A 34-year-old woman at 38 weeks gestation in active labor with a complete breech presentation, 4 cm cervical dilation, no progress after two hours, estimated fetal weight 2.9 kg, and a reassuring cardiotocography (CTG) – what is the appropriate next step?

Emergency Cesarean Section is Indicated

This patient requires emergency cesarean section due to the combination of complete breech presentation with active labor arrest at 4 cm dilation after 2 hours of no progress. 1

Rationale for Emergency Cesarean Section

Breech Presentation with Labor Arrest is a Strong Indication

• 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

• 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. 1

Two-Hour Arrest Threshold is Appropriate

• Recent evidence suggests that 2 hours of arrest is safer as a threshold for intervention rather than waiting the traditional 4 hours. 1

• This patient has met the 2-hour arrest criterion with no cervical change from 4 cm dilation, which constitutes active phase arrest. 1

Why Other Options Are Inappropriate

External Cephalic Version (ECV) is contraindicated:

• ECV should not be attempted once active labor has begun, as the patient is already 4 cm dilated. 1
• The risk of complications (placental abruption, cord accidents) increases significantly when attempting version in active labor.

Observation for two more hours is not recommended:

• 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

Critical Management Points

Avoid oxytocin augmentation:

• Do not attempt oxytocin augmentation for breech presentation with arrest—this increases risks without improving outcomes and may worsen fetal compromise. 1

Maintain continuous monitoring:

• Continue cardiotocography (CTG) to ensure fetal well-being remains reassuring until delivery. 1
• Although the CTG is currently reassuring, this does not change the indication for cesarean section given the breech presentation with arrested labor. 1

Proceed expeditiously:

• Emergency cesarean delivery should be performed to immediately intervene to improve maternal or fetal outcome. 2
• The estimated fetal weight of 2.9 kg is appropriate for vaginal delivery size-wise, but the breech presentation combined with labor arrest makes cesarean section the safest option. 1