A 25-year-old G1P0 patient at 37 weeks presents to labor and delivery reporting gross rupture of membranes and painful uterine contractions. The tocometer shows contractions every 2 to 3 minutes, and the fetal heart tracing is category I. On cervical examination, she is 4-cm dilated and completely effaced with the presenting part at -3 station. The presenting part is soft and felt to be the fetal buttock. A bedside ultrasound reveals a breech presentation with both hips flexed and knees extended. The estimated weight of the fetus is approximately 6 lb.
Which of the following is the best method to achieve delivery?A. Deliver the fetus vaginally by breech extraction
The patient described here has a fetus in frank breech presentation, which occurs when both hips are flexed and both knees are extended so that the feet lie in close proximity to the head and the fetal buttocks is the presenting part. With a complete breech presentation, both hips and knees are flexed. In the case of an incomplete breech presentation, one or both hips are not completely flexed; this may result in single footling or double footling presentations. Due to improved outcomes, it is generally recommended that fetuses with breech presentations undergo cesarean delivery. External cephalic version is a procedure whereby the presentation of the fetus is changed from breech to cephalic by manipulating the fetus externally through the abdominal wall. It is not indicated in this patient because the membranes are ruptured and the risk of cord prolapse is great. In addition, this procedure generally requires that the uterus be soft and relaxed, which is not the case with this patient in labor. Internal podalic version is a procedure used in the delivery of a second twin. It involves turning the fetus by inserting a hand into the uterus, grabbing both feet, and delivering the fetus by breech extraction.