## Management of Breech Presentation at 36 Weeks **Key Point:** External cephalic version (ECV) is the first-line intervention for breech presentation in the third trimester, provided contraindications are absent. ### Rationale for ECV At 36 weeks gestation, this primigravida is an ideal candidate for ECV because: - She is at term or near-term (≥36 weeks) - No contraindications are mentioned (intact membranes, normal CTG, adequate liquor) - Success rates for ECV are 40–60% overall, higher in multiparous women and those with adequate amniotic fluid - ECV can convert breech to cephalic presentation, enabling vaginal delivery **High-Yield:** ECV should be offered to all women with breech presentation at ≥36 weeks unless contraindications exist. It reduces the need for cesarean delivery. ### Contraindications to ECV | Absolute Contraindications | Relative Contraindications | |---|---| | Placenta previa | Oligohydramnios | | Abnormal CTG | Previous cesarean section | | Ruptured membranes | Maternal obesity | | Major fetal anomaly | Recurrent antepartum hemorrhage | | Multiple pregnancy (usually) | Fetal growth restriction | **Clinical Pearl:** ECV should be performed in a setting where emergency cesarean delivery is available. Tocolytics (nifedipine or terbutaline) improve success rates by 10–15%. ### Why Not Vaginal Breech Delivery? While vaginal breech delivery is possible in selected cases with experienced attendants and strict criteria (frank or complete breech, adequate pelvis, estimated fetal weight 2500–3800 g, flexed fetal head), it requires careful selection and skilled attendance. ECV offers the opportunity to achieve cephalic presentation first. **Mnemonic:** **TERM** for ECV timing — **T**erm or near-term (≥36 weeks), **E**xclusion of contraindications, **R**ight conditions (adequate liquor, normal CTG), **M**ultiparity or primiparity (both can be offered).
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