A 28-year-old primigravida at 36 weeks of gestation presents to the antenatal clinic for routine check-up. Abdominal examination reveals a hard mass in the lower uterine segment, and the fetal heart sounds are heard at the level of the umbilicus. Ultrasound confirms a transverse lie with the fetus in a left occipito-anterior position. The patient is counseled about the risks and management options. Which of the following is the most appropriate next step in management?

Explanation

## Management of Transverse Lie at 36 Weeks **Key Point:** External cephalic version (ECV) is the first-line intervention for transverse lie at ≥36 weeks in a primigravida with no contraindications, as it reduces the need for cesarean delivery. ### Clinical Context At 36 weeks, a transverse lie is unlikely to correct spontaneously, particularly in a primigravida. The standard of care per Williams Obstetrics (26e, Ch. 28) and RCOG Green-top Guideline No. 20a is to offer ECV before resorting to cesarean section, provided there are no contraindications. ### Rationale for ECV **High-Yield:** ECV has a success rate of **40–60% in primigravidas** and **>60% in multiparas** when performed at 36+ weeks. The lower success rate in primigravidas (due to a tighter uterus and abdominal wall) makes pre-procedure counseling about possible failed ECV — and the consequent need for cesarean — especially important. **Clinical Pearl:** ECV should be performed: - After exclusion of contraindications (placenta previa, previous uterine scar with classical incision, ruptured membranes, fetal compromise, oligohydramnios, multiple gestation) - With **tocolytic cover** (nifedipine or salbutamol) to relax the uterus and improve success rates - Under **continuous fetal heart rate monitoring** before, during, and after the procedure - In a setting where **emergency cesarean delivery** is immediately available - With **ultrasound guidance** to confirm lie, placental location, and liquor volume ### Note on Stem Terminology The stem mentions "left occipito-anterior position," which is anatomically imprecise for a transverse lie (occiput-based positions apply to vertex presentations). The correct descriptor would be "left dorso-anterior" (fetal back facing left and anteriorly). This does not affect the management decision. ### Why Other Options Are Incorrect | Approach | Why Not Recommended | |----------|---------------------| | **Bed rest alone** | Transverse lie rarely converts spontaneously after 36 weeks; expectant management increases risk of cord prolapse and obstructed labor | | **Immediate cesarean** | Premature surgical delivery without attempting ECV first increases maternal morbidity; reserved for failed ECV, contraindications to ECV, or onset of labor | | **Internal podalic version** | Obsolete technique with high maternal and fetal morbidity; only considered in rare intrapartum emergencies (e.g., delivery of second twin, cord prolapse in labor with fully dilated cervix) | **Mnemonic: ECV-SAFE** — External Cephalic Version is Safe, Appropriate, First-line, and Effective at 36+ weeks. [cite: Williams Obstetrics 26e Ch. 28; RCOG Green-top Guideline No. 20a — External Cephalic Version and Reducing the Incidence of Breech Presentation]