Management of Footling Breech Presentation in Labor
For a 31-year-old G4P3 at 39 weeks in spontaneous labor with a footling breech presentation and cervical dilation of 5 cm, immediate cesarean section is the safest course of action.
Rationale for Immediate Cesarean Section
A footling breech presentation (where a foot is presenting in the vagina) represents a significant obstetrical emergency requiring prompt intervention. Unlike a frank or complete breech where the buttocks present first, footling breech carries substantially higher risks:
- Higher risk of cord prolapse due to the incomplete filling of the pelvis by the presenting part
- Increased risk of head entrapment as the body delivers before the head
- Greater likelihood of birth trauma compared to other breech presentations
Evidence Supporting Immediate Cesarean Section
The Society of Obstetricians and Gynaecologists of Canada (SOGC) guidelines clearly state that any presentation other than a frank or complete breech with a flexed or neutral head attitude is a contraindication to vaginal breech delivery 1. A footling breech presentation falls into this category of contraindications.
The presence of a foot in the vagina with 5 cm cervical dilation indicates:
- This is not a frank or complete breech (which would be safer for vaginal delivery)
- The risk of cord prolapse is imminent and significant
- The fetus is already descending through an incompletely dilated cervix
Why Other Options Are Not Appropriate
Ultrasound to confirm head position before proceeding with vaginal delivery
- While ultrasound can provide valuable information, the finding of a foot in the vagina already confirms a footling breech presentation, which is a contraindication to vaginal delivery regardless of head position 1
- Delaying for ultrasound increases the risk of cord compression and fetal compromise
Augmentation of labor for vaginal breech delivery
- SOGC guidelines specifically state that induction of labor is not recommended for breech presentation 1
- While oxytocin augmentation may be acceptable in some breech presentations with uterine dystocia, it is contraindicated in footling breech due to increased risks 1
- Research shows that even in carefully selected cases, the cesarean section rate for breech presentations remains high (32-34%) 2
Expectant management
- Not appropriate given the active labor status (5 cm dilation) and the presence of a foot in the vagina
- Increases risk of cord prolapse, which is a life-threatening emergency for the fetus
Important Considerations for Cesarean Section
- Timing: Immediate preparation for cesarean section is critical to minimize risks
- Team preparation: Ensure availability of:
- Experienced obstetrician
- Anesthesia team
- Neonatal resuscitation team
- Technique: Special care during extraction to avoid fetal trauma
- Cesarean delivery reduces but does not eliminate the risk of traumatic injury 3
- Careful extraction technique is essential to prevent femur fractures or other injuries
Special Considerations for This Patient
This patient has several favorable factors that should be acknowledged:
- Multiparous (G4P3) with three previous term vaginal deliveries
- Uncomplicated pregnancy
- Term gestation (39 weeks)
However, these favorable factors do not outweigh the risks associated with footling breech presentation. Even in experienced centers following strict protocols, vaginal delivery of a footling breech carries unacceptable risks.
Conclusion
Despite the patient's history of successful vaginal deliveries, the presence of a footling breech presentation necessitates immediate cesarean section to ensure the best outcomes for both mother and baby. This approach is supported by current obstetrical guidelines and evidence-based practice.