A 24-year-old woman, gravida 2 para 1, comes to the office for a routine prenatal visit. The patient is at 37 weeks gestation based on her last menstrual period and first-trimester ultrasound. She has some irregular contractions but has had no vaginal bleeding or leakage of fluid. Fetal movement is normal. This pregnancy has been uncomplicated, and her last pregnancy ended with a term spontaneous vaginal delivery to a 4 kg (8 lb 8 oz) boy. The patient would like to have a vaginal delivery with this pregnancy. She has no chronic medical conditions and has had no previous surgeries. Vital signs are normal. Fetal heart tones are 135/min. Fundal height is 37 cm. Digital cervical examination reveals a closed cervix and an unengaged fetal presenting part. Ultrasonography shows a fundal placenta, a single deepest vertical pocket of amniotic fluid of 3 cm, and a fetus in incomplete breech presentation. Which of the following is the best next step in management of this patient?

Question

A 24-year-old woman, gravida 2 para 1, comes to the office for a routine prenatal visit.  The patient is at 37 weeks gestation based on her last menstrual period and first-trimester ultrasound.  She has some irregular contractions but has had no vaginal bleeding or leakage of fluid.  Fetal movement is normal.  This pregnancy has been uncomplicated, and her last pregnancy ended with a term spontaneous vaginal delivery to a 4 kg (8 lb 8 oz) boy.  The patient would like to have a vaginal delivery with this pregnancy.  She has no chronic medical conditions and has had no previous surgeries.  Vital signs are normal.  Fetal heart tones are 135/min.  Fundal height is 37 cm.  Digital cervical examination reveals a closed cervix and an unengaged fetal presenting part.  Ultrasonography shows a fundal placenta, a single deepest vertical pocket of amniotic fluid of 3 cm, and a fetus in incomplete breech presentation.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_da74_1444_bc81_f1cc24c4fd22_MD0003_00 Breech presentation occurs when the buttocks or feet are the fetal part closest to the maternal cervix. Risk factors include prematurity, multiparity, multiple gestation, uterine anomalies (eg, septate uterus), leiomyomas, placenta previa, and some fetal anomalies (eg, hydrocephaly). Breech presentation is typically diagnosed via ultrasound; however, examination findings consistent with a breech fetus include subcostal pain or a palpation of a hard mass near the uterine fundus (due to the fetal head) or lack of a fetal presenting part on digital cervical examination. Patients with breech presentation and no contraindications to vaginal delivery (eg, placenta previa, prior classical cesarean delivery) are offered external cephalic version (ECV), a procedure in which the fetus is manually rotated to cephalic presentation (Choice A). If the fetus is successfully rotated to cephalic presentation, patients can attempt a vaginal delivery. ECV has a risk of prelabor rupture of membranes, abruptio placentae, and preterm labor that may necessitate delivery; therefore, the procedure is performed at ≥37 weeks gestation to decrease the risks associated with premature delivery. manually rotated (Choices B and E) Vaginal delivery may be appropriate for select patients spontaneously laboring with a fetus in frank or complete breech presentation. However, vaginal delivery is contraindicated in patients with footling or incomplete breech presentation (such as this patient) due to the risk of head entrapment through an incompletely dilated cervix after delivery of the body, which is an obstetric emergency. Because this patient desires a vaginal delivery, ECV should be attempted; however, if the procedure is unsuccessful, a scheduled cesarean delivery is indicated. complete breech presentation (Choice D) Internal podalic version facilitates vaginal delivery of the second twin by grasping the feet and performing a breech extraction. It is not indicated in the management of singleton gestations. Internal podalic version Educational objective: Patients at ≥37 weeks gestation with breech presentation are offered external cephalic version, a procedure in which the fetus is manually rotated to cephalic presentation. Patients who have a successful procedure have lower cesarean delivery rates compared with those who are managed expectantly. References: Maternal outcomes of term breech presentation delivery: impact of successful external cephalic version in a nationwide sample of delivery admissions in the United States. (http://www.ncbi.nlm.nih.gov/pubmed/27392035) Practice bulletin no. 161: external cephalic version. (http://www.ncbi.nlm.nih.gov/pubmed/26942387) External cephalic version for breech presentation at term. (http://www.ncbi.nlm.nih.gov/pubmed/23076883)

A 24-Year-Old Woman, Gravida 2 Para 1, Comes to the Office