A 32-year-old multiparous woman at 38 weeks of gestation presents with spontaneous rupture of membranes. On examination, the uterus is tender, and the fetal heart rate is 160 bpm with variable decelerations. Ultrasound confirms a frank breech presentation with the fetus in good condition otherwise. The patient is in early labor with contractions every 4–5 minutes. What is the most appropriate management?

Explanation

## Management of Breech Presentation in Active Labor **Key Point:** Cesarean section is the standard of care for breech presentation in labor in most modern obstetric units, following the Term Breech Trial (2000) and subsequent guidelines. ### Why Cesarean Section Is Indicated **High-Yield:** The Term Breech Trial demonstrated that planned cesarean delivery for term breech presentation reduces perinatal mortality and serious neonatal morbidity compared to vaginal breech delivery. **Clinical Pearl:** Vaginal breech delivery is no longer routinely offered in most countries, including India, due to: - Increased risk of head entrapment (especially in frank breech) - Risk of cord prolapse - Difficulty managing the delivery of the head in an unprepared pelvis - Loss of experienced providers for vaginal breech delivery - Medicolegal concerns ### Contraindications to Vaginal Breech Delivery Even in units where vaginal breech delivery is considered, the following preclude it: - **Active labor** (as in this case) — version becomes impossible - **Fetal distress** (variable decelerations present here) - **Ruptured membranes** — increases risk of cord prolapse - **Footling breech** — highest risk of cord prolapse - **Hyperextended fetal head** — risk of head entrapment ### Why Other Options Are Incorrect | Option | Why Not Appropriate | |--------|---------------------| | **Trial of vaginal breech delivery** | Contraindicated in active labor, with ruptured membranes, and fetal distress; cesarean section is safer | | **External cephalic version** | Contraindicated in labor and with ruptured membranes; high risk of cord prolapse and placental abruption | | **Corticosteroids and deferral** | Patient is already in active labor at term; deferral increases risk of cord prolapse and obstructed labor | **Mnemonic: BREACH-SAFE** — Breech in labor, Ruptured membranes, Early labor, Active labor → Always Cesarean for Safety and Efficacy. [cite:ACOG Practice Bulletin 13, Williams Obstetrics 26e Ch 28]