Transnational Journal of Science and Technology May 2013 edition vol.3, No.

5 ISSN 1857-8047

DELIVERY TECHNIQUES AT ELECTIVE CAESAREAN

SECTION FOR THE SINGLETON TERM TRANSVERSE-
LYING FETUS IN A NIGERIAN TEACHING HOSPITAL

Atim Udo, (Dr)

University of Calabar, Calabar
Mabel Ekott (Dr)
University of Calabar, Calabar
Etim Ekanem (Dr)
University of Calabar, Calabar
Ubong Akpan (Dr)
University of Calabar, Calabar
Efiok Efiok (Dr)
University of Calabar, Calabar

Abstract:
Differing recommendations regarding the optimum delivery techniques for term singleton
transverse-lying fetuses at elective caesarean section led to this study to document the
University of Calabar Teaching Hospitals experience for the first time. This cross-sectional
retrospective study aimed to establish the intra-operative delivery techniques applied and the
immediate outcome. Techniques at delivery and immediate maternal and fetal complications
were extracted from theater/labor ward registers and case notes of women who met the
criteria over 5 years. About 31% of the women had a previous uterine scar. Low-isthmic
transverse uterine incisions, low uterine body transverse incisions, upper vertical incisions
and low vertical incision were applied in 91.6%, 5.6%, 2.8% and 0% of the patients
respectively. Intra-uterine version was applied in all cases. Delivery was as breech in 83%
and cephalic in 16.7% of the women. About 33% of fetuses delivered cephalic were by
forceps. Maternal complications were lateral tears of low isthmic incisions, conversion to
inverted T incisions, blood loss >1000mls and blood transfusion in 5.6%, 5.6 %, 11.1% and
2.8% respectively. Conversions to inverted T incisions were in women with poorly formed
lower segments. 5-minute Apgar score <7 and death occurred in an infant with multiple

32
Transnational Journal of Science and Technology May 2013 edition vol.3, No.5 ISSN 1857-8047

anomalies. Conclusions Delivery through low isthmic transverse incisions following

intrauterine version to breech presentation is preferred in the hospital. It is successful
regardless of fetal back position but may not be the best option if the lower segment is poorly
formed. Maternal and fetal outcome are good.

Keywords: Singleton, term transverse-lying, incisions, version, elective, caesarean

1. Introduction
Elective caesarean section (CS) has continued to play a dominant role in the
management of the singleton term fetus in transverse lie. Although this is so, clinicians
continue to face challenging decisions when performing abdominal deliveries of fetuses in
abnormal lie regardless of whether the surgery is planned or unplanned. This is made more
difficult if there are associated pathologies like placenta praevia and large cervical fibroids.
There is always the lurking danger of difficult fetal extraction with attendant fetal and
[1].
maternal consequences. Fetal mortality rates of 0-10% have been reported for caesarean
births of transverse-lying fetuses. [2]
One of the major decisions facing the surgeon is the type of uterine incision to make.
While the low isthmic transverse uterine incision made in the lower uterine segment is
generally popular because of its safety, it is limited by the relatively poor access it provides
[3]
for delivery compared to the vertical incisions. However, the upper vertical incision
applied in classical caesarean (CCS) has major implications for future reproduction even
[4, 5]
though many authorities still favor this incision for the transverse-lying fetus. The
drawbacks of the aforementioned incisions have other authorities advocating for the use of
[6].
the low vertical uterine incision. It is not favored by some others because of the risk of
[7]
inadvertent extensions to the upper segment. There are no comparative studies on the
safety of using a low uterine body transverse incision placed just above the lower segment as
an alternative to the upper vertical incision of CCS.
An important component of the delivery process is version of the fetus to longitudinal
lie. Phelan and muller (1986) advocate that external version (ECV) should be done before
[8]
making the abdominal incision. Pelosi et al (1979) make a case for extra-uterine version
before placing the uterine incision. [9] Others are advocates of intra-uterine version and breech
[5]
extraction. The aims of this descriptive study are to establish the preferred methods
employed by surgeons in the University of Calabar Teaching Hospital (UCTH) to deliver the

33
Transnational Journal of Science and Technology May 2013 edition vol.3, No.5 ISSN 1857-8047

singleton term fetus in transverse lie at elective caesarean section and the immediate maternal
and fetal outcome of such deliveries.

