Do Not Perform ECV in This Patient – Stabilize and Deliver
External cephalic version is absolutely contraindicated in a patient with active or persistent vaginal bleeding, regardless of gestational age. 1
Why ECV is Contraindicated
Active vaginal bleeding at 36 weeks strongly suggests placenta previa or placental abruption, both of which are absolute contraindications to ECV because manipulation could trigger catastrophic hemorrhage. 1
Digital pelvic examination must be avoided until placenta previa has been excluded by transvaginal ultrasound, as manipulation can precipitate life-threatening bleeding. 1
The patient requires immediate diagnostic evaluation with transvaginal ultrasound (after transabdominal screening) to identify the source of bleeding—placenta previa has sensitivity of 90.7% and specificity of 96.9% with this approach. 1
Immediate Management Priorities
Hospitalization is mandatory for any woman with active bleeding to allow continuous monitoring and rapid access to emergency cesarean delivery. 1
Baseline laboratory assessment should include platelet count, prothrombin time, partial thromboplastin time, and fibrinogen levels at the initiation of bleeding. 1
Optimize hemoglobin values and treat anemia with oral or intravenous iron as needed, and notify the blood bank given the frequent need for large-volume transfusion in bleeding complications. 1
Administer antenatal corticosteroids immediately because delivery before 37 weeks is likely, and steroids are indicated when delivery is anticipated before 37 0/7 weeks. 1, 2
Delivery Planning for Breech with Bleeding
If placenta previa is confirmed, the American College of Obstetricians and Gynecologists recommends planned cesarean delivery at 34 0/7 to 35 6/7 weeks in stable patients, balancing neonatal complications against increased maternal bleeding risk after 36 weeks. 1
Delivery should not be delayed beyond 36 0/7 weeks in placenta previa because approximately 50% of women with placenta accreta spectrum beyond 36 weeks require emergent delivery for hemorrhage. 1
Earlier delivery is indicated for persistent bleeding, preeclampsia, labor, rupture of membranes, or fetal compromise. 1
Breech presentation at 36 weeks with bleeding mandates cesarean delivery—vaginal breech delivery in the setting of hemorrhage would compound both maternal and neonatal risk. 3
Why Each Answer Option is Wrong
Option A (now): Premature at 36 weeks without confirmed fetal lung maturity, though may be necessary if bleeding cannot be controlled. 1
Option B (37 weeks): ECV remains contraindicated if bleeding source is placenta previa; cesarean delivery is the appropriate intervention, not version. 1
Option C (39 weeks) and D (40 weeks): Dangerous delay—women with placenta previa should not wait beyond 36 weeks due to hemorrhage risk, and ECV is never appropriate with placental bleeding. 1
Evidence on ECV Timing (When NOT Contraindicated)
In uncomplicated breech presentations without bleeding, ECV initiated at 34 to 36 weeks reduces non-cephalic presentation at birth (RR 0.81) compared with waiting until 37 to 38 weeks, though it increases late preterm birth risk (RR 1.51). 4
However, active vaginal bleeding is a clear contraindication to ECV regardless of timing, as systematic reviews confirm that contraindications should be limited to those with clear pathophysiological relevance—and hemorrhage clearly poses catastrophic risk. 5
Critical Pitfall to Avoid
The single most dangerous error would be attempting ECV in a patient with vaginal bleeding—this could convert a manageable bleeding episode into uncontrolled hemorrhage, uterine rupture, or fetal demise. 1, 5 The correct answer is none of the above—this patient needs diagnostic imaging, stabilization, multidisciplinary delivery planning at a tertiary center, and cesarean delivery, not external cephalic version at any gestational age. 1