What is the recommended course of action for a pregnant woman at 38 weeks gestation in labor with breech presentation, 4 cm dilated, and no change after 2 hours with a normal Cardiotocography (CTG)?

Management of Breech Presentation at 38 Weeks in Active Labor

A - Cesarean section is the recommended course of action for a patient at 38 weeks gestation in active labor with breech presentation at 4 cm dilation, even with a normal CTG.

Rationale for Cesarean Section

When breech presentation is diagnosed during active labor (4 cm dilation), cesarean delivery is the safest option because external cephalic version is contraindicated once labor has begun. 1

Why External Cephalic Version is NOT an Option

• External cephalic version (ECV) must be performed BEFORE labor begins, typically between 36-37 weeks gestation, and requires immediate access to an operating room for emergency cesarean if complications arise 2
• Once a patient is in active labor with cervical dilation, attempting ECV carries unacceptable risks including:
  • Placental abruption during manipulation 2
  • Cord prolapse if membranes rupture 1
  • Fetal distress requiring emergency delivery 2
  • The procedure itself becomes technically more difficult with engaged presenting part 3

Evidence Supporting Cesarean Section for Breech in Labor

• The safest course when breech presentation is diagnosed in labor without adequate preparatory data is delivery by cesarean section 1
• Maternal morbidity (febrile morbidity, blood transfusion, wound infections) is significantly greater with cesarean section, but this is outweighed by improved neonatal safety when breech is diagnosed unexpectedly in labor 4
• Vaginal breech delivery requires specific criteria to be met safely (frank breech, adequate pelvis on x-ray pelvimetry, experienced operator), which cannot be adequately assessed once labor is already established at 4 cm 4

Clinical Decision Algorithm

For breech presentation discovered in active labor:

1. Confirm breech presentation with bedside ultrasound 1
2. Assess cervical dilation status - if ≥4 cm, patient is in active labor 1
3. Proceed directly to cesarean section - do NOT attempt ECV 1, 2
4. Ensure continuous fetal monitoring until delivery 2

Common Pitfalls to Avoid

• Never attempt external cephalic version once labor has begun - this dramatically increases risks of placental abruption, cord accidents, and fetal distress 2
• Do not delay cesarean section to obtain x-ray pelvimetry or other assessments that would be needed for trial of vaginal breech delivery - these should have been done before labor 4
• Avoid assuming vaginal breech delivery is safe without meeting strict criteria: frank breech presentation, proven adequate pelvis, vertex position maintained, experienced operator, and immediate cesarean capability 4