2. Materials and Methods

The maternity section of UCTH provides services for women in Calabar and its
[10]
environs whether they are referred or not. It has a caesarean section rate of 19.8%. This
retrospective study involved all women with a singleton term fetus in transverse lie who were
delivered by elective CS between January 2006 and December 2011. Term was defined as a
gestational age of 37-42 completed weeks. [11] The information on each patient was extracted
from the operating theatre register, labor ward registers and the case notes. This included
maternal age, parity prior to the index delivery, the last menstrual period and the gestational
age at delivery. Other maternal information gleaned were the type of uterine incision and
maneuver employed to deliver the fetus. Immediate maternal complications were noted and
included deliberate or inadvertent extension of the uterine incision, blood loss of >1000mls,
blood transfusion and maternal death. Blood loss of >1000mls was considered to be
[12]
significant. Infant information was from the attending pediatricians notes and included
the birth weight and immediate complications like Apgar score <7 at 5 minutes, evidence of
delivery-related trauma, fresh still birth and cause of death. A 5-minute Apgar score of <7
[13]
was considered to be significant because of its association with neurologic disabilities.
Descriptive statistical analysis was performed on the data.

3. Results:
Thirty-six women were studied and they made up 68% of the 53 women with
transverse-lying fetuses who had a CS during the study period and 0.27% of the 13,340
deliveries that occurred during the period. The gestational age at delivery ranged from 37-41
weeks, but 24 (66.7%) were delivered at 38 completed weeks. The birth weight of the
infants ranged from 2.1kg to 3.9 kg with a mean of 3.2 0.6 kg. The fetal position was
documented for 27 women and was dorso-posterior for 10 (37%) and dorso-superior for 17
(63%) women.

34
Transnational Journal of Science and Technology May 2013 edition vol.3, No.5 ISSN 1857-8047

Table 1: Demographic data and co-existing disorders/complications prior to surgery

Variable No. of women Percentage
N=36
Age
<20 - -
20-30 14 38.9
>30 22 61.1
Parity
0-1 20 55.6
2-4 13 36.1
5 3 8.3
Co-existing complications
Previous CS 10 27.8
Previous myomectomy 1 2.8
Placenta praevia 5 13.8
Uterine fibroids 3 8.3
Gestational diabetes mellitus 1 2.8
Oligohydramnios fetal
growth restriction 3 8.3
Multiple congenital
anomalies 1 2.8

The age of the women ranged from 24-39 years with a mean of 30.8 3.9 years. The
parity of the women ranged from 0-8 with a mean of 1.91.6. Twenty (55.5%) women were
of low parity (para 0-1) as shown on table 1. As also shown on the table, 19 (53%) women
had at least one other obstetric high risk problem. About 27.8% of the women had at least one
previous cesarean section and 1 (2.8%) had a previous myomectomy; 5 (13.8%) women had
placenta praevia, 3(8.3%) had large uterine fibroids and 3 (8.3%) women had growth-
restricted (IUGR) fetuses and oligohydramnios.

35
Transnational Journal of Science and Technology May 2013 edition vol.3, No.5 ISSN 1857-8047

Table 2: Delivery techniques and the outcome

Variable No. of patients Frequency
Uterine incisions
Low isthmic transverse 35 91.6
Low uterine body transverse 2 5.6
Upper vertical (CCS) 1 2.8
Low vertical - -

Maneuvers for delivery

Intra-uterine version 36 100
Breech 30 83.3
Cephalic delivery 6 16.7
External cephalic version - -
Extra-uterine version - -

Maternal outcome
Incision extension 4 11.1
Inverted T 2 5.6
Lateral tear 2 5.6
Blood loss >1000mls 4 11.1
Blood transfusion 1 2.8
Caesarean hysterectomy - -
Maternal death - -
Fetal outcome
Apgar score <7 at 5 mins 1 2.8
Delivery trauma - -
Perinatal death 1 2.8

Table 2 shows the intra-operative techniques employed. It shows that low isthmic
transverse incisions were applied in 33 (91.6%) of the patients and low uterine body
transverse incisions were applied in 2 (5.6%) patients with large cervical fibroids. One (2.8%)
CCS was performed in a woman with placenta previa and an adherent bladder from 3

36
Transnational Journal of Science and Technology May 2013 edition vol.3, No.5 ISSN 1857-8047

previous CS. A low vertical incision was not performed in this series and there was no
caesarean hysterectomy.
Intrauterine version was applied in all the patients. Cephalic delivery was achieved for
6 (16.7%) fetuses but after application of obstetric forceps in 2 (33.3%) of the group because
of a high head, while 30 (83.3%) fetuses were delivered by grasping and applying traction on
the feet and completing delivery as a breech. ECV and extra-uterine version were not
performed on any patient.
Also shown on table 2 are the immediate maternal and fetal outcomes. Low isthmic
transverse uterine incisions were converted to inverted T incisions in 2 (5.6%) women
because of poorly-formed lower uterine segments. There were 2 (5.6%) lateral incision
extensions or tears. Maternal blood loss exceeded 1000mls in 4 (11.1%) women. One (2.8%)
patient with placenta previa and post-delivery uterine atony had blood transfusion. There was
no maternal death. One (2.8%) infant with multiple congenital anomalies had a 5-minute
Apgar score of <7 and survived for an hour. There were no delivery-related traumas.

