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The Effect of Spinal Anesthesia on the Success Rate of External Cephalic Version: A Randomized Trial

From the Departments of Obstetrics and Gynecology and Anesthesia, the University of Colorado Health Sciences Center, Denver, Colorado.

Address reprint requests to: Lorraine Dugoff, MD, Department of Obstetrics and Gynecology, University of Colorado Health Sciences Center, 4200 East Ninth Avenue, Box B-198, Denver, CO 80262, E-mail: lorraine.dugoff{at}uchsc.edu

	Abstract

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Objective: To identify the effect of spinal anesthesia on the success rate of external cephalic version after 36 weeks’ gestation.

Methods: Women with singleton breech presentations after 36 weeks’ gestation were offered enrollment. Those who agreed were randomized to receive spinal anesthesia or no anesthesia. Up to four attempts were made using ultrasound surveillance. External cephalic version was terminated with patient discomfort or fetal heart decelerations. Statistical analysis based on intent-to-treat was performed using ², Student t tests, and multivariate analysis. Sample size projection based on 20% difference in success rate from a baseline of 50% indicated a need for 50 women in each group.

Results: One hundred two women were entered in the study from October 1993 to August 1997. There were no differences between groups in parity, maternal age, amniotic fluid index, gestational age, birth weight, placental location, type of breech presentation, maternal weight, or gestational age at delivery. Forty-four external cephalic versions were successful. Fifty (49%) women received spinal anesthesia, and 52 (51%) did not; there was no difference in the overall success rate between groups (44% spinal versus 42% no spinal). Spontaneous version occurred before external cephalic version was attempted in four patients in the spinal group (after the spinal was given) and one patient in the no-spinal group. These patients were included in the analysis.

Conclusion: Spinal anesthesia does not increase the external cephalic version success rate in singleton pregnancies with breech presentations after 36 weeks’ gestation.

Breech presentation occurs in approximately 3% of term pregnancies.¹ The management of breech at term includes attempting external cephalic version, attempting vaginal breech delivery, or cesarean delivery. Successful external cephalic version can decrease costs by avoiding operative deliveries and decreasing maternal morbidity. External cephalic version success has ranged from 35–86%, averaging approximately 58%.^2–6 Success can depend on many factors, including tocolytic before the version attempt, gestational age, parity, placental location, fetal position, and experience of obstetricians.^7–12

Many patients find external cephalic version uncomfortable, tense their abdominal muscles, and in some cases, request that version be discontinued. Investigators reported that epidural anesthesia increases external cephalic version success rates, although success rates in controls were considerably lower than expected.^13,14 One of those studies was a retrospective review, and the other included patients with breech and transverse lies. The objective of our study was to determine whether use of spinal anesthesia increases success rates of external cephalic version after 36 weeks’ gestation in patients with breech presentations.

	Materials and Methods

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Women who met our study criteria, who were to have external cephalic version done at the University of Colorado Health Sciences Center or Denver Health Medical Center between October 1993 and August 1997, were offered participation in this prospective study. To be eligible, subjects had to be at no less than 36 weeks’ gestation. Other inclusion factors included breech presentation (not transverse or oblique lie); reactive non-stress test; intact membranes with a minimum 2 x 2–cm pocket of amniotic fluid (AF); absence of gross fetal anomalies, uterine malformation, macrosomia (estimated fetal weight [EFW] greater than 4000 g), fetal growth restriction, or placenta previa; no known maternal history of third-trimester vaginal bleeding; labor; and no contraindications to spinal anesthesia or terbutaline.

The procedures were done in labor-delivery rooms in the labor and delivery suite. Before external cephalic version, real-time ultrasonography was done to assess presentation, placental location, AF volume, and estimated fetal weight. A nonstress test and digital cervical examination were done before the procedure. If a patient met all inclusion criteria, she was invited to participate. Women with scheduled external cephalic versions at our institutions are asked not to eat or drink anything after midnight the night before the procedure.

