Breech presentation at term and external cephalic version — structured SAQ (15 marks)

(a) ECV counselling — timing, success, complications (5 marks)

One mark per point, maximum five. ^[1][5]

• Timing: offer ECV at 36-37 weeks — after most spontaneous version has occurred, while the fetus remains turnable, and if a complication requires delivery the baby is essentially term.^[5]
• Success rate: approximately 50% overall, with higher success in multiparous women, with good liquor volume, an unengaged breech, and under neuraxial analgesia.^[1]
• Complications are rare: the most common is transient abnormal CTG changes at about 5.7% which almost always resolve; emergency caesarean in about 0.43% of versions; persisting pathological CTG 0.37%, vaginal bleeding 0.47%, placental abruption 0.12%, perinatal mortality 0.16%.^[4]
• Evidence: the Cochrane review found ECV reduced non-cephalic presentation at birth (RR 0.42) and caesarean section (RR 0.57) with no significant increase in complications.^[1]
• Setting: performed in a hospital where emergency caesarean is available within an agreed timeframe, with consent and fasting.^[5]

(b) Contraindications to ECV (3 marks)

One mark for any three valid contraindications. ^[5]

• A caesarean already indicated for another reason (e.g. placenta praevia).^[5]
• Antepartum haemorrhage within the preceding seven days.^[5]
• An abnormal CTG.^[5]
• A major uterine anomaly or significant cavity-distorting fibroid.^[5]
• Ruptured membranes.^[5]
• Multiple pregnancy (singleton ECV does not apply).^[5]
• Note: a previous single lower-segment caesarean is not an absolute contraindication — ECV may be offered with informed counselling on the small rupture risk.^[5]

(c) The ECV procedure step by step (4 marks)

One mark per stage. Marks are lost for omitting anti-D or the post-procedure CTG. ^[1][5]

• Pre-procedure: consent; CTG to confirm fetal wellbeing; ultrasound to confirm breech type, placental site and liquor volume; check maternal blood group; fasting.^[5]
• Tocolysis: a beta-agonist (e.g. terbutaline or salbutamol) to relax the uterine wall; alternatives include nitroglycerin or atosiban.^[1]
• The manoeuvre: warm hands, talc or oil to reduce friction; lift the breech out of the pelvis, then rotate the fetus in a forward or backward roll (forward more common); monitor the CTG throughout.^[5]
• Post-procedure: repeat CTG for 30-60 minutes; confirm presentation by ultrasound; give anti-D immunoglobulin to Rh-negative women (fetomaternal transfusion risk); document the outcome and agree the birth plan.^[4][5]

(d) Mode-of-birth counselling after failed ECV (3 marks)

One mark per point. Must quote both trials. ^[2][3]

• Term Breech Trial (Hannah 2000): planned caesarean reduced the composite of perinatal/neonatal mortality or serious morbidity — 1.6% versus 5.0% (RR 0.33) — with no difference in serious maternal morbidity. This drove the global shift to planned caesarean.^[2]
• PREMODA (Goffinet 2006): under strict selection, planned vaginal breech carried a combined adverse neonatal outcome of 1.60% that did not differ significantly from planned caesarean (adjusted OR 1.40, 95% CI 0.89-2.23). It supports planned vaginal as a defensible option where strict criteria are met.^[3]
• Counselling synthesis: planned caesarean carries the lowest neonatal risk in unselected populations; planned vaginal under strict selection (frank or complete breech, no fetal compromise, adequate pelvis, experienced accoucheur, continuous monitoring) is a reasonable option. The choice is the woman's, made on informed counsel.^[3][5]