4. Discussion:
The preference for low isthmic transverse uterine incision and non-use of the low
vertical incision for the delivery of the transverse-lying fetus as found in this study is in
keeping with the findings of some other studies elsewhere. [5, 14] This incision was applied in
all but the three patients in whom the lower segment could not be accessed. The established
integrity of the resultant scar is likely to account for the preference, although our prevailing
surgical tradition may also play a role. Low isthmic transverse uterine incisions were utilized
with success despite oligohydramnios or dorso-inferior position; factors which some authors
consider to be indications for a low vertical incision. [2,3]. Our findings are in agreement
with those of Shoham et al who also found that this incision is reliable regardless of the
[5]
aforementioned factors. A known demerit of the incision was however apparent in the
study, the risk of incision extension, inadvertent or deliberate, both of which are associated
[15-17]
with increased blood loss and prolonged surgical time. About 5.6 % had lateral tears.
Incisions were also converted to an inverted T in 5.6% of the women because of poorly-
[2]
developed lower uterine segments probably occasioned by the abnormal lie. This type of
[18]
incision is relatively more difficult to repair and is associated with poorer healing.
Consideration should therefore be given to applying the low vertical incision when there is
suspicion that the lower uterine segment cannot accommodate an adequate length of incision
transversely. [2, 3]

37
Transnational Journal of Science and Technology May 2013 edition vol.3, No.5 ISSN 1857-8047

Classical caesarean section and tubal ligation was performed on a multiparous

woman, because the lower segment could not be accessed while low uterine body transverse
incisions were performed in two low parity women for the same reason but without tubal
ligation. This reflects the dilemma of the surgeon when confronted with an indication for a
CCS in a low parity woman in our society were high parity is greatly desired by husbands
and yet there is no guaranty that the patient will return to utilize orthodox maternity services
for care of subsequent pregnancies. Studies are required to determine the comparative
integrity of a transverse incision placed close to the relatively quiescent lower uterine
segment and the upper vertical incision of the ccs. Better blood supply usually associated
with transverse incisions may enable better healing than may obtain with a classical incision.
Intra-uterine version was performed to deliver all the fetuses. Majority of the infants
were delivered successfully by applying traction on the fetal feet and completing delivery as
breech. A quarter of the infants were delivered cephalic after version, but 33.3% of these
infants required forceps application to deliver a floating head. That ECV was not performed
in this series mirrors the very low rate of the procedure done in the hospital to correct
abnormal lie. Since the procedure for the less popular extra-uterine version is similar to ECV,
that it was not performed may in turn reflect the low frequency of performance of ECV in the
hospital. This needs to be corrected to provide data for comparison with internal version, and
in general, to reduce the rate of caesarean deliveries because of abnormal lie.
There were no fetal complications attributable to any of the maneuvers in this study.
The low Apgar score at 5 minutes was documented for a 2.1kg infant with multiple
congenital anomalies who survived for one hour. There was no recorded delivery trauma.
Maternal outcome was also favorable despite the strikingly high prevalence of co-existing
risk factors for adverse surgical outcome. An unexpected find which requires further study to
determine the causes was a high prevalence of previous cs similar to the finding of
[19]
kalogiannidis et al, 2010) for women with fetuses presenting by the breech in Greece.
Excess blood loss occurred in 11.6% of the patients. This is not unexpected in a population
with a high prevalence of risk factors for significant bleeding like placenta praevia, uterine
fibroids and previous scars. The rate of blood transfusion was low and occurred in one
instance of a patient who had placenta praevia and uterine atony. Caesarean hysterectomy
was not performed in this series and there was no maternal death. Our experience of a low
rate of complications using low isthmic transverse uterine incisions and caesarean breech
extraction approach is similar to the experience in Kaplan Hospital. [5]

38
Transnational Journal of Science and Technology May 2013 edition vol.3, No.5 ISSN 1857-8047

5. Conclusion
The preferred method of delivering the term transverse-lying-fetus at elective
caesarean section in UCTH is by intra-uterine version and delivery as breech through a low
isthmic transverse uterine incision. The rates of adverse maternal and fetal outcomes are low
despite a high prevalence of co-existing factors which are independently associated with
adverse surgical outcomes. Hence, we recommend this approach for the delivery of the
transverse-lying fetus at term. We however make the observation that the low isthmic
incision might be inappropriate if the lower uterine segment is poorly-formed as occurs in
association with some fetal transverse lie at term. The low vertical incision may be a prudent
option. We also note that there is a need to increase ECV performance in the hospital which
will improve the rates done at CS and provide data for comparison of outcomes with intra-
uterine version. Longitudinal studies are also needed to determine if the low uterine body
transverse incision is a preferable alternative to the classical upper vertical incision in terms
of its integrity considering that the majority of women are of low parity. We also need further
studies to determine the reason for the high prevalence of previous uterine scars among this
population of women and larger studies to confirm our findings.