Subjects were asked to review and sign written informed consent forms before enrollment. Those younger than 18 years of age were asked to sign an assent form, and their legal guardians also signed the consent forms. The study and consent forms were approved by the University of Colorado Health Sciences Center Institutional Research Review Board. Randomization was done with a computer-generated number sequence. Cards designating "spinal" or "no spinal" were placed in sealed opaque envelopes that were opened after subjects signed consent forms. All investigators and physicians participating in the clinical aspects of this study were blinded to the randomization sequence.

Spinal anesthesia was given under the supervision of a staff anesthesiologist. Ten µg sufentanil and 1 mL of 0.25% bupivacaine were administered after prehydration with 500 mL of lactated Ringer’s solution. The level of anesthesia in each patient was the sixth thoracic dermatome. Ten to 15 minutes after the spinal was placed, a single 0.25-mg dose of terbutaline was administered intravenously. Version was done approximately 5 minutes later.

External cephalic versions were done by staff physicians under direct supervision of attending physicians. Ninety-four of 102 external cephalic versions were done by two physicians. One tried to lift the breech upward from the pelvis, then the other tried to roll the fetus to vertex presentation with a forward or backward roll. If unsuccessful, a roll in the opposite direction was attempted. A maximum of four attempts were made. Real-time ultrasonography was used between attempts to assess fetal heart rate (FHR) and position. External cephalic version was stopped upon success, fetal bradycardia, patient discomfort, or failure after four attempts. After external cephalic version, FHR was monitored continuously for a minimum of 1 hour. Rh-negative women were given Rh immunoglobulin. Patients were discharged home after external cephalic version unless they had evidence of FHR abnormalities, were in labor, or the physician chose to admit the patient for delivery or induction of labor.

Statistical analysis was performed using Student t test and ² when appropriate. Logistic regression was used for multivariate analysis to adjust for potential confounding factors. P < .05 was statistically significant. Sample size was estimated on the basis of a error of .05, ß error of .2, and a clinically significant difference of an increase of 20% from baseline success rate of 50% (one-tailed test). A sample size of 50 in each group was calculated on the basis of these characteristics (Stat-graphics Plus, version 7.0; Manugistics Inc., Rockville, MD). The baseline success rate of 50% was based on data from our institution.

	Results

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We enrolled 102 patients, 50 (49%) of whom were assigned to receive spinal and 52 (51%) to receive no spinal anesthesia. There were no significant differences in pregnancy-related factors identified as relevant to the success of external cephalic version, such as placental location, AF volume, fetal presentation, cervical dilation, and fetal station (Table 1).

Univariate analysis of the potential effect of different variables on success rates of external cephalic version is shown in Table 2. Parity and history of cesarean were significant at P = .001. Multivariate analysis found that none of the factors we evaluated, including parity, history of cesarean, placental position, and fetal position had statistically significant effects on external cephalic version success rates (Table 3).

	Discussion

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A MEDLINE search, 1966–July 1998, using the search terms "version," "fetal," "anesthesia," and "spinal," identified no published reports evaluating the effect of spinal anesthesia on external cephalic version success rates. In our series of 102 patients, the use of spinal anesthesia had no effect on success of external cephalic version.

We chose to use spinal anesthesia instead of epidural (as used in the other studies) because of lower potential risk to patients.^15,16 There is a higher risk of local anesthetic toxicity associated with epidural anesthesia compared with spinal, as a result of greater concentration and volume of drug used with epidural. The incidence of unexpected high block after epidural anesthesia is approximately 1:1400.¹⁷ Spinal doses of local anesthetic are chosen to produce a certain level, and therefore might be less likely to become inadvertently high. Hypotension and headache occur at similar rates after spinal and epidural anesthesia.^18,19 In addition to requiring less time to give and to take effect, spinal anesthesia is less potentially toxic to patients, while providing similar muscular relaxation and analgesia as epidural. Because our patients were almost always discharged home, there was no need for epidural catheters to provide prolonged anesthetic. A mixture of 10 µg of sufentanil and 2.5 mg of bupivacaine was chosen for its excellent analgesia during labor and delivery. It causes minimal motor blockade, allowing early discharge. In prior attempts, we found excessive hypotension associated with 5% lidocaine (50–75 mg) and inadequate somatic analgesia with sufentanil alone.

