A 28-year-old G2P1 at 34 weeks of gestation is admitted with transverse lie. She is in active labor with intact membranes. Fetal heart rate is reassuring. What is the most appropriate immediate management?

Explanation

## Management of Transverse Lie in Active Labor **Key Point:** Transverse lie in active labor is an absolute indication for emergency cesarean section. Vaginal delivery is impossible (no presenting part), and ECV is contraindicated once labor has begun due to high risk of placental abruption, uterine rupture, and fetal compromise. ### Why Cesarean Section Is Mandatory 1. **Anatomical Impossibility:** In transverse lie, the fetus lies perpendicular to the maternal long axis. There is no presenting part (head or buttocks) to dilate the cervix or descend the birth canal. 2. **Labor Complications:** Active labor with transverse lie risks: - Uterine rupture (especially if ECV attempted) - Placental abruption - Cord prolapse (if membranes rupture) - Obstructed labor → fetal hypoxia and death 3. **Timing:** At 34 weeks with active labor, vaginal delivery is not an option; cesarean is the only safe route. ### Contraindications to ECV in Labor | Scenario | ECV Possible? | Reason | |----------|---------------|--------| | Transverse lie, no labor, <37 weeks | Yes | Adequate time, uterus relaxed, low risk | | Transverse lie, active labor, any gestation | **No** | **Uterine contractions increase abruption/rupture risk** | | Transverse lie, ruptured membranes | No | Cord prolapse risk; immediate cesarean | | Transverse lie, fetal distress | No | Fetal compromise; immediate cesarean | **High-Yield:** Transverse lie in labor is a **surgical emergency**. The combination of active labor + impossible vaginal delivery + risk of catastrophic complications (abruption, rupture, cord prolapse) mandates immediate cesarean. [cite:ACOG Practice Bulletin 161] **Mnemonic: TRANSVERSE LIE IN LABOR = CESAREAN** - **T**ransverse = perpendicular lie - **R**isk of abruption, rupture, prolapse - **A**ctive labor = contractions increase danger - **N**o vaginal delivery possible - **S**urgical emergency - **V**ersion contraindicated - **E**mergency cesarean - **R**epeat: no delay - **S**ection (cesarean) is the answer - **E**very minute counts ### Pre-Operative Preparation - Inform anesthesia (general or regional, depending on urgency) - Type & cross blood - Continuous fetal monitoring until delivery - Prepare for possible neonatal resuscitation (prematurity at 34 weeks) - Counsel on increased maternal morbidity (emergency surgery, infection, hemorrhage)