References:
Ali R, Abrar A. Transverse lie; predisposing factors, maternal and perinatal outcome.
Professional Med J 2011;18:208-211.
Seeds J. Malpresentations. In: Gabbe SG, Niebyl JR, Simpson JL, editors. Obstetrics Normal
and Problem Pregnancies, 2nd edn. New York: Churchill Livingstone; 1991. p. 539-68.
Johanson R. Malposition, malpresentation, cephalopelvic dysproportion. In: Edmonds K,
editor. Dewhursts Textbook of Obstetrics and Gynaecology, 6th edn. Oxford: Blackwell
Publishing; 2007. p. 277-90.
Dunn IJ. Caesarean Section and other obstetric operations. In: Danforth DN, Scott JR,
editors. Obstetrics and Gynecology, 5th edn. Philadelphia: JB Lippincot; 1986. p. 737-54.
Shoham Z, Blickstein I, Zosmer A, Katz Z, Borensteinin R. Transverse uterine incision for
cesarean delivery of the transverse-lying fetus. Eur J Obstet Gynecol Reprod Biol
1989;32:67-70.
St George L, Kuah KB. Low vertical uterine incision in caesarean section. Aust N Z J Obstet
Gynaecol 1987;27:10-3.

39
Transnational Journal of Science and Technology May 2013 edition vol.3, No.5 ISSN 1857-8047

Cunningham FG, Pritchard JA, Leveno KJ, MacDonald PC, Gant NF, Gilstrap LC. Cesarean
section and cesarean hysterectomy. In: Cunningham FG, Pritchard JA, editors. Williams
Obstetrics, 19th edn. London: Appleton and Lange; 1993. p. 591-s625.
Phelan JP, Boucher M, Mueller E, McCart D, Horenstein J, Clark Sl. The non-laboring
transverse lie: A management dilemma. J Reprod Med 1986;31:184.
Pelosi MA, Appuzio J, Friechione D, Gowda VV. The intra-abdominal version technique for
delivery of transverse lie by low segment caesarean section. Am J Obstet Gynecol
1979;135:1009 - 11.
Iklaki CU, Ekabua JE, Agan TU, Ekanem EI, Asuquo EEJ, Current trends in caesarean
section in University of Calabar Teaching Hospital Calabar-Nigeria. Mary Slessor Journal of
Medicine 2005;5:41-5.
Dubreuil VL. Standard term of pregnancy. Midwifery Today Int Midwife 2004;72:51-3.
Coker A, Oliver R. Definitions and classifications. In: B-lynch C, Keith LG, Lalonde AB,
Karoshi M, editors. A Textbook of Postpartum Hemorrhage: Comprehensive Guide to
Evaluation, Management and Surgical Intervention. Kirkmahoe: Sapiens Publishing; 2006. p.
11-6.
Ehrenstein V , Pedersen L, Grijota M, Nielsen GL, Rothman KJ Srensen H T. Association
of Apgar score at five minutes with long-term neurologic disability and cognitive function in
a prevalence study of Danish conscripts. BMC Pregnancy and Childbirth 2009;9:14.
Segal S, Gemer O, Sassoon E. Transverse lower segment uterine incision in cesarean sections
for transverse lie: A retrospective survey. Arch Gynecol Obstet 1994;255:171-2.
de la Torre L, Gonzalez-Quintero VH, Mayor-Lynn K, Smarkusky L, Hoffman MC, Saab A,
Diro M. Significance of accidental extensions in the lower uterine segment during cesarean
delivery. American Journal of Obstetrics and Gynecology 2006;194:4-6.
Patterson LS, Oconnell CM, Baskett TF. Maternal and perinatal morbidity associated with
1
classic and inverted T cesarean incisions. Obstet Gynecol
2002;100:633-7.
Boyle JG, Gabbe SG. T and J vertical extensions in low transverse caesarean births. Obstet
Gynecol 1996;87:238-43.
El-Mowafi DM. Caesarean section. Geneva Foundation for Medical Education and Research
[Internet]. 2008 Sept [cited 2013 May 17]:[about 1 p.]. Available from:
http://www.gfmer.ch/Obstetrics_simplified/caesarean_section.htm

40
Transnational Journal of Science and Technology May 2013 edition vol.3, No.5 ISSN 1857-8047

Kalogiannidis I, Masouridou N, Dagklis T, Masoura S, Goutzioulis M, Prapas Y, Prapas N.

Previous cesarean section increases the risk for breech presentation at term pregnancy. Clin
Exp Obstet Gynecol 2010;37:29-32.

41