What is the appropriate management of a term fetus in a prograde presentation with a transverse lie?

Management of Transverse Lie at Term

Cesarean delivery is the definitive management for transverse lie at term, and the fetus should be delivered via low transverse cesarean section using internal version techniques to avoid the need for classical cesarean section. 1, 2

Delivery Approach

• Cesarean section is the delivery method of choice for all transverse presentations of viable fetuses because vaginal delivery is not possible with this malpresentation 1, 3
• External cephalic version should be attempted before labor if conditions are favorable, but once labor is established or membranes are ruptured, cesarean delivery becomes necessary 1

Surgical Technique Considerations

Preferred Incision Type

• Low transverse cesarean section is preferred over classical cesarean section for transverse lie when using appropriate internal version techniques 2, 3
• The traditional recommendation for classical cesarean section can be avoided by using the "intra-abdominal version technique" which permits safe delivery through a low-segment incision 3

Key Technical Steps

• Make a rather wide uterine incision to prevent uterine injury during fetal manipulation and delivery 2
• Initially identify the presenting part of the fetus (shoulder or arm in transverse lie) and guide it appropriately 2
• Perform internal version to convert to breech extraction as the basic rule is to deliver the presenting part first, but in transverse lie this requires conversion 2, 3
• The internal version technique involves reaching into the uterus, grasping the fetal feet, and performing breech extraction through the low transverse incision 2, 3

Critical Complications to Anticipate

Maternal Risks

• Extension of the uterine incision is more likely with transverse lie due to the additional manipulations required 2
• Risk of injury to uterine arteries, veins, bladder, and ureters during difficult extraction 2
• If the transverse incision fails to adequately access the uterine cavity or allow safe delivery, be prepared to extend to an inverted T-shaped or J-shaped incision 2

Fetal Considerations

• Transverse lie cesarean sections require additional manipulations including liberation of the arms and after-coming head delivery, making them more technically complex than cephalic presentations 2
• Smooth delivery via breech extraction prevents excessive stress or injury to the fetus 2

Important Pitfalls to Avoid

• Do not attempt vaginal delivery for transverse lie at term—this is associated with significant maternal and neonatal morbidity 1, 4
• Do not hesitate to abandon rotational procedures and proceed directly to cesarean delivery if conversion or descent does not occur with relative ease 1
• Avoid making the uterine incision too small, as this increases risk of traumatic delivery and uterine extension 2
• Be cautious in cases with intrapelvic adhesions, endometriosis, or cervical myomas, as these increase risk of difficult delivery and may require alternative incision placement 2