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OG14.1-3,OG15.1-2 | Abnormal and Operative Obstetrics — PBL Case

CLINICAL SETTING

Mrs SF is a 28-year-old primigravida, G1P0, at 37 weeks and 4 days gestation. She has had uncomplicated antenatal care and attends the obstetrics outpatient clinic for a routine visit. Her midwife, during Leopold's manoeuvres, notes a hard, round mass at the fundus and a soft, irregular mass in the lower pole. The fetal heart is best heard in the upper abdomen. The midwife documents a likely breech presentation and refers Mrs SF immediately to the registrar. Ultrasound confirms a frank (extended) breech presentation with estimated fetal weight 3.2 kg, normal liquor volume (AFI 14 cm), and an anterior fundal placenta. No fetal anomalies are seen. The cervix is long and closed (Bishop score 2). Mrs SF is anxious. She has heard that 'breeches always need a caesarean' and is asking the registrar to explain all her options.

Trigger 1: Options at 37 Weeks: What Can We Offer?

The registrar discusses the three management options with Mrs SF: (1) External Cephalic Version (ECV) at 37-38 weeks; (2) planned caesarean section at 39 weeks; (3) a trial of vaginal breech delivery (offered only at centres with specific expertise under strict criteria). She is informed that ECV has a success rate of approximately 50-60% in primigravidas with tocolysis, and that it is associated with <1% serious complications. Her questions: 'What will the doctor actually do during ECV? Does it hurt the baby? What if it doesn't work?'

DISCUSSION POINTS

  • What are the absolute contraindications to ECV in this patient, and are any present here? (Review: placenta praevia, fetal compromise, multiple pregnancy, severe oligohydramnios, ruptured membranes, previous uterine surgery.)
  • Describe the technique and monitoring required for ECV: pre-procedure CTG, tocolysis (commonly terbutaline 0.25 mg SC), forward vs backward roll, post-procedure CTG. Why is immediate CS access required?
  • What is the difference between frank, complete, and footling breech, and does the type affect ECV success or vaginal breech delivery feasibility?
Click to reveal Trigger 2: ECV Attempted — But Then What? (discuss previous trigger first!)

Trigger 2: ECV Attempted — But Then What?

ECV is attempted at 37+5 weeks under tocolysis. After two attempts at forward roll, the fetus partially rotates to transverse but immediately reverts to frank breech. The CTG immediately post-procedure shows a 2-minute bradycardia that recovers spontaneously to a normal pattern within 6 minutes. Mrs SF is distressed and asks, 'Did something go wrong? Is the baby safe now? What do we do next?' The senior obstetrician reviews the post-procedure CTG (now normal after 30 minutes) and discusses the options going forward.

DISCUSSION POINTS

  • Classify this ECV as failed. What are the immediate clinical actions required after a transient bradycardia during ECV? At what point would emergency CS be indicated after ECV?
  • What are the criteria for offering a trial of vaginal breech delivery (Criteria: frank breech, estimated fetal weight 1.5-4 kg, no CPD, flexed fetal head on ultrasound, experienced operator, continuous monitoring)? Does Mrs SF meet them?
  • Given the anterior fundal placenta and primiparity, discuss why this patient's ECV success rate was lower than average and what factors predict ECV success.
Click to reveal Trigger 3: Labour Onset at 38+3 Weeks (discuss previous trigger first!)

Trigger 3: Labour Onset at 38+3 Weeks

Mrs SF declines a planned caesarean at 38 weeks and opts for expectant management. At 38+3 weeks, she spontaneously goes into labour and presents to the labour ward with contractions every 5 minutes. On examination, the breech is at the pelvic brim (station -1), the cervix is 4 cm dilated. CTG is reassuring. The duty obstetrician confirms she meets the local criteria for a trial of vaginal breech delivery and Mrs SF consents. The team begins continuous monitoring. Two hours later, she is fully dilated (10 cm) with breech at station +2.

DISCUSSION POINTS

  • What are the three main techniques used for vaginal breech delivery, and which is used for a frank breech (Burns-Marshall vs Bracht vs Lovset's)? Define the difference between 'assisted breech delivery' (the standard) vs 'spontaneous breech delivery' and 'breech extraction'.
  • What is the 'hands-off the breech until the navel' principle, and why is it important? At what point does the operator actively assist? What manoeuvre is used to deliver the aftercoming head?
  • What is the most dangerous complication of vaginal breech delivery, and what manoeuvre addresses it? (Head entrapment — use Mauriceau-Smellie-Veit manoeuvre or Piper's forceps.)
Click to reveal Trigger 4: Unexpected Finding — Now What? (discuss previous trigger first!)

