In a pregnant woman in active labor with a breech fetus, 4 cm cervical dilation, good uterine contractions, stable maternal and fetal status, and a reassuring cardiotocograph, what is the most appropriate next step in management?

Emergency Cesarean Section

The most appropriate next step is emergency cesarean section (Option C). Once a patient is in active labor at 4 cm dilation with a breech presentation, immediate cesarean delivery is indicated because vaginal breech delivery carries markedly higher perinatal morbidity and mortality, and expectant management is inappropriate. 1

Why Cesarean Section is Mandatory

• Active labor with breech presentation is an absolute indication for cesarean delivery because the labor is already established and continuing to vaginal delivery would expose the fetus to unacceptable risks of birth trauma, cord prolapse, and perinatal asphyxia. 1

• The patient is at 4 cm dilation with good contractions, confirming she is in the active phase of labor, which eliminates any opportunity for alternative management strategies. 1

• Continuous fetal heart rate monitoring must be maintained throughout preparation and during the cesarean delivery because breech presentation in labor predisposes to cord compression or prolapse. 1

Why Other Options are Contraindicated

External Cephalic Version (Option D) is Absolutely Contraindicated

• ECV cannot be performed once labor has begun because the procedure requires a relaxed uterus and is only performed in the antepartum period at approximately 36-37 weeks gestation. 1

• Attempting ECV during active labor would be both technically impossible and dangerous for both mother and fetus. 1

Oxytocin Augmentation (Option A) is Inappropriate and Unsafe

• Oxytocin is only indicated for protracted active-phase labor (cervical dilation < 0.6 cm/hour) or arrest disorders; neither condition is present in this patient who has adequate contractions and is progressing at 4 cm. 1, 2

• Administering oxytocin in a breech presentation would accelerate vaginal delivery, which carries unacceptable risks compared with cesarean delivery. 1

• The patient has "good uterine contractions" and "labor is progressing well," meaning there is no indication for uterotonic stimulation. 3

Reassessment After 2 Hours (Option B) is Dangerous Delay

• Continuing to observe labor progression would unnecessarily postpone definitive treatment and increase maternal-fetal risk. 1

• Expectant management is explicitly inappropriate once active labor is established with a breech presentation. 1

• The 2-hour reassessment window applies only to protracted labor patterns when cephalopelvic disproportion must be excluded, not to breech presentations in active labor. 2

Immediate Preparation Steps

• The surgical team should be mobilized immediately, with anesthesia consultation and informed consent obtained, to proceed with cesarean section without delay. 1

• Maintain continuous cardiotocography monitoring during preparation and transfer to the operating room. 1, 4