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

Cesarean Section is Indicated

Proceed immediately with cesarean section (Option A) for this patient with breech presentation in active labor at 38 weeks. External cephalic version (ECV) is absolutely contraindicated once labor has begun, particularly at 4 cm dilation with 2 hours of arrest. 1

Why ECV is Not an Option

• ECV is only performed before labor onset, typically at 36-40 weeks gestation in women who are not in labor 2, 3, 4
• Active labor with 4 cm dilation represents a complete contraindication to attempting ECV, as the procedure requires a relaxed uterus and is performed under controlled conditions with tocolysis 5
• The patient has already progressed to active labor (≥4 cm dilation), making any attempt at version both technically impossible and dangerous 1

Why Cesarean Section is Required

Breech Presentation in Labor

• Breech presentation at term in active labor is a standard indication for cesarean delivery in most modern obstetric practice, particularly when labor has already commenced 2, 6
• The combination of breech presentation with labor arrest significantly increases risks of cord prolapse, head entrapment, and birth trauma if vaginal delivery is attempted 1

Labor Arrest Considerations

• The patient demonstrates arrest of active phase labor (no cervical change after 2 hours at 4 cm dilation) 1
• Recent evidence suggests that 2 hours of arrest is safer as a threshold for intervention rather than waiting the traditional 4 hours 1
• Arrest of active phase is strongly associated with cephalopelvic disproportion (CPD) in 40-50% of cases, which further complicates breech delivery 1
• The guideline explicitly states: "It is better to err on the side of intervention by CD in the presence of uncertainty about potential harm than to allow labor in the false hope that safe vaginal delivery may occur" 1

Combined Risk Profile

• Breech presentation + labor arrest creates a compound risk scenario where attempting vaginal delivery would expose both mother and fetus to unacceptable morbidity 1
• Even in cephalic presentations, arrest at 4 cm with no progress after 2 hours warrants evaluation for cesarean delivery if CPD cannot be ruled out 1
• In breech presentation, the threshold for cesarean delivery should be even lower given the additional mechanical challenges 6

Critical Clinical Algorithm

Immediate Assessment Required:

1. Confirm fetal presentation via ultrasound if any doubt exists 2, 4
2. Perform continuous cardiotocography (CTG) to ensure fetal well-being remains reassuring 1
3. Assess for signs of CPD: molding, deflexion, asynclitism, lack of descent 1

Decision Tree:

• If CTG remains normal AND no signs of CPD → Still proceed to cesarean section due to breech presentation in arrested labor 1
• If CTG shows any non-reassuring patterns → Urgent cesarean section immediately 1
• If signs of CPD are present → Cesarean section is mandatory 1

Common Pitfalls to Avoid

• Do not attempt ECV in active labor - this is dangerous and contraindicated 2, 3, 5
• Do not attempt oxytocin augmentation for breech presentation with arrest - this increases risks without improving outcomes and may worsen fetal compromise 1
• Do not wait for the traditional 4-hour arrest threshold - recent evidence supports 2 hours as safer, and breech presentation lowers this threshold further 1
• Do not consider trial of vaginal breech delivery in the setting of labor arrest - this combination dramatically increases maternal and neonatal morbidity 1, 6

Why This Patient Missed the ECV Window

• ECV should have been offered at 36-37 weeks gestation before labor onset 2, 3, 4, 5
• Success rates for ECV at 38 weeks range from 22-44% when performed before labor 3, 6
• Once labor begins, the window for ECV has definitively closed 2, 5