Emergency Cesarean Section is Indicated
For a 38-week pregnant woman with breech presentation, 4 cm dilation, and arrest of labor (no cervical change after 2 hours), emergency cesarean section should be performed immediately, even with a reassuring CTG. 1
Why Cesarean Section is the Correct Answer
Breech Presentation with Labor Arrest is a Strong Indication
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
Arrest of active phase labor (no cervical change after 2 hours at 4 cm dilation) is a strong indication for cesarean delivery in breech presentation. 1
Recent evidence supports that 2 hours of arrest is a safer threshold for intervention rather than waiting the traditional 4 hours, and breech presentation lowers this threshold further. 1
Guidelines Support Cesarean for Breech in Active Labor
The American College of Obstetricians and Gynecologists recommends cesarean delivery for breech presentation at term in active labor, particularly when labor has already commenced. 1
Even with reassuring fetal monitoring (reactive CTG), the structural risks of breech presentation combined with labor arrest mandate cesarean delivery. 1
Why Other Options Are Incorrect
Option A (Wait 2 More Hours) - Dangerous Delay
Do not wait for the traditional 4-hour arrest threshold in breech presentation—this increases maternal and neonatal morbidity without improving outcomes. 1
The combination of breech presentation with arrest dramatically increases risks, making further observation inappropriate. 1
Option C (External Cephalic Version) - Contraindicated in Active Labor
ECV should be performed from 36 weeks gestation before labor begins, not during active labor at 4 cm dilation. 2
ECV attempt requires immediate access to an operating room for emergency cesarean and should be performed with tocolysis, which is inappropriate once active labor has commenced. 2
Once a woman is in active labor with breech presentation, the opportunity for ECV has passed. 3, 2
Option D (Induction of Labor) - Explicitly Not Recommended
Induction of labor is not recommended for breech presentation. 3
Do not attempt oxytocin augmentation for breech presentation with arrest—this increases risks without improving outcomes and may worsen fetal compromise. 1
While oxytocin augmentation is acceptable in the presence of uterine dystocia for carefully selected breech presentations, this patient already has arrest of labor, indicating failed progress that will not be overcome by augmentation. 3
Clinical Pitfalls to Avoid
Do not consider trial of vaginal breech delivery in the setting of labor arrest—this combination dramatically increases maternal and neonatal morbidity. 1
Do not delay for additional monitoring when both breech presentation and labor arrest are present—the structural risks mandate intervention regardless of fetal heart rate pattern. 1
Recognize that a reactive CTG does not eliminate the mechanical risks of breech delivery with cephalopelvic disproportion suggested by labor arrest. 1