What is the recommended mode of delivery for a pregnant woman with a complete breech presentation and a fetal weight of approximately 2.8 kilograms (kg)?

Cesarean Section is Recommended

For a pregnant woman with complete breech presentation and fetal weight of 2.8 kg at term, cesarean section is the recommended mode of delivery, though planned vaginal delivery remains a reasonable option if strict selection criteria are met and the woman is fully informed and consents.

Evidence-Based Rationale

Primary Recommendation

• Planned cesarean delivery is generally preferred for breech presentation at term because it may be associated with lower risk of composite perinatal mortality or serious neonatal morbidity compared to planned vaginal delivery 1
• The fetal weight of 2.8 kg (2,800 g) falls within the acceptable range (2,500-3,500 g) for considering vaginal delivery if specific criteria are met 2
• Complete breech presentation is not, by itself, a contraindication to planned vaginal delivery 3, 1

When Vaginal Delivery Can Be Considered

If the woman strongly desires vaginal delivery, the following criteria must ALL be met:

• Pelvimetry at term should be performed to assess pelvic adequacy (anteroposterior diameter of inlet ≥105mm, transverse diameter of inlet ≥120mm, transverse interspinous diameter ≥100mm) 3
• Ultrasound must confirm the fetal head is NOT hyperextended before attempting vaginal delivery 3, 1
• Estimated fetal weight between 2,500-4,000 g (this patient at 2.8 kg qualifies) 4
• Frank or complete breech with flexed or neutral head attitude 4
• No clinically inadequate maternal pelvis 4
• Availability of continuous electronic fetal monitoring 4
• Immediate access to cesarean section within 30 minutes 4
• A health care provider skilled and experienced in vaginal breech delivery must be present 4, 1

Critical Safety Considerations

• Vaginal breech delivery requires an experienced obstetrician-gynecologist comfortable in performing vaginal breech delivery to be present at delivery 4
• The delivery should take place in or near an operating room with equipment and personnel available for timely cesarean section 4
• A health care professional skilled in neonatal resuscitation must be in attendance 4
• If adequate progress in labor does not occur, cesarean section is mandatory 4

Outcomes Comparison

• Planned vaginal delivery may carry higher risk of perinatal mortality (approximately 2 per 1,000 births) and serious short-term neonatal morbidity (approximately 2%) with careful case selection 4
• Long-term neurodevelopmental outcomes at 2 years, cognitive outcomes at 5-8 years, and adult intellectual performance do not differ by planned mode of delivery 1
• Cesarean delivery increases risks in subsequent pregnancies including uterine rupture, placenta accreta spectrum disorders, and hysterectomy 1

Common Pitfalls to Avoid

• Do not attempt vaginal delivery without proper pelvimetry and ultrasound assessment of fetal head position 3, 1
• Do not proceed with vaginal delivery if an experienced provider is not immediately available 4
• Avoid total breech extraction for term singleton breech delivery 4
• Do not induce labor for breech presentation unless criteria for planned vaginal delivery are met 4

Decision-Making Algorithm

1. Confirm breech type and fetal weight by ultrasound (complete breech, 2.8 kg - both acceptable) 3
2. Check for hyperextension of fetal head - if present, cesarean mandatory 3, 1
3. Assess provider experience and facility capabilities - if inadequate, cesarean mandatory 4
4. If vaginal delivery considered: perform pelvimetry - if inadequate measurements, cesarean mandatory 3
5. Obtain informed consent after discussing risks/benefits of both routes 4, 1
6. Default to cesarean section if any criterion is not met or woman prefers cesarean 1

Informed Consent Requirements

• The woman must be informed that planned cesarean may reduce short-term neonatal risks but does not affect long-term neurodevelopmental outcomes 1
• She should understand that vaginal delivery requires strict adherence to labor management protocols and may still result in emergency cesarean 4
• The woman's autonomous choice must be respected after full informed consent 1