Cesarean Section
Proceed immediately to cesarean section for this patient with complete breech presentation, ruptured membranes, 5 cm dilation, and arrest of labor after 2 hours. 1
Critical Decision Points Against Vaginal Delivery
Absolute Contraindications Present
- Induction of labor is not recommended for breech presentation, making oxytocin augmentation inappropriate in this clinical scenario 1
- Labor arrest (no progress after 2 hours at 5 cm) in breech presentation mandates cesarean delivery, as adequate progress in labor is the best indicator of fetal-pelvic proportions 1
- The combination of ruptured membranes with arrested labor significantly increases infection risk, with chorioamnionitis risk rising approximately 2% per hour after membrane rupture 2
Why Other Options Are Contraindicated
External cephalic version (Option D) is absolutely contraindicated because:
- Version should never be attempted after labor has begun with ruptured membranes and cervical dilation 3, 4
- The patient is already 5 cm dilated and in active labor, making version technically impossible and dangerous 3
Oxytocin augmentation (Option B) is inappropriate because:
- Induction or augmentation of labor in breech presentation is explicitly not recommended by current guidelines 1
- While some studies suggest oxytocin augmentation is acceptable for uterine dystocia in breech labor, this applies only to patients already meeting strict vaginal delivery criteria, which this patient does not 1, 5
- The arrest of labor suggests cephalopelvic disproportion or inadequate fetal-pelvic proportions, making further labor dangerous 1
Reassessment after 2 hours (Option A) is dangerous because:
- The patient has already demonstrated 2 hours without progress, meeting criteria for labor arrest 1
- Delaying delivery increases infection risk exponentially with ruptured membranes 2
- After 18 hours of membrane rupture, antibiotic prophylaxis becomes mandatory regardless of other factors, but intervention should occur much earlier 2, 6
Evidence-Based Rationale for Cesarean Section
Labor Arrest Criteria Met
- In breech presentation, absence of adequate progress in labour mandates cesarean section 1
- Good progress in labor is the best indicator of adequate fetal-pelvic proportions; the absence of progress after 2 hours suggests disproportion 1
Infection Risk Management
- With ruptured membranes and arrested labor, the risk of chorioamnionitis increases continuously 2
- The combination of breech presentation, ruptured membranes, and labor arrest creates compounding risks that favor immediate delivery 2, 6
Safety Profile
- Vaginal breech birth can be associated with higher risk of perinatal mortality and short-term neonatal morbidity than elective cesarean section 1
- While carefully selected vaginal breech delivery can achieve good outcomes, this patient does not meet selection criteria due to labor arrest 1
Critical Pitfalls to Avoid
- Never attempt oxytocin augmentation in breech presentation without meeting strict vaginal delivery criteria, including demonstrated labor progress 1
- Never delay cesarean section when labor arrest is documented in breech presentation, as this increases both maternal infection risk and fetal compromise 1, 2
- Never attempt external cephalic version after labor has begun, membranes have ruptured, or significant cervical dilation has occurred 3, 4
- Do not wait for the 18-hour threshold for antibiotic prophylaxis when other obstetric indications for delivery already exist 2, 6