Two studies provided information relevant to the present study. A nonrandomized, retrospective study by Carlan et al¹³ included a total of 61 patients. The external cephalic version success rate was 24% in the no-epidural group and 59% in the group that received epidurals. In a randomized trial, Schorr et al¹⁴ evaluated the use of epidural anesthesia in 69 women, all of whom received tocolysis with terbutaline. External cephalic version was successful in 32% of women in the no-epidural group and in 69% of women who received epidurals. Nine patients in that study had fetuses in transverse lie. The authors believed that the epidural allowed for a more aggressive vaginal manipulation to elevate the breech. Carlan et al¹³ also had a second examiner assist by raising the breech through a vaginal approach in some patients who had epidurals.

There are several potential explanations for discrepancy between our results and those of the other studies. The articles by Carlan et al¹³ and Schorr et al¹⁴ were published after our protocol was established and our study begun. They used techniques that, in retrospect, we might have used to improve our success rate in the spinal group. We did not attempt to elevate the breech using a vaginal approach. It also is possible that there was some inherent bias in the Carlan et al paper,¹³ because the choice to use epidural anesthesia was based on the personal preference of the physician. Lastly, our success rate in the no-spinal group was 42%, higher than in those other studies.

Tocolysis is another potentially important variable. All patients enrolled in our study received a dose of terbutaline before the external cephalic version attempt. Although existing data are controversial as to whether tocolytics increase external cephalic version success rates, there are some data suggesting that terbutaline and ritodrine might improve success rates, at least in nulliparous patients.^7,8 Because of this, we chose to treat all women with terbutaline before external cephalic version attempts.

Although it did not increase the external cephalic version success rate in our study, the use of spinal anesthesia with external cephalic version might have some benefits. Subjectively, the patients in the spinal group were able to tolerate the version procedure without any discomfort, whereas the majority of patients in the no-spinal group found the procedure at least somewhat uncomfortable. Four women in the no-spinal group requested that external cephalic version be discontinued, because of intolerable pain. This variable might be worth investigating in an objective fashion in a future study.

In our study, the use of spinal anesthesia did not increase external cephalic version success rates after 36 weeks’ gestation. We would not recommend spinal anesthesia for routine version attempts unless the patient cannot tolerate the discomfort of attempted version without anesthesia. Spinal or epidural anesthesia also could be considered in those cases in which cesarean will be performed if version is unsuccessful.

	Footnotes

 
The authors thank Dennis C. Lezotte, PhD, for his assistance with the statistical analysis.

PII S0029-7844(98)00456-6

Received May 14, 1998. Received in revised form September 2, 1998. Accepted September 24, 1998.

	References

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4. Mahomed K, Seeras R, Coulson R. External cephalic version at term. A randomized controlled trial using tocolysis. Br J Obstet Gynaecol 1991;98:8–13.[Medline]

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13. Carlan SJ, Dent JM, Huckaby T, Whittington EC, Shaefer D. The effect of epidural anesthesia on safety and success of external cephalic version at term. Anesth Analg 1994;79:525–8.[Abstract/Free Full Text]

14. Schorr SJ, Speights SE, Ross EL, Bofill JA, Rust OA, Norman PE, et al. A randomized trial of epidural anesthesia to improve external cephalic version success. Am J Obstet Gynecol 1997;177:1133–7.[Medline]

15. Hawkins JL, Koonin LM, Palmer SK, Gibbs CP. Anesthesia-related deaths during obstetric delivery in the United States, 1979–1990. Anesthesiology 1997;86:277–84.[Medline]

16. Chadwick HS. An analysis of obstetric anesthesia cases from the American Society of Anesthesiologists closed claims project database. Int J Obstet Anesth 1996;5:258–63.

17. Paech MJ, Godkin R, Webster F. Complications of obstetric epidural analgesia and anaesthesia: A prospective analysis of 10,995 cases. Int J Obstet Anesth 1998;7:5–11.

18. Norris MC, Grieco WM, Borkowski M, Leighton BL, Arkoosh VA, Huffnagle HJ, et al. Complications of labor analgesia: Epidural versus combined spinal epidural techniques. Anesth Analg 1994; 79:529–37.[Abstract/Free Full Text]

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