A 28-year-old primigravida at 36 weeks gestation presents to the antenatal clinic for a routine check-up. On abdominal examination, the head is palpable in the fundus and the buttocks are in the lower uterine segment. Fetal heart rate is 142 bpm and reactive. Ultrasound confirms frank breech presentation. The patient is counselled about delivery options. What is the most appropriate management for this patient?

Explanation

## Management of Breech Presentation at Term **Key Point:** External cephalic version (ECV) is the first-line intervention for singleton breech presentation at ≥36 weeks in women without contraindications, with planned caesarean delivery as backup. ### Current Evidence & Guidelines Following the Term Breech Trial (2000) and subsequent meta-analyses, the standard of care has evolved: 1. **ECV Attempt (37 weeks):** Success rate 50–60% in multiparas, 40–50% in primiparas. Reduces need for caesarean delivery by ~50%. 2. **Contraindications to ECV:** Placenta previa, previous uterine surgery (relative), fetal anomalies, oligohydramnios, abnormal CTG, maternal hypertension (uncontrolled). 3. **If ECV Successful:** Vaginal delivery may be attempted in selected cases with experienced attendants; most centres now offer planned caesarean at 39 weeks. 4. **If ECV Fails or Contraindicated:** Planned caesarean section at 39 weeks is standard. ### Why This Patient? - **Primigravida, 36 weeks, frank breech, no contraindications mentioned** → ECV is indicated. - Timing: ECV is safest and most effective at 37 weeks (lower risk of spontaneous reversion, adequate amniotic fluid). - Informed consent is essential; discuss success rates, risks (labour induction in 1–2%, placental abruption <1%), and delivery plan. **High-Yield:** The Term Breech Trial changed practice globally. ECV with tocolysis (nifedipine or terbutaline) improves success. [cite:RCOG Green-top Guideline 20b] **Clinical Pearl:** Fetal well-being assessment (reactive NST, adequate liquor) is mandatory before ECV. Ultrasound confirmation of presentation and exclusion of contraindications is essential. **Mnemonic — ECV Contraindications: PACED** - **P**lacenta previa - **A**bnormal CTG / Anomalies - **C**esarean scar (relative) - **E**xtreme oligohydramnios - **D**iabetes (uncontrolled) / Distress ### Decision Tree ```mermaid flowchart TD A[Breech at 36+ weeks]:::outcome --> B{Contraindications to ECV?}:::decision B -->|Yes| C[Planned CS at 39 weeks]:::action B -->|No| D[Counsel & attempt ECV at 37 weeks]:::action D --> E{ECV successful?}:::decision E -->|Yes| F[Vaginal delivery trial or planned CS]:::action E -->|No| G[Planned CS at 39 weeks]:::action F --> H[Delivery with experienced attendant]:::action G --> H ```