What is the best action for a pregnant woman at 33 weeks gestational age (Ga) with a cervix (Cat) dilation of 2 and the fetal head palpable in the vagina, with all other parameters being normal?

Immediate Cesarean Section is Indicated

At 33 weeks gestation with 2 cm cervical dilation and the fetal head palpable in the vagina, cesarean section (CS) is the safest and most appropriate management to prevent catastrophic maternal and neonatal complications associated with preterm breech delivery. 1

Clinical Assessment Confirms Breech Presentation

The clinical scenario describes a breech presentation where:

• The fetal head is palpable in the vagina (meaning it's at the fundus, not engaged in the pelvis)
• At 33 weeks, the fetus is in breech position with early cervical dilation
• This represents a preterm breech presentation requiring immediate intervention 1

The description "head felt in the vagina" is anatomically impossible unless this is breech presentation - in a vertex presentation, the head would be felt in the pelvis/cervix, not accessible vaginally at 2 cm dilation. 1

Why Cesarean Section is Mandatory

Preterm Breech Delivery Carries Extreme Risk

• Neonatal mortality is significantly higher with vaginal delivery in preterm breech: pooled risk ratio shows 11.5% mortality with vaginal delivery versus 3.8% with CS (RR 0.63,95% CI 0.48-0.81) 2
• At 33 weeks specifically, vaginal breech delivery risks include: entrapment of the aftercoming head, cord prolapse, and delivery room death 3
• Extremely preterm breech presentations (25-27 weeks) show delivery room mortality of 12.4% with planned vaginal delivery versus 0% with planned CS 3

Contraindications to All Other Options

Forceps (Option B) - Absolutely Contraindicated:

• Forceps are only appropriate for vertex presentations with the head engaged in the pelvis 4
• Using forceps on a breech presentation would cause catastrophic fetal trauma 1
• At 33 weeks with preterm breech, operative vaginal delivery increases risk of complications 4

Vacuum (Ventouse) (Option C) - Absolutely Contraindicated:

• Vacuum extraction requires vertex presentation with scalp access 4
• Cannot be applied to breech presentation 1
• Would cause severe fetal injury if attempted 4

Fetal Sampling (Option D) - Inappropriate and Dangerous:

• Fetal scalp sampling requires vertex presentation with adequate cervical dilation 4
• Delays definitive management when CS is clearly indicated 5
• At 2 cm dilation with breech presentation, sampling is technically impossible and clinically irrelevant 1

Evidence-Based Timing and Approach

Optimal Gestational Age for Preterm Breech CS

• At 33 weeks, immediate CS is recommended rather than expectant management 6
• The Society for Maternal-Fetal Medicine recommends delivery at 33-34 weeks for high-risk preterm scenarios 6
• Waiting for labor progression in preterm breech dramatically increases neonatal mortality (NNT = 8 to prevent one neonatal death) 3

Preparation Requirements

Before proceeding to CS at 33 weeks: 6

• Administer antenatal corticosteroids for fetal lung maturation (if not already given) 6
• Administer magnesium sulfate for neonatal neuroprotection at <34 weeks 6
• Ensure neonatal team availability for preterm infant resuscitation 6
• Multidisciplinary coordination with anesthesia, neonatology, and obstetrics 6

Critical Pitfalls to Avoid

Do NOT attempt vaginal delivery: 3, 7

• Even with "everything else normal," preterm breech vaginal delivery carries unacceptable risk
• Risk factors for adverse outcomes include the preterm gestational age itself 7
• Delivery room deaths in preterm breech are associated with entrapment and cord prolapse 3

Do NOT administer oxytocin: 1

• Oxytocin is contraindicated when CS is indicated 1
• Augmenting labor in preterm breech presentation increases risk of fetal trauma 1

Do NOT delay for further assessment: 5

• Once preterm breech presentation is confirmed at 33 weeks with cervical change, CS should be performed promptly 1
• Waiting for "fetal distress" on monitoring delays necessary intervention 5

Mode of Delivery Evidence Summary

The evidence overwhelmingly supports CS for preterm breech:

• Cochrane review shows major maternal complications occur more frequently with CS (RR 7.21,95% CI 1.37-38.08), but this is outweighed by the dramatic reduction in neonatal mortality 8
• Recent cohort data (2021) confirms delivery room mortality is exclusively associated with attempted vaginal delivery in preterm breech 3
• Finnish national data demonstrates specific risk factors (oligohydramnios, growth restriction, maternal obesity) further increase adverse outcomes with vaginal delivery, but preterm breech itself is sufficient indication for CS 7

Answer: A - Cesarean Section 1, 2, 3