Lessons learned from a single institution’s retrospective analysis of emergent cesarean delivery following external cephalic version with and without neuraxial anesthesia

Patient characteristics associated with complications of external cephalic version

BACKGROUND

Patient characteristics associated with external cephalic version success are well documented; however, the association between patient characteristics and the likelihood of external cephalic version complications is poorly understood.

OBJECTIVE

This study aimed to assess the frequency of patient characteristics associated with complications that lead to unanticipated delivery during external cephalic version.

STUDY DESIGN

This retrospective study included pregnant women aged at least 18 years with singleton gestations who underwent an external cephalic version attempt between 2006 and 2016 at a single quaternary care center. External cephalic version complications were defined as persistent nonreassuring fetal status, placental abruption, labor, spontaneous rupture of membranes, and umbilical cord prolapse. Complications were only considered if they led to unanticipated induction or cesarean delivery within 24 hours of external cephalic version. Patient characteristics including maternal age, height, weight, body mass index, parity, fetal sex, gestational age, estimated fetal weight, the type of fetal malpresentation, and placental location were analyzed for their association with external cephalic version complications using univariable analysis and multivariable logistic regressions.

RESULTS

Among the 1138 patients included in this analysis, external cephalic version complications occurred in 6.7% (n=76). These complications (not mutually exclusive) included nonreassuring fetal status (4.8%, n=55), placental abruption (1.6%, n=18), labor (1.0%, n=11), spontaneous rupture of membranes (0.6%, n=7), and cord prolapse (0.1%, n=1). Neonatal outcomes for those with complications included intensive care unit admission (10.5%, n=8), 5-minute Apgar scores <5 (1.3%, n=1), cord arterial pH <7 (6.6%, n=5), head cooling (1.3%, n=1), and anemia (6.6%, n=5). There were no perinatal deaths. In multivariable analysis, higher body mass index (adjusted odds ratio, 0.90 per kg/m²; 95% confidence interval, 0.84-0.97) and estimated fetal weight (adjusted odds ratio, 0.998 per gram; 95% confidence interval 0.998-0.999) were associated with decreased likelihood of experiencing external cephalic version complications, whereas greater gestational age at procedure (adjusted odds ratio, 1.95 per week; 95% confidence interval, 1.4-2.7) and anterior placental location (adjusted odds ratio, 2.0; 95% confidence interval, 1.1-3.7) were associated with increased likelihood of experiencing external cephalic version complications.

CONCLUSION

In this large series, complications that led to delivery during external cephalic version occurred in 6.7% patients and were associated with body mass index, estimated fetal weight, gestational age, and placental location.

Utilization of epidural volume extension technique for external cephalic version

External cephalic version (ECV) has been successfully utilized to reduce breech presentations at term and offers an alternative to elective cesarean delivery. Unfortunately, there is not a consensus on which type of regional anesthesia conveys the highest chances for a successful ECV. This case report describes the use of the epidural volume extension technique to provide surgical anesthesia for ECV with a reduced dose of local anesthetic, with the goals of minimizing motor block and hypotension in the setting of an outpatient procedure.

A Systematic Review and Meta-analysis of Clinical Trials of Neuraxial, Intravenous, and Inhalational Anesthesia for External Cephalic Version

BACKGROUND

External cephalic version (ECV) is a frequently performed obstetric procedure for fetal breech presentation to avoid cesarean delivery. Neuraxial, intravenous, and inhalational anesthetic techniques have been studied to reduce maternal discomfort caused by the forceful manipulation. This study compares the effects of these anesthetic techniques on ECV and incidence of cesarean delivery.

METHODS

We conducted a comprehensive literature search for published randomized controlled trials (RCTs) or well-conducted quasi-randomized trials of ECV performed either without anesthesia or under neuraxial, intravenous, or inhalational anesthesia. Pairwise random-effects meta-analyses and network meta-analyses were performed to compare and rank the perinatal outcomes of the 3 anesthetic interventions and no anesthesia control, including the rate of successful version, cesarean delivery, maternal hypotension, nonreassuring fetal response, and adequacy of maternal pain control/satisfaction.

RESULTS

Eighteen RCTs and 1 quasi-randomized trial involving a total of 2296 term parturients with a noncephalic presenting singleton fetus were included. ECV under neuraxial anesthesia had significantly higher odds of successful fetal version compared to control (odds ratio [OR] = 2.59; 95% confidence interval [CI], 1.88-3.57), compared to intravenous anesthesia (OR = 2.08; 95% CI, 1.36-3.16), and compared to inhalational anesthesia (OR = 2.30; 95% CI, 1.33-4.00). No association was found between anesthesia interventions and rate of cesarean delivery. Neuraxial anesthesia was associated with higher odds of maternal hypotension (OR = 9.33; 95% CI, 3.14-27.68). Intravenous anesthesia was associated with significantly lower odds of nonreassuring fetal response compared to control (OR = 0.36; 95% CI, 0.16-0.82). Patients received neuraxial anesthesia reported significantly lower visual analog scale (VAS) of procedure-related pain (standardized mean difference [SMD] = -1.61; 95% CI, -1.92 to -1.31). The VAS scores of pain were also significantly lower with intravenous (SMD = -1.61; 95% CI, -1.92 to -1.31) and inhalational (SMD = -1.19; 95% CI, -1.58 to -0.8) anesthesia. The VAS of patient satisfaction was significantly higher with intravenous anesthesia (SMD = 1.53; 95% CI, 0.64-2.43).

CONCLUSIONS

Compared to control, ECV with neuraxial anesthesia had a significantly higher successful rate; however, the odds of maternal hypotension increased significantly. All anesthesia interventions provided significant reduction of procedure-related pain. Intravenous anesthesia had significantly higher score in patient satisfaction and lower odds of nonreassuring fetal response. No evidence indicated that anesthesia interventions were associated with significant decrease in the incidence of cesarean delivery compared to control.