Can a woman with a history of one previous cesarean (C-section) delivery and a current fetus in breech presentation at 32 weeks' gestation attempt a vaginal delivery?

From the Guidelines

The most appropriate response by the physician is option C: "Most fetuses spontaneously convert to cephalic presentation as they get closer to term. If that happens, a vaginal delivery will be possible." This is the best answer because at 32 weeks gestation, there is still significant time for the fetus to spontaneously turn to a head-down position before delivery. Approximately 25% of fetuses are in breech presentation at 32 weeks, but only 3-4% remain breech at term. The physician should reassure the patient that spontaneous version is likely and avoid making premature decisions about delivery method. The patient's previous cesarean delivery was for breech presentation, not due to pelvic inadequacy or other factors that would necessarily contraindicate a vaginal birth after cesarean (VBAC) 1. Some key points to consider in this scenario include:

• Women who have had a previous cesarean delivery can still be considered for a trial of labor, as the risk of uterine rupture is low if they have had only one previous cesarean delivery 1.
• The benefits and harms of a trial of labor should be discussed with the patient, taking into account their individual risk factors, values, and preferences 1.
• Short-term maternal outcomes are as good or better with a trial of labor compared to repeat cesarean delivery, although perinatal mortality may be higher 1. Option A is inappropriate because scheduling a cesarean at 37 weeks is too early without medical indication. Option B incorrectly suggests attempting vaginal breech delivery, which is generally not recommended due to increased risks. Option D is premature since external cephalic version is typically not performed until 37 weeks. Option E incorrectly focuses on VBAC considerations when the primary issue is the current breech presentation. Given the current evidence, the best course of action is to wait and see if the fetus will spontaneously convert to a cephalic presentation, and then reassess the situation closer to term 1.

From the Research

Response to the Patient's Concerns

The patient is worried about delivery because her last baby was in breech presentation. She asks the physician if the baby can be delivered vaginally.

• The patient has a history of previous cesarean delivery, which is an important factor to consider when deciding on the mode of delivery for the current pregnancy.
• The current pregnancy is uncomplicated, and the patient is at 32 weeks' gestation with a fetus in breech presentation.
• The patient's concern about vaginal delivery is valid, given her previous cesarean delivery.

Consideration of Vaginal Birth After Cesarean (VBAC)

• Studies have shown that VBAC is a reasonable option for women with a previous low transverse cesarean section 2, 3, 4, 5, 6.
• The risk of uterine rupture is a concern with VBAC, but it is relatively low, ranging from 0.03% to 0.47% 3, 5.
• The American College of Obstetricians and Gynecologists (ACOG) recommends that women with a previous low transverse cesarean section be offered a trial of labor after cesarean (TOLAC) if they desire a vaginal birth 4.

External Cephalic Version (ECV)

• ECV is a procedure that can be used to rotate the fetus from a breech presentation to a cephalic presentation.
• Studies have shown that ECV can be successful in women with a previous cesarean delivery, with a success rate of 82% in one study 2.
• However, the decision to attempt ECV should be individualized and based on the patient's specific circumstances.

Response to the Patient

• The most appropriate response by the physician would be to discuss the options for delivery with the patient, including VBAC and ECV.
• The physician should explain the risks and benefits of each option, including the risk of uterine rupture with VBAC.
• The patient should be counseled on the likelihood of success with ECV and the potential benefits of a vaginal birth.
• Ultimately, the decision on the mode of delivery should be based on the patient's individual circumstances and her informed decision.

Options for the Patient

• Option E is the most appropriate response, as it takes into account the patient's history of previous cesarean delivery and the current breech presentation of the fetus.
• The physician should explain that because the patient had only one cesarean delivery in the past, the risk of uterine rupture during vaginal birth is low, and therefore, a trial of labor can be attempted.