Trigger 4: Unexpected Finding — Now What?

During the active second stage, after the fetal trunk delivers to the level of the umbilicus, the operator notices that the fetal arms are extended upwards alongside the fetal head (nuchal arms). The delivery is temporarily halted while the team formulates the approach. The fetal heart remains reassuring. A senior consultant is called urgently.

DISCUSSION POINTS

  • What is Lovset's manoeuvre and when is it used? Describe the rotating and downward traction technique that brings each arm into a deliverable position. Why must the manoeuvre be performed with downward traction to prevent head entrapment?
  • Once the arms are delivered, the head is brought to the pelvic floor. Describe the Mauriceau-Smellie-Veit (MSV) manoeuvre: finger placement on the maxilla, body on the operator's forearm, and how the assistant applies suprapubic pressure. What are the dangers of undue traction on the neck?
  • If the aftercoming head becomes entrapped at a partially dilated cervix — a rare but catastrophic event — what emergency manoeuvres are available? (Dührssen's incisions, general anaesthesia with uterine relaxation, Prague manoeuvre as last resort.)
Click to reveal Trigger 5: Outcome, Debrief, and Reflection (discuss previous trigger first!)

Trigger 5: Outcome, Debrief, and Reflection

Lovset's manoeuvre is successfully performed by the consultant, both arms are delivered, and the MSV manoeuvre delivers the head safely within 3 minutes of the arms. The baby is born with Apgar scores of 7 at 1 minute and 9 at 5 minutes. Mrs SF has a second-degree perineal tear which is repaired by the registrar. In the postnatal debrief, the team reviews the entire case: the ECV attempt, the decision to allow a trial of labour, and the operative management of the complications.

DISCUSSION POINTS

  • Apgar score has 5 components scored at 1 and 5 minutes: heart rate (0-2), respiratory effort (0-2), muscle tone (0-2), reflex irritability (0-2), colour (0-2). Total 0-10. Do NOT confuse with Bishop score (5 parameters for cervical favourability: dilatation, effacement, station, consistency, position). Explain both scoring systems and their different purposes.
  • For the perineal repair: classify the tear (first-degree = mucosa only; second-degree = perineal muscles but intact sphincter; third-degree = partial/full external sphincter; fourth-degree = mucosa to rectal mucosa). What layer is sutured first in a second-degree repair, and what suture material and technique is used?
  • Reflect on the informed consent process in this case. What information was required for Mrs SF to make an autonomous decision at each decision point (ECV, vaginal breech trial)? What elements of the consent discussion are legally and ethically mandated under current Indian medical standards?

Group Task Assignments

  • Map the full decision tree for a term breech presentation: ECV → success (proceed with labour) vs failure → planned CS vs trial of vaginal breech delivery. At each branch, identify the criteria that determine the path.
  • List all OG15.1 procedures covered in this case (ECV, assisted breech delivery, Lovset's manoeuvre, MSV manoeuvre, episiotomy/perineal repair) and identify which the NMC CBME framework specifies as 'observe', 'assist', or 'perform independently'.
  • Prepare a 3-minute oral presentation summarising: (a) why frank breech at term is not always a mandatory CS indication, (b) the two key manoeuvres that can rescue a complicated vaginal breech delivery, and (c) one systems-level recommendation for safe vaginal breech delivery in a district hospital.

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [OG14.3] What are the exact clinical and ultrasound criteria that must be met before offering a trial of vaginal frank breech delivery at term?
  2. [OG15.1] What is the step-by-step technique for Lovset's manoeuvre, and when specifically is it indicated versus Bracht's manoeuvre?
  3. [OG15.1] What are the ECV prerequisites, contraindications, success rate determinants, and monitoring protocol according to current evidence?
  4. [OG15.2] How is the Mauriceau-Smellie-Veit manoeuvre performed, and how does it differ from the use of Piper's forceps for the aftercoming head?
  5. [OG14.3] How does the Bishop score differ from the Apgar score in terms of parameters, purpose, and clinical application?