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

Management of Breech Presentation at 38 Weeks in Active Labor

Proceed directly to cesarean section—external cephalic version (ECV) is contraindicated once active labor has begun, particularly at 4 cm dilation. 1, 2

Why Cesarean Section is the Correct Choice

ECV is not performed during active labor. The procedure is only indicated before labor onset, typically after 36 weeks gestation but before contractions establish active labor patterns. 2, 3, 4 Once a patient reaches 4 cm dilation with a breech presentation, the window for version has closed and attempting manipulation would be both ineffective and dangerous.

Key Evidence Against ECV in This Scenario

• ECV protocols specifically exclude patients in active labor. Studies demonstrating 47-51% success rates with ECV were performed on patients diagnosed with breech presentation before active labor commenced. 2, 3
• The uterus during active labor is contracting and not amenable to external manipulation, even with tocolysis. Tocolytic agents used for ECV (such as fenoterol) are designed to relax a quiescent uterus, not to halt established labor. 4
• At 4 cm dilation with no progress after 2 hours, this represents either labor dystocia or inadequate pelvic dimensions—both of which are contraindications to vaginal breech delivery even if the presentation could theoretically be corrected. 5, 2

Why Immediate Cesarean Section is Indicated

When breech presentation is diagnosed in active labor without adequate data for safe vaginal breech delivery, cesarean section is the safest course. 1

Supporting Rationale

• Lack of preparatory assessment: Safe vaginal breech delivery requires specific criteria including pelvimetry, estimated fetal weight, fetal attitude assessment, and experienced personnel—none of which appear to have been established in this case before labor onset. 1, 5
• Labor arrest at 4 cm: The absence of cervical change over 2 hours suggests either cephalopelvic disproportion or inadequate uterine activity. In breech presentation, inadequate pelvic dimensions account for 59% of failed trials of labor. 5
• Normal CTG does not guarantee safe vaginal breech delivery: While reassuring for current fetal status, it does not address the mechanical risks of breech extraction through a potentially inadequate pelvis. 1

Critical Timing Considerations

Do not delay the decision for cesarean section. Once the determination is made that vaginal delivery is not appropriate:

• Prepare for cesarean section with standard precautions including left uterine displacement to avoid aortocaval compression. 6
• Administer prophylactic antibiotics within 60 minutes of skin incision. 6
• Use regional anesthesia when possible for optimal maternal and neonatal outcomes. 6

Common Pitfalls to Avoid

• Attempting ECV during active labor: This is outside established protocols and exposes both mother and fetus to unnecessary risk without realistic chance of success. 2, 3, 4
• Allowing prolonged labor with breech presentation without established criteria for safe vaginal delivery: This increases risk of cord prolapse, head entrapment, and birth trauma. 1
• Underestimating the significance of labor arrest: In breech presentation, this often indicates pelvic inadequacy that would make vaginal delivery dangerous. 5