What is the best course of action for a 38-week pregnant woman with a complete breech presentation, 4 cm dilation, estimated fetal weight of 2.9 kg, and a reactive Cardiotocography (CTG), who has shown no change in dilation after 2 hours?

Emergency Cesarean Section is Indicated

For a pregnant woman at 38 weeks with complete breech presentation, 4 cm dilation, and no cervical change after 2 hours of labor, emergency cesarean section (Option C) is the recommended management.

Why Cesarean Section is the Correct Choice

Breech Presentation in Active Labor is a Contraindication to Vaginal Delivery

• Induction of labor with oxytocin is absolutely contraindicated because the patient is already in active labor (4 cm dilation with 2 hours of observation), and augmentation would be inappropriate for breech presentation 1
• The Society of Obstetricians and Gynaecologists of Canada explicitly states that induction of labor is not recommended for breech presentation 1
• Oxytocin augmentation is only acceptable for breech presentation in the presence of uterine dystocia with adequate progress, which is not the case here given the arrest of dilation 1

Arrest of Active Phase Labor Signals High Risk

• This patient demonstrates arrest of active phase labor - defined as no cervical change over 2 hours at 4 cm dilation 2
• The American College of Obstetricians and Gynecologists notes that 40-50% of patients with arrest of active phase have concomitant cephalopelvic disproportion (CPD), making this a high-risk scenario 2
• Recent evidence suggests that 2 hours of arrest is safer than waiting 4 hours before proceeding to cesarean delivery 2
• Waiting an additional 2 hours (Option B) would delay necessary intervention and increase maternal and fetal risk 2

External Cephalic Version is Not Appropriate

• External cephalic version (Option D) is contraindicated once labor has begun - it should only be attempted from 36 weeks gestation in a non-laboring patient 3
• ECV requires immediate access to an operating room for emergency cesarean and should be performed with tocolysis, which is inappropriate for a patient already in active labor 3
• The timing for ECV has passed - it should have been offered before 38 weeks for optimal success 4

Breech Presentation Criteria for Vaginal Delivery Are Not Met

Multiple Contraindications Present

• The Society of Obstetricians and Gynaecologists of Canada specifies that vaginal breech delivery requires frank or complete breech with flexed or neutral head attitude - while this patient has complete breech, other criteria are not met 1
• Arrest of labor progression is a contraindication - the guideline states "in the absence of adequate progress in labour, Caesarean section is advised" 1
• The patient does not meet the labor management criteria requiring continuous progress through active phase 1

Fetal Weight is Acceptable But Labor Pattern is Not

• The estimated fetal weight of 2.9 kg (2900 g) falls within the acceptable range of 2500-4000 g for vaginal breech delivery 1, 5
• However, fetal weight alone does not justify vaginal delivery when labor is arrested 1
• Normal progression of labor is mandatory for safe vaginal breech delivery, which is absent in this case 5

Critical Safety Considerations

Perinatal Risk in Breech Presentation

• Vaginal breech birth carries higher risk of perinatal mortality and short-term neonatal morbidity compared to elective cesarean section 1
• Even with careful case selection, perinatal mortality occurs in approximately 2 per 1000 births and serious short-term neonatal morbidity in approximately 2% of breech infants 1
• Arrest of dilation in breech presentation significantly increases these baseline risks 2, 1

The Danger of Delayed Intervention

• Proceeding with oxytocin or waiting longer when CPD is likely (as suggested by arrest pattern) creates unnecessary risk 2
• The American College of Obstetricians and Gynecologists emphasizes that it is better to err on the side of intervention by cesarean delivery in the presence of uncertainty about potential harm 2
• Astute clinicians should recognize potential problems before strict time limits are reached, especially with malpresentation 2

Common Pitfalls to Avoid

• Do not attempt oxytocin augmentation for breech presentation with arrested labor - this combines two high-risk factors and is not supported by guidelines 1
• Do not wait for 4 hours of arrest - while older guidelines suggested this timeframe, recent evidence favors earlier intervention at 2 hours 2
• Do not attempt ECV in active labor - this is dangerous and contraindicated 3
• Do not assume that reactive CTG alone indicates safety to continue labor - arrest of dilation in breech presentation requires delivery regardless of fetal heart rate pattern 1