A 24-year-old primigravid woman at 35 weeks gestation comes to the office for a routine prenatal visit. The patient reports no leakage of fluid or vaginal bleeding but has noticed occasional painless uterine contractions over the past week. Fetal movement is normal. Her pregnancy has been uncomplicated. The patient has no chronic medical conditions and has had no surgeries. She takes a daily prenatal vitamin and has not used tobacco, alcohol, or illicit drugs during the pregnancy. The patient takes a prenatal yoga class 3 times a week. Blood pressure is 130/80 mm Hg and pulse is 68/min. BMI is 28 kg/m². The fetal heart rate is 142/min by Doppler ultrasound. Fundal height is 32 cm. Pelvic examination shows the cervix to be closed and long with the fetal presenting part at 0 station. Ultrasound reveals a fetus in footling breech presentation with an estimated fetal weight at the 25th percentile for gestational age, a fundal placenta, and a normal amniotic fluid level. The diagnosis of breech presentation is reviewed with the patient, who responds by saying "I am really hoping for a vaginal delivery." Which of the following is the most appropriate response to this patient?

Question

Quizplus · Accepted Answer

Explanation: 11ec2b69_c023_6c7f_8f63_396018cfc5ee_MD0005_00 A breech presentation occurs when the feet or buttocks are the closest presenting part to the cervix. Many preterm fetuses are in breech presentation; however, most spontaneously convert to cephalic presentation by term (eg, >37 weeks gestation). Risk factors for persistent breech presentation include uterine anomalies (eg, leiomyoma, bicornuate uterus), placental anomalies (eg, placenta previa), and fetal anomalies. Vaginal breech delivery can be complicated by umbilical cord compression and fetal head entrapment, resulting in fetal asphyxia and neurological injury. Due to the risks associated with a vaginal breech delivery, patients with a breech presentation at term are offered an external cephalic version (ECV). Patients with contraindication to ECV are offered a cesarean delivery. An ECV, the transabdominal manipulation of the fetus from a breech to cephalic presentation, may improve the odds of a cephalic presentation at delivery. However, an ECV can cause nonreassuring fetal heart rate abnormalities (due to abruptio placentae) that necessitate an emergent cesarean delivery. Delaying an ECV until >37 weeks gestation allows time for a spontaneous version to a cephalic presentation and eliminates a possible iatrogenic preterm birth (Choice C). Therefore, this patient can be reassessed in 2 weeks (eg, at term); if the fetus is still breech, an ECV can be offered. (Choice A) Cesarean delivery is indicated for breech presentations that have either failed or have a contraindication to ECV (eg, active herpes, placenta previa, multifetal gestation, fetal growth restriction). This patient has no contraindications to an ECV or vaginal delivery; therefore, an ECV can be performed. (Choice D) Vaginal delivery of a fetus in breech presentation is associated with an increased risk for fetal asphyxia from umbilical cord compression and fetal birth trauma from head entrapment. These risks are highest in a footling breech presentation; therefore, footling breech presentation is an absolute contraindication to vaginal delivery. footling breech presentation (Choice E) There is no evidence to support that maternal postural maneuvers (eg, knee-chest position, supine head down position) cause conversion of a breech baby to cephalic presentation. Educational objective: A breech vaginal delivery is associated with an increased risk of asphyxia and fetal injury. External cephalic version is offered to patients with persistent breech presentation at >37 weeks gestation to rotate the fetus to a cephalic presentation. References: Practice bulletin no. 161: external cephalic version. (http://www.ncbi.nlm.nih.gov/pubmed/26942387) Management of fetal malpresentation. (http://www.ncbi.nlm.nih.gov/pubmed/25811125)

A 24-Year-Old Primigravid Woman at 35 Weeks Gestation Comes to the Office