## Management of Breech Presentation at Term **Key Point:** External cephalic version (ECV) with tocolytic support is the first-line intervention for breech presentation at ≥36 weeks in appropriately selected candidates, followed by planned cesarean section if unsuccessful or if ECV is contraindicated. ### Current Evidence & Guidelines The Term Breech Trial (2000) and subsequent meta-analyses demonstrated that planned cesarean section for breech presentation reduces perinatal mortality and serious neonatal morbidity compared to planned vaginal delivery. However, ECV with tocolytics significantly improves the chance of cephalic presentation and vaginal delivery. **High-Yield:** ECV success rate is 40–60% at term; higher in multiparas and with tocolytic use. If ECV is successful, vaginal delivery can be planned. If unsuccessful or contraindicated, planned cesarean section at 39 weeks is standard. ### Indications for ECV Attempt - Breech or transverse lie at ≥36 weeks - No contraindications (placenta previa, prior uterine surgery, rupture of membranes, fetal compromise, multiple pregnancy) - Adequate amniotic fluid - Reactive fetal heart rate ### Contraindications to ECV - Placenta previa - Abnormal cardiotocography - Rupture of membranes - Previous cesarean section (relative; can be attempted with caution) - Multiple pregnancy (relative) - Fetal anomalies incompatible with vaginal delivery **Clinical Pearl:** Tocolytics (nifedipine or terbutaline) increase ECV success by relaxing uterine muscle and reducing discomfort. Success is higher when attempted before 36 weeks but can be offered at 36–37 weeks. ### Why This Patient? At 36 weeks with frank breech and no mention of contraindications, ECV with tocolytic support is the evidence-based first step. If successful, vaginal delivery becomes possible. If unsuccessful, planned cesarean at 39 weeks follows. [cite:RCOG Green-top Guideline 20b, ACOG Practice Bulletin 161]
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