A 34-year-old woman, gravida 2 para 1, at 34 weeks gestation comes to the office to establish prenatal care. The patient recently moved but had routine prenatal care in another state. She has had no contractions, vaginal bleeding, or leakage of fluid. Fetal movement is normal. The patient had a classical cesarean delivery at 25 weeks gestation due to eclampsia and fetal growth restriction. This pregnancy has been uncomplicated, and her only medications are a daily aspirin and prenatal vitamin. Blood pressure is 118/70 mm Hg. Fetal heart tones are 145/min and fundal height is 38 cm. Urine dipstick is negative for protein and glucose. An ultrasound is performed due to a uterine size/dates discrepancy. The ultrasound shows a posterior placenta, normal amniotic fluid volume, and a fetus in a frank breech presentation with an estimated fetal weight at the 50th percentile for gestational age. The patient would like to attempt a vaginal delivery with this pregnancy. Which of the following is the best next step in management of this patient?

Question

A 34-year-old woman, gravida 2 para 1, at 34 weeks gestation comes to the office to establish prenatal care.  The patient recently moved but had routine prenatal care in another state.  She has had no contractions, vaginal bleeding, or leakage of fluid.  Fetal movement is normal.  The patient had a classical cesarean delivery at 25 weeks gestation due to eclampsia and fetal growth restriction.  This pregnancy has been uncomplicated, and her only medications are a daily aspirin and prenatal vitamin.  Blood pressure is 118/70 mm Hg.  Fetal heart tones are 145/min and fundal height is 38 cm.  Urine dipstick is negative for protein and glucose.  An ultrasound is performed due to a uterine size/dates discrepancy.  The ultrasound shows a posterior placenta, normal amniotic fluid volume, and a fetus in a frank breech presentation with an estimated fetal weight at the 50th percentile for gestational age.  The patient would like to attempt a vaginal delivery with this pregnancy.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_da74_b085_bc81_236fe87cb8de_MD0003_00 Patients with a breech presentation, a fetal malpresentation in which the buttocks or feet are the parts closest to the maternal cervix, are typically managed with a cesarean delivery at term. This is because breech vaginal deliveries have a higher rate of complications (eg, umbilical cord prolapse, asphyxia) compared with cephalic vaginal deliveries. Patients with breech presentation who do not want to undergo scheduled cesarean delivery can be offered an external cephalic version (ECV), a procedure that manually rotates the fetus to cephalic presentation. buttocks feet external cephalic version However, in contrast to a prior low-transverse cesarean delivery, a prior classical cesarean delivery (vertical uterine incision), is a contraindication to a vaginal delivery due to the increased risk of uterine rupture during labor-an obstetric emergency (Choices A and B). Other contraindications to vaginal delivery include placenta previa or a prior extensive uterine myomectomy. In these patients, an ECV is not performed as it exposes them to possible complications (eg, abruptio placentae, fetal demise) with no maternal-fetal benefit or change in management. Therefore, patients with breech presentation and contraindication to vaginal delivery require a scheduled cesarean delivery. In those with a prior classical cesarean delivery, a repeat cesarean is typically performed at 37 weeks gestation to decrease the risk of neonatal complications and spontaneous labor. (Choice C) ECV can cause contractions, fetal distress, and prelabor rupture of membranes, which require immediate delivery. Therefore, the procedure is performed in patients without contraindications at ≥37 weeks gestation to decrease prematurity risks if delivery is required. (Choice D) This patient will undergo a cesarean delivery regardless of fetal presentation; a repeat ultrasound to reevaluate presentation is not indicated as it does not change the mode of delivery. Educational objective: Patients with breech presentation typically are offered an external cephalic version (ECV), which manually rotates the fetus to a cephalic presentation. In contrast, those with breech presentation and contraindications to vaginal delivery (eg, prior classical cesarean delivery, placenta previa), ECV is not performed and patients undergo cesarean delivery at 37 weeks gestation. References: External cephalic version for breech presentation at term. (http://www.ncbi.nlm.nih.gov/pubmed/23076883) Practice bulletin no. 161: external cephalic version. (http://www.ncbi.nlm.nih.gov/pubmed/26942387)

A 34-Year-Old Woman, Gravida 2 Para 1, at 34 Weeks