Study Suggests Regional Anesthesia Increases External Cephalic Version Success

Regional anesthesia is associated with better success rates of external cephalic version, according to new research. The study was published in the November issue of Obstetrics & Gynecology.

Breech presentation occurs in about 3% to 4% of all term pregnancies. It is the third most frequent indication for cesarean section; about 12% of c-sections are due to breech pregnancies (not including repeat c-sections resulting from previous breech pregnancies). External cephalic version is a relatively safe and effective means for decreasing breech presentation at term, and is recommended by the American College of Obstetricians and Gynecologists to help decrease the need for c-sections and allow for vaginal delivery. Despite its efficacy, however, the success rate hovers only at about 58%.

Dr Katherine R. Goetzinger, maternal-fetal medicine clinical fellow at Washington University School of Medicine, and colleagues sought to determine the effects of anesthesia on the success of external cephalic version in breech presentations. They conducted a systematic review and meta-analysis of six published randomized controlled trials conducted between 1996 and 2011that compared regional anesthesia with no regional anesthesia for external cephalic version. Goetzinger and colleagues found 6 studies that met inclusion criteria for a total of 253 external cephalic versions completed with the use of regional anesthesia and 255 with intravenous analgesia or no pain control.

Goetzinger et al. found that regional anesthesia was associated with higher success rates of external cephalic version as compared to those external cephalic versions completed with intravenous or no analgesia (59.7% and 37.6%, respectively; pooled relative risk=1.58). The significant association continued despite the type of anesthesia; the odds of a successful cephalic version were 91% higher with epidural anesthesia and 46% higher with spinal anesthesia. The researchers noted that adverse events were rare, and they did not find a significant difference between the two groups. Moreover, Goetzinger and colleagues found lower pain levels reported in the regional anesthesia group among three studies that employed a visual analog scale.

The researchers also found a lower rate of delivery via c-sections in the regional anesthesia group as compared to the control group (48.4% and 59.3%, respectively), but they failed to find statistical significant difference. They did find, however, one emergency delivery via c-section in each of the treatment groups. Terminal fetal bradycardia was the direct cause in both cases; placental abruption was also present in the control group (no regional anesthesia).

Overall, Goetzinger and colleagues concluded that regional anesthesia is associated with a higher success rate of external cephalic version. However, they were not proponents of making the use of regional anesthesia for external cephalic version standard care. They explained, “Further well-powered studies designed specifically to investigate the effect of regional anesthesia use during external cephalic version on subsequent cesarean delivery rates are warranted.”

Reference:
Goetzinger KR, Harper LM, Tuuli MG, et al. Effect of regional anesthesia on the success rate of external cephalic version: a systematic review and meta-analysis. Obstet Gynecol. 2011;118(5):1137-44.

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