What are the risks and benefits of a cesarean section (C-section) versus attempting to flip the baby for vaginal delivery in a patient with preeclampsia and an incomplete breech presentation at 37 weeks gestation?

Cesarean Section Counseling for Preeclamptic Patient with Incomplete Breech at 37 Weeks

Cesarean section is strongly recommended for a patient with preeclampsia and incomplete breech presentation at 37 weeks, as this approach offers the safest delivery option for both mother and baby compared to attempting external cephalic version (ECV) and vaginal delivery. 1, 2

Maternal Risks with Preeclampsia

Immediate Concerns

• Preeclampsia at 37 weeks requires delivery as the definitive treatment 2
  • ISSHP guidelines recommend delivery at 37 weeks (and zero days) gestation for all women with preeclampsia 2
• Attempting ECV may:
  • Exacerbate hypertension during the procedure
  • Increase risk of placental abruption in an already compromised placenta
  • Delay definitive treatment (delivery) of preeclampsia
  • Potentially trigger severe features requiring emergency cesarean under less controlled circumstances

Blood Pressure Management

• Antihypertensive treatment must be continued during labor and delivery to maintain:
  • SBP <160 mmHg
  • DBP <110 mmHg 2
• Planned cesarean allows for more controlled blood pressure management compared to the stress of labor

Fetal Risks with Breech Presentation

Incomplete Breech Specific Risks

• Incomplete breech (footling or knee presentation) carries higher risks than frank breech:
  • Increased risk of cord prolapse
  • Higher likelihood of head entrapment
  • Greater difficulty with delivery of aftercoming head 3
  • Higher conversion rate to emergency cesarean (41.8% median rate) 4

Evidence on Breech Delivery Outcomes

• Recent meta-analysis (2022) shows planned cesarean section for term breech:
  • Reduces risk of perinatal mortality (RR 0.36,95% CI 0.25-0.51) 4
  • Reduces risk of low 5-minute Apgar scores <7 (RR 0.1,95% CI 0.14-0.26) 4
  • Reduces risk of very low 5-minute Apgar scores <4 (RR 0.39,95% CI 0.19-0.81) 4
  • Reduces risk of acidosis with pH <7.0 (RR 0.23,95% CI 0.12-0.43) 4

Combined Risks of Preeclampsia and Breech

• The combination of preeclampsia and breech presentation compounds risks:
  • Increased likelihood of fetal distress during labor
  • Higher probability of emergency cesarean under less optimal conditions
  • Greater risk of maternal complications if emergency anesthesia is required 5
  • General anesthesia (more likely in emergency) associated with 7-fold increase in maternal mortality compared to regional anesthesia in preeclamptic women 5

External Cephalic Version Considerations

• ECV is contraindicated or relatively contraindicated with:
  • Preeclampsia (due to potential placental insufficiency)
  • Need for imminent delivery (as is the case at 37 weeks with preeclampsia)
  • Incomplete breech (higher failure rate than frank breech)
  • Lower success rates in primigravidas

Counseling Points for the Patient

1. Definitive treatment: Preeclampsia requires delivery at 37 weeks, and cesarean is the safest approach with breech presentation 2, 1

2. Maternal safety: Planned cesarean allows for:

   • Controlled blood pressure management
   • Optimal anesthesia planning (regional preferred over general)
   • Reduced risk of emergency situations

3. Fetal safety: Cesarean section for breech significantly reduces:

   • Perinatal mortality
   • Birth trauma
   • Low Apgar scores
   • Acidosis 4

4. ECV risks: Attempting ECV with preeclampsia may:

   • Worsen maternal condition
   • Delay necessary delivery
   • Have low success rate
   • Still result in cesarean (high conversion rate)

5. Future pregnancies: While cesarean does impact future pregnancies:

   • The immediate safety benefits outweigh future risks
   • VBAC may be an option in future pregnancies if no other complications develop

Conclusion

While vaginal delivery is generally preferred for hypertensive disorders when feasible 2, the combination of preeclampsia requiring delivery at 37 weeks and incomplete breech presentation creates a clinical scenario where the benefits of planned cesarean section clearly outweigh the risks of attempting version and vaginal delivery.