Breech at term and external cephalic version — structured oral station (12 minutes)

Opening prompt — "She has a breech at 36 weeks. Walk me through your management."

Model response — say it in this order: ^[1][5]

• "I'd confirm the breech by ultrasound — type, placental site, liquor volume, fetal wellbeing — and exclude contraindications. Then I'd offer external cephalic version at 36-37 weeks, which is the recommended gestation."^[5]
• "I'd counsel her that ECV succeeds in roughly 50 percent of attempts, that complications are rare — emergency caesarean in about 0.4 percent — and that the procedure is done in hospital where theatre is available."^[1][4]
• "If ECV succeeds, she's a candidate for a normal cephalic birth. If it fails or she declines, I'd counsel planned caesarean versus planned vaginal breech under strict selection."^[5]

Probe 1 — "What are the contraindications to ECV?"

• "A caesarean already indicated for another reason, antepartum haemorrhage within the preceding seven days, an abnormal CTG, a major uterine anomaly, ruptured membranes, and multiple pregnancy."^[5]
• "A previous single lower-segment caesarean is not an absolute contraindication — I'd offer ECV with counselling on the small rupture risk."^[5]

Probe 2 — "Describe how you perform an ECV."

• "Pre-procedure: consent, CTG, ultrasound to confirm, fasting, theatre available, check blood group."^[5]
• "Tocolysis with a beta-agonist to relax the uterus, then warm hands with talc or oil; I lift the breech out of the pelvis and rotate the fetus in a forward roll, monitoring the CTG throughout."^[1][5]
• "Post-procedure: repeat CTG for 30-60 minutes, confirm presentation by ultrasound, give anti-D if she's Rh-negative because of the fetomaternal transfusion risk, and document the outcome and plan."^[4][5]

Probe 3 — "ECV fails. She asks whether a vaginal breech birth is safe. What do you say?"

• "I'd present both options honestly. The Term Breech Trial, a large randomised trial, found planned caesarean reduced the serious adverse neonatal outcome — 1.6 percent versus 5.0 percent, a relative risk of 0.33 — with no difference in maternal morbidity."^[2]
• "But PREMODA, a large observational study from France and Belgium, showed that under strict selection planned vaginal breech carried a low adverse neonatal outcome of 1.60 percent that did not differ significantly from planned caesarean. So where strict criteria are met, planned vaginal is a defensible option."^[3]
• "For a frank breech with a well-grown baby, an adequate pelvis, no fetal compromise, and an experienced accoucheur with continuous monitoring, planned vaginal is reasonable. The choice is hers, on informed counsel."^[3][5]

Probe 4 — "She asks about moxibustion. What do you tell her?"

• "The Cochrane review found moxibustion plus usual care probably reduces the chance of a non-cephalic presentation at birth — risk ratio 0.87 — but probably has little to no effect on the caesarean rate."^[6]
• "It may help turn the baby but doesn't change the outcome that matters most. I'd offer it as a low-harm adjunct if she's interested, without overselling it."^[6]

Probe 5 — "Communication: she is anxious about the ECV and asks if it will hurt the baby. How do you respond?"

Demonstrate this out loud — it is a scored domain: ^[4][5]

• Move to her eye level, acknowledge the anxiety, and explain plainly: "Most women feel pressure and some discomfort, not sharp pain. The baby is monitored throughout, and the serious risks are very rare — about 4 in 1000 need an emergency caesarean."
• Frame the benefit honestly and offer time to decide, and a support person if she wishes.
• Commit to stopping if it is too uncomfortable and to a clear plan regardless of the outcome.^[4]