In a woman in active labor with a 4‑cm cervical dilation, good uterine contractions, breech presentation, and a reassuring fetal heart rate tracing, what is the most appropriate next step in management?

Emergency Cesarean Section

In a woman presenting in active labor at 4 cm dilation with breech presentation, the most appropriate next step is emergency cesarean section (Option C). External cephalic version is contraindicated once labor has begun, and expectant management or oxytocin augmentation are inappropriate when the fundamental issue is malpresentation, not labor dystocia.

Why External Cephalic Version is Contraindicated

• External cephalic version (ECV) should be attempted starting at 36 weeks of gestation in women with breech presentation before labor begins 1.
• Once a woman is in active labor with established uterine contractions and cervical dilation, ECV is no longer a safe or feasible option 1, 2.
• The window for ECV has passed in this clinical scenario 1.

Why Oxytocin and Expectant Management are Inappropriate

• Oxytocin augmentation is indicated for protracted active phase labor (cervical dilation <0.6 cm/hour) or arrest of labor in cephalic presentations, not for managing malpresentation 3.
• This patient has good uterine contractions and labor is progressing well, meaning there is no labor dystocia requiring augmentation 3.
• Reassessing after 2 hours would be appropriate for monitoring labor progression in cephalic presentations, but does not address the fundamental problem of breech presentation 3, 4.
• The primary issue here is fetal malpresentation, not inadequate uterine activity 5.

Evidence for Cesarean Delivery in Breech Presentation During Labor

• Planned vaginal delivery of breech presentation may be associated with a higher risk of composite perinatal mortality or serious neonatal morbidity compared to planned cesarean birth 1.
• Breech presentation is associated with significantly increased risk of perinatal morbidity and mortality due to cord compression, nuchal arm, and difficulty delivering the aftercoming head 2.
• While some protocols allow planned vaginal breech delivery under strict selection criteria (frank breech, normal fetal size, proven pelvic adequacy, hyperextended head ruled out), these assessments must be completed before labor 1, 2.

Critical Decision Point: Active Labor Changes Management

• The French College of Gynecologists and Obstetricians considers planned vaginal delivery a reasonable option for breech presentation when criteria are met and the decision is made before labor 1.
• However, this patient is already in active labor at 4 cm dilation without documented pre-labor assessment of pelvimetry, fetal head position, or fetal weight 1.
• Routine cesarean delivery of term breeches is considered a reasonable option by many physicians, particularly when strict selection criteria for vaginal breech delivery have not been met prospectively 2.

Safety Considerations

• Both mother and fetus are currently stable with reassuring CTG, making this an appropriate time for cesarean delivery rather than waiting for potential complications 6.
• Delaying cesarean delivery until complications arise (fetal distress, cord prolapse, arrest of descent) significantly increases maternal and neonatal morbidity 1, 2.