External Cephalic Version in Term Multiparae With/Without Spinal Analgesia
External Cephalic Version in Term Multiparae With/Without Spinal Analgesia
Background: Neuraxial analgesia significantly increases the success rate of external cephalic version (ECV) among nulliparae. The study objective was to compare ECV success among multiparae with and without spinal analgesia.
Methods: Prospective randomized controlled trial performed over a pre-defined 6 yr period in a tertiary referral delivery suite. Healthy multiparae at term requesting ECV for breech presentation, without fetal or uterine anomaly, were enrolled after written informed consent. Women were randomized to receive either spinal analgesia (bupivacaine 7.5 mg) or no analgesia before the ECV. The primary outcome was successful conversion from breech to vertex presentation, confirmed by ultrasound. Visual analogue pain score and adverse outcomes (complications of anaesthesia or ECV) were recorded. Statistical analysis was performed according to intention to treat using two-sided tests.
Results: Among 265 multiparae who underwent ECV, 65 consented to enrol, one subsequently refused ECV; therefore, data from 64 women were analysed. ECV was successful in 27 of 31 patients (87.1%) receiving spinal analgesia vs 19 of 33 (57.5%) with no analgesia (P=0.009; 95% CI of difference: 0.075–0.48). ECV with spinal analgesia reduced visual analogue pain score, mean (SD) 1.7 (2.4) vs 5.5 (2.9) without (P<0.0001). Maternal hypotension was seen after spinal analgesia in 10 of 31 (32%) (P=0.0003) and easily treated without adverse outcome. No complications were noted after the ECV.
Conclusions: Administration of spinal analgesia significantly increased the rate of successful ECV among multiparae at term with increased patient comfort.
Almost 90% of women in developed countries with a breech-presenting fetus at term are delivered by Caesarean section because of concerns about fetal safety. This exposes women to risks such as uterine rupture and placenta accreta during subsequent deliveries. Furthermore, maternal and fetal morbidity is lower with vertex vaginal delivery than with Caesarean section. Since women with a breech-presenting fetus are more likely to have a breech-presenting fetus during a subsequent pregnancy, it becomes important to succeed with external cephalic version (ECV) in each individual pregnancy in order to avoid unnecessary Caesarean sections with their cumulative risk.
Neuraxial analgesia significantly increases the chance of successful ECV among nulliparae, thus an otherwise mandatory Caesarean delivery can potentially be avoided. The success rate of ECV among multiparae is known to be higher (57–67%) than among nulliparae; therefore, neuraxial analgesia may not have the same positive impact on the success rate of ECV among multiparae.
The primary aim of this randomized prospective controlled trial was to examine the effect of spinal analgesia on the success rate of ECV performed among multiparae at term.
Abstract and Introduction
Abstract
Background: Neuraxial analgesia significantly increases the success rate of external cephalic version (ECV) among nulliparae. The study objective was to compare ECV success among multiparae with and without spinal analgesia.
Methods: Prospective randomized controlled trial performed over a pre-defined 6 yr period in a tertiary referral delivery suite. Healthy multiparae at term requesting ECV for breech presentation, without fetal or uterine anomaly, were enrolled after written informed consent. Women were randomized to receive either spinal analgesia (bupivacaine 7.5 mg) or no analgesia before the ECV. The primary outcome was successful conversion from breech to vertex presentation, confirmed by ultrasound. Visual analogue pain score and adverse outcomes (complications of anaesthesia or ECV) were recorded. Statistical analysis was performed according to intention to treat using two-sided tests.
Results: Among 265 multiparae who underwent ECV, 65 consented to enrol, one subsequently refused ECV; therefore, data from 64 women were analysed. ECV was successful in 27 of 31 patients (87.1%) receiving spinal analgesia vs 19 of 33 (57.5%) with no analgesia (P=0.009; 95% CI of difference: 0.075–0.48). ECV with spinal analgesia reduced visual analogue pain score, mean (SD) 1.7 (2.4) vs 5.5 (2.9) without (P<0.0001). Maternal hypotension was seen after spinal analgesia in 10 of 31 (32%) (P=0.0003) and easily treated without adverse outcome. No complications were noted after the ECV.
Conclusions: Administration