnataka. Aim of the study was to know the maternal and fetal outcome, to study caesarean rate, maternal and neonatal complications following caesarean. Out of 6116 deliveries 100 cases were transverse lie during 2year period from April 1999 to January 2001. The foetus was said to be in transverse lie when its longitudinal axis is perpendicular to the maternal spine.
The study includes the obstetrical behavior of these women during labour and postpartum period. On admission to the hospital, their relevant data were recorded, including name, maternal age, socio economic status, address, antenatal visits and previous obstetric history. History of duration of labour pains and leak (if present) were noted. General, systemic and obstetric examination was done, per vaginal examination was done, pelvis was assessed to rule out contracted pelvis Routine investigations were done, diagnosis of placenta previa was made on ultrasound, lower segment masses which could predispose to transverse lie were excluded by USG. During caeserean section uterine anomalies are ruled out, maternal and neonatal outcome were noted.
Data analysis to derive percentages were done using Statistical Package for Social Sciences (SPSS) version.

RESULTS:
Out of 6116 deliveries100 cases were transverse lie giving incidence of 1.64%.
Out of 100 cases 35 cases had regular antenatal care in our hospital, 65 cases were unbooked, table-1 and came in labour with different modes of presentation like shoulder presentation, hand prolapse, hand and cord prolapse, transverse lie with obstructed labour, rupture uterus etc. Out of 100 cases 80% had previous normal deliveries, 10% had previous LSCS, table -5. Multiparity is the most common etiological factor for transverse lie, 75 (75%) cases were multipara, 10 cases (10%) had uterine anomalies, 7 cases had placenta previa,3 cases had contracted pelvis, 3 had twin gestation, 2 cases cause was unknown, table-6.
Majority of the cases came late in labour between 13-24 hours after the onset of labour pains giving incidence of 61%, one case presented above 36 hours with rupture uterus with haemorrhagic shock, table-7.
Seventy-six cases(76%) underwent caesarean section with a foetal loss of 34. 64 cases were emergency LSCS, 12 cases were elective sections, IPV were done in 12 cases, 1 case was previous LSCS with hand prolapsed and a live baby was delivered, for 2 nd twin in 2 cases IPV was done. The incidence of twin pregnancy with transverse lie in our study is 3%. 2 cases underwent emergency laparotomy, table -9.The indications for caesarean section in transverse lie are set out in Table 10.
Foetal morbidity and mortality are high in cases of transverse lie due to complications associated with it. Out of 100 cases48 cases were live birth, 45 were still births, 7 cases were neonatal deaths, 2 babies has injuries fracture humerus, 1 had multiple congenital anomalies. Out of 104 cases studied by Jacob et al 5 in 1971mode of delivery by caesarean section were 22, in our study out of 100 cases for 76 cases caesarean section was done internal podalic version were done in 73, in our study 12 IPV was done spontaneous delivery 2, in our study 7 cases spontaneously delivered, subtotal hysterectomy 3, in our study 2 cases required subtotal hysterectomy, destructive procedure evisceration were nil, in our study 3 cases evisceration was done, repair of rupture uterus were 3 and external cephalic version followed by normal delivery was 1, in our study there were no cases. Thompson (1964) 6 reported an incidence of placenta praevia of 7% in 127 cases of transverse lie. In our study also incidence of placenta previa was 7%.
Winkler & Cangello (1960) 7 however, do not consider that 'uncomplicated' transverse lie is an absolute indication for caesarean section. In our study, twelve cases were dealt by internalpodalic version and seven babies were lost.

CONCLUSION:
Transverse lie constitutes one of the categories of high risk pregnancies. It may result in neglected or impacted shoulder presentation leading to obstructed labour, rupture uterus and postpartum haemorrhage which may result in death of the mother, if not adequately managed in labour. Elective caesarean section should be advised in all booked cases with transverse lie at term, after ruling out congenital anomalies of the fetus by anomaly scan.
In modern obstetrics destructive operations are done in minimal cases because of high maternal morbidity and mortality. Hence caesarean section is better than vaginal delivery because of facilities available (Higher antibiotics, anesthesia facilities and blood transfusions).
The introduction of high risk pregnancy screening at primary level, adequate training of health personnel and paramedical staff for recognizing high risk cases and referral to higher centers for management.  Internal podalic version 2 2% 5

Booked cases Un booked cases
Retained placenta 1 1%      Our study 52%