Reducing the Baby: A Breech Presentation at Term
A 31-year-old woman, gravida 2 para 1, attends the antenatal clinic at 37 weeks. Her previous delivery was a spontaneous vaginal birth of a 3.4 kg baby. Current pregnancy has been uncomplicated. Ultrasound confirms a singleton fetus in frank breech presentation, estimated fetal weight 3.2 kg, normal amniotic fluid and normal placental position. She is normotensive, with no diabetes or hypertension. She has read about breech birth and asks whether she can 'just try normally'. The unit has a consultant obstetrician with experience in vaginal breech delivery on call today, but the on-call rota for the next two weeks includes several junior staff. The woman is anxious and wants a plan today.
1. What are the options, and what factors determine whether vaginal breech birth is reasonable?
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Options: external cephalic version (ECV), planned vaginal breech birth, or elective caesarean section.
ECV should be offered first: at 37 weeks, with ultrasound guidance and CTG before and after, success rates are around 50%, and it reduces caesarean rates. Consider tocolysis. Contraindications include antepartum haemorrhage, abnormal CTG, ruptured membranes, multiple pregnancy, and uterine anomaly.
Vaginal breech birth is reasonable only if all of the following hold:
- Frank breech (hips flexed, knees extended) - footling and complete breech carry higher cord prolapse risk.
- Estimated fetal weight 2.5–3.8 kg and clinically adequate pelvis.
- No fetal anomaly, normal amniotic fluid, normal placental site, no growth restriction.
- An experienced clinician present for the delivery, with facilities for immediate caesarean and neonatal resuscitation.
- Informed maternal choice.
Caesarean section reduces perinatal mortality and serious neonatal morbidity compared with planned vaginal breech birth (Term Breech Trial), but increases maternal morbidity and has implications for future pregnancies.
The judgement point here is the rota. This woman is an ideal candidate on clinical grounds, but the unit cannot guarantee an experienced operator for the next two weeks. A safe plan must account for who will actually be there. Options: schedule delivery when the experienced consultant is on duty (e.g., induction/planned section on a day the consultant is present), or offer elective caesarean. Do not promise a vaginal breech birth that the unit cannot safely supervise.
2. She asks what you would advise if she chooses vaginal breech birth. Outline the counselling and the intrapartum safeguards.
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Counselling (document it):
- Explain that planned caesarean lowers the risk of serious neonatal problems but increases her risks of infection, thromboembolism, longer recovery and uterine scar for future pregnancies.
- Explain that vaginal breech birth is possible but requires an experienced attendant and continuous monitoring, and that if labour does not progress or the fetal heart is abnormal, emergency caesarean will be needed.
- Confirm she understands the plan may change if the rota cannot provide an experienced operator.
Intrapartum safeguards:
- Continuous CTG and one-to-one midwifery care.
- IV access and cross-matched blood available.
- Senior obstetrician and anesthetist on site, with theater ready.
- Avoid oxytocin augmentation unless carefully supervised; augmented breech labours have higher failure rates.
- Do not rush the second stage - 'hands off the breech' until the scapulae are visible; then controlled delivery with Mauriceau–Smellie–Veit or Burns–Marshall manoeuvre as needed.
- Neonatal team present at delivery.
- Have a low threshold for caesarean for failure to progress or fetal compromise.
Judgement: the answer is not 'breech = section' nor 'breech = vaginal'; it is 'individualize, and only offer vaginal breech where the team and the setting can support it'. The candidate must mention the rota constraint explicitly.