HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by MANCUSO, K. M. Articles by MARKENSON, G. R. Search for Related Content PubMed PubMed Citation Articles by MANCUSO, K. M. Articles by MARKENSON, G. R.

Epidural Analgesia for Cephalic Version: A Randomized Trial

From the Department of Obstetrics and Gynecology, Tripler Army Medical Center, Honolulu, Hawaii.

Address reprint requests to: Michael K. Yancey, MD Department of Obstetrics and Gynecology MCHK-OB 1 Jarrett White Road TAMC, HI 96859-5000

	Abstract

Top Abstract Materials and Methods Results Discussion References

 
Objective: To determine if epidural analgesia improves the success rate of external cephalic version.

Methods: Women with singleton fetuses in breech or transverse presentation of at least 37 weeks’ gestation were offered enrollment in a randomized trial. Inclusion criteria included maternal age of 18 years or older, nonvertex presentation confirmed by ultrasound, intact membranes, reactive fetal nonstress test, and estimated fetal weight (EFW) between 2000 and 4000 g. Women in the epidural group had lumbar epidural catheters inserted, through which 2% lidocaine and 100 µg of fentanyl were infused. External cephalic version attempts were done with ultrasound guidance in a standard fashion for both groups. The primary outcome variable was the successful version of the fetus to a cephalic presentation.

Results: There were no statistically significant differences between groups in gestation at time of procedure, placental location, fetal lie, gravity, parity, EFW, or amniotic fluid index. External cephalic version was successful in 32 of 54 women (59%) with epidural anesthesia compared with 18 of 54 (33%) with no anesthesia (relative risk [RR] 1.8, 95% confidence interval [CI] 1.2, 2.8, P < .05). Vaginal delivery occurred in 29 of 54 women (54%) in the epidural group and 16 of 54 women (30%) in the control group (RR 1.9, 95% CI 1.2, 2.9, P < .05).

Conclusion: Epidural analgesia increased the success rate of external cephalic version and the likelihood of subsequent vaginal delivery.

Nonvertex presentations complicate approximately 4% of term pregnancies.¹ Treatment options include cesarean delivery, attempted external cephalic version, trial of labor with attempted vaginal delivery, or expectant management with anticipation of spontaneous version to cephalic presentation. Low spontaneous version rates, concerns about fetal morbidity and mortality associated with vaginal breech delivery, and increases in maternal morbidity after cesarean delivery have made external cephalic version the preferred option for term parturients with fetuses in nonvertex presentations in many centers. External cephalic version has been reported to reduce cesarean delivery rates for malpresentation, particularly in centers where vaginal breech deliveries are seldom done.^2–4 Maternal discomfort and involuntary splinting of abdominal musculature might interfere with version efforts. The purpose of our investigation was to determine if epidural analgesia increased the success rate of external cephalic version.

	Materials and Methods

Top Abstract Materials and Methods Results Discussion References

 
This study was conducted from December 1, 1994, until June 30, 1998, at Tripler Army Medical Center. The protocol was approved by the institutional review board, and all subjects provided written informed consent before assignment. Eligible women were at least 18 years of age with singleton pregnancies of at least 37 weeks’ gestation in breech or transverse presentations with intact membranes, estimated fetal weight (EFW) between 2000 g and 4000 g, and reassuring fetal heart rate (FHR) testing. Exclusion criteria included placenta previa, prior classical cesarean delivery, third-trimester bleeding, an amniotic fluid index (AFI) of less than 5 cm or greater than 25 cm, known uterine malformation, uncontrolled hypertension, suspected major fetal anomaly, or active-phase labor.

Before enrollment, each subject was examined, including cervix, and an obstetric ultrasound assessment was done. All received intravenous infusions of 1500 mL of lactated Ringer’s solution before version attempts. Randomization was by a computer-generated random numbers table, with group assignments sealed in sequentially numbered opaque envelopes. Adequate randomization of subjects with varying probabilities of successful version was compared by a quantitative score described by Newman et al.⁴

Women assigned to the epidural group had lumbar epidural catheters placed, through which was infused a 3-mL dose of 2% lidocaine with 1:200,000 epinephrine. If no adverse effects were noted, 10 mL of 2% lidocaine with 100 µg fentanyl were infused. Blood pressure (BP) and pulse were assessed every minute for the first 10 minutes after application of epidural anesthesia, then every 2 minutes for 10 minutes, then every 5 minutes after 20 minutes. External cephalic version was attempted after a tenth thoracic level of anesthesia was achieved.

Subjects in each group received 0.25 mg of subcutaneous terbutaline approximately 20 minutes before version attempts. The precise method for version was left to the discretion of attending obstetricians. In general, up to two attempts each were made with the forward-roll method initially, followed by a backward roll if unsuccessful. Durations of attempts were neither stipulated nor recorded. Transvaginal elevation of breeches was not used in either group. Resident physicians did versions with assistance from experienced attending obstetricians. Post-procedure maternal and fetal assessment continued for at least 4 hours. Women with favorable cervices (Bishop score of at least 6) desiring trials of labor subsequently had labor induction. Those with unsuccessful versions and gestational ages of less than 39 weeks who declined trials of labor were managed expectantly unless there was an obstetric indication for delivery. Women with unsuccessful versions and gestational ages of at least 39 weeks who declined trials of labor were offered immediate cesarean deliveries.

A priori sample size estimation was done with an of .05 and ß of .20. Based on observations of the version success rates at our institution before the investigation, we estimated that the success rate without epidural anesthesia would be approximately 30%. A total sample of 108 women was estimated to provide 80% power to exclude more than a two-fold increase in success with epidural anesthesia.

Categoric variables were compared with ² with Yates continuity correction or Fisher exact tests. Ordinal variables were compared with Mann-Whitney U test, and continuous variables were compared with two-tailed Student t test. P < .05 was considered statistically significant.

	Results

Top Abstract Materials and Methods Results Discussion References

 
During the study, there were 9298 total singleton deliveries with breech or transverse fetal presentations in 276 term parturients (3%). Noncephalic malpresentation was detected before onset of labor in 198 women; the remaining 78 parturients were diagnosed with malpresentation during the active phase of labor or after spontaneous rupture of membranes. Among 198 women at term with noncephalic malpresentation detected before onset of active-phase labor or spontaneous amniorrhexis, 108 were enrolled in the study, with 54 women in the epidural group and 54 controls. Among the remaining 90 who declined enrollment, 68 had attempts at version outside the protocol and without epidural analgesia, five elected to attempt trials of labor and vaginal breech deliveries, and 17 had cesarean deliveries without attempts at version.

Demographic information for the study groups is presented in Tables 1 and 2. Outcome information is presented in Table 3 and Figure 1. There were no adverse fetal or maternal outcomes, such as maternal hypotension, in either group. The success rate at our institution of external cephalic version in women who had external cephalic version before the onset of labor, who declined enrollment in this study, was 35% (24 of 68), a statistically insignificant difference compared with the success rate in controls.

View larger version (21K): [in this window] [in a new window]   Figure 1. Outcome of study and control groups.

	Discussion

Top Abstract Materials and Methods Results Discussion References

Carlan and colleagues³ reported a retrospective study of uncontrolled epidural anesthesia to aid external cephalic version. Procedures done with epidural were successful in 19 of 32 women (59%) compared with 9 of 37 (24%) without anesthesia (RR 2.4, 95% CI 1.3, 4.6, P < .05). Schorr and colleagues¹⁴ also reported a randomized trial of epidural during version, examining 69 women, with successful version in 69% with epidural compared with 32% in controls (RR -2.1, 95% CI 1.2, 3.6, P < .05). There were no apparent detrimental effects related to epidural in either investigation.

A recent randomized trial of spinal anesthesia with version by Dugoff et al¹⁵ found no difference in the overall success rates between spinal and control groups, 44% versus 42%, respectively. The discrepancy between their result and those of previous studies might have been due to differing methods of external cephalic version, such as transvaginal elevation of breechs with operators’ hands in women with regional analgesia,^3,14 or differences in populations.

Our current results were consistent with Carlan et al³ and Schorr et al,¹⁴ suggesting that the success rate of external cephalic version can be improved with epidural analgesia, even without transvaginal elevation. However, there were several limitations in our study and the previous investigations, which must be considered when interpreting our results. Whereas the current investigation and that reported by Schorr and colleagues¹⁴ were randomized trials, none of the investigations have been masked. Thus, there is potential for treatment bias by providers who were obviously aware of the study group and might have modified their efforts to accomplish version with an underlying belief about the efficacy of epidural during the procedures. The current study was initiated before publication of the randomized trial by Schorr, and the lack of difference in version success rates in controls compared with women who had version outside the study makes us believe that it was unlikely any prevailing bias accounted for the differences between study groups.

A second limitation, which must be examined before we consider applying our findings to other populations, was the relatively low success rate of external cephalic version in our control population. That finding was consistent in the two previous reports and the current one.^3,14 Whereas all three investigations found statistically significant increases in the success rate of version associated with epidural, the success rates are consistent with the mean success rates from reported controlled trials of version without epidural. Potential explanations for the relatively low background success of version include patients who likely were in early labor at enrollment, a large percentage of women of low parity in the study population, and relative inexperience of physicians doing the procedures.¹⁶ Our results, and those of Carlan et al³ and Schorr et al,¹⁴ suggest that version success rates can be improved by using epidural in a setting with a relatively low baseline success rate. The mechanism by which that was achieved, and the effect in a population with a relatively high background success rate, remains unknown.

The collective reported experience with epidural as an adjunct to version remains low. There have been no reported instances of major maternal or fetal morbidity in these investigations, but it is possible that epidural could result in more forceful attempts at version compared with procedures done without it. Excessive force during version could cause direct fetal or maternal trauma. Therefore, if epidural is used during version, it is important to remember that the analgesia is to allow for relaxation of maternal musculature, not for greater force to be exerted.

	Footnotes

 
The opinions and assertions contained herein are the expressed views of the authors and are not to be construed as official or reflecting the opinions of the Department of Defense or the Department of the Army.

PII S0029-7844(99)00611-0

Received August 19, 1999. Received in revised form October 18, 1999. Accepted October 27, 1999.

	References

Top Abstract Materials and Methods Results Discussion References

 
1. Hickok DE, Gordon DC, Milberg JA, Williams MA, Daling JR. The frequency of breech presentation by gestational age at birth: A large population-based study. Am J Obstet Gynecol 1992;166: 851–2.[Medline]

2. Zhang J, Bowes WA Jr, Fortney JA. Efficacy of external cephalic version: A review. Obstet Gynecol 1993;82:306–12.[Abstract/Free Full Text]

3. Carlan SJ, Dent JM, Huckaby T, Whittington EC, Schaefer 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]

4. Newman RB, Peacock BS, Van Dorsten JP, Hunt HH. Predicting success of external cephalic version. Am J Obstet Gynecol 1993; 169:245–50.[Medline]

5. American College of Obstetricians and Gynecologists. Practice patterns. External cephalic version. Washington, DC: American College of Obstetricians and Gynecologists, 1997;4:1–8.

6. Laros RK Jr, Flanagan TA, Kilpatrick SJ. Management of term breech presentation: A protocol of external cephalic version and selective trial of labor. Am J Obstet Gynecol 1995;172:1916–23.[Medline]

7. Flanagan TA, Mulchahey KM, Korenbrot CC, Green JR, Laros RK Jr. Management of term breech presentation. Am J Obstet Gynecol 1987;156:1492–502.[Medline]

8. Flamm BL, Fried MW, Lonky NM, Giles WS. External cephalic version after previous cesarean section. Am J Obstet Gynecol 1991;165:370–2.[Medline]

9. Van Dorsten JP, Schifrin BS, Wallace RL. Randomized control trial of external cephalic version with tocolysis in late pregnancy. Am J Obstet Gynecol 1981;141:417–24.[Medline]

10. Benifla JL, Goffinet F, Darai E, Madelenat P. Antepartum transabdominal amnioinfusion to facilitate external cephalic version after initial failure. Obstet Gynecol 1994;84:1041–2.[Abstract/Free Full Text]

11. Johnson RL, Strong TH Jr, Radin TG, Elliott JP. Fetal acoustic stimulation as an adjunct to external cephalic version. J Reprod Med 1995;40:696–8.[Medline]

12. Johnson RL, Elliott JP. Fetal acoustic stimulation, an adjunct to external cephalic version: A blinded, randomized crossover study. Am J Obstet Gynecol 1995;173:1369–72.[Medline]

13. Cardini F, Weixin H. Moxibustion for correction of breech presentation: A randomized controlled trial. JAMA 1998;280:1580–4.[Abstract/Free Full Text]

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

15. Dugoff L, Stamm CA, Jones OW 3rd, Mohling SI, Hawkins JL. The effects of spinal anesthesia on the success rate of external cephalic version: A randomized trial. Obstet Gynecol 1999;93:345–9.[Abstract/Free Full Text]

16. Calhoun BC, Edgeworth D, Brehm W. External cephalic version at a military teaching hospital: Predictors of success. Aust N Z J Obstet Gynaecol 1995;35:277–9.[Medline]

This article has been cited by other articles:

				C. F. Weiniger, Y. Ginosar, U. Elchalal, E. Sharon, M. Nokrian, and Y. Ezra External Cephalic Version for Breech Presentation With or Without Spinal Analgesia in Nulliparous Women at Term: A Randomized Controlled Trial Obstet. Gynecol., December 1, 2007; 110(6): 1343 - 1350. [Abstract] [Full Text] [PDF]

				G. Cherayil, B. Feinberg, J. Robinson, and L. C. Tsen Central Neuraxial Blockade Promotes External Cephalic Version Success After a Failed Attempt Anesth. Analg., June 1, 2002; 94(6): 1589 - 1592. [Abstract] [Full Text] [PDF]

				D. J. Birnbach, J. Matut, D. J. Stein, J. Campagnuolo, C. Drimbarean, A. Grunebaum, M. M. Kuroda, and D. M. Thys The Effect of Intrathecal Analgesia on the Success of External Cephalic Version Anesth. Analg., August 1, 2001; 93(2): 410 - 413. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by MANCUSO, K. M. Articles by MARKENSON, G. R. Search for Related Content PubMed PubMed Citation Articles by MANCUSO, K. M. Articles by MARKENSON, G. R.