A 28-year-old primigravida at 36 weeks of gestation presents to the antenatal clinic for routine check-up. Abdominal examination reveals a hard, round mass in the fundus and fetal heart sounds are heard at the umbilicus. On per vaginum examination, the cervix is closed and uneffaced. Ultrasound confirms a frank breech presentation with adequate amniotic fluid and an estimated fetal weight of 2800 g. The patient has no contraindications to vaginal delivery. What is the most appropriate next step in management?

Explanation

## Clinical Context This is a primigravida at 36 weeks with frank breech presentation, adequate amniotic fluid, and no contraindications. The question tests knowledge of current breech management guidelines. ## Key Management Principle **Key Point:** External cephalic version (ECV) is the first-line intervention for breech presentation at ≥36 weeks in women without contraindications, offered after informed consent and fetal assessment (NST, ultrasound). **High-Yield:** The Term Breech Trial (2000) showed increased perinatal mortality with planned vaginal breech delivery, leading to widespread adoption of planned cesarean delivery. However, ECV is attempted BEFORE this decision to convert to cephalic presentation. ## ECV Eligibility Criteria | Criterion | Status in This Case | |-----------|--------------------| | Gestational age ≥36 weeks | ✓ Yes (36 weeks) | | No contraindications (placenta previa, abnormal CTG, previous uterine surgery) | ✓ Yes | | Adequate amniotic fluid | ✓ Yes | | Singleton pregnancy | ✓ Implied | | Frank or complete breech (not footling) | ✓ Yes (frank breech) | | Estimated fetal weight 2500–4000 g | ✓ Yes (2800 g) | ## Pre-ECV Assessment 1. Perform NST to exclude fetal distress 2. Confirm presentation and exclude contraindications on ultrasound 3. Obtain informed consent (success rate ~50–60%, risk of emergency cesarean ~0.5%) 4. Have tocolytic agent (nifedipine or terbutaline) and emergency cesarean capability available **Clinical Pearl:** ECV success is higher in multiparous women and those with adequate amniotic fluid. If ECV is successful, vaginal cephalic delivery is then planned. If unsuccessful or declined, planned cesarean at 39 weeks is offered. ## Why Not Immediate Cesarean? At 36 weeks, ECV is the standard of care before committing to surgical delivery. Cesarean is reserved for failed ECV or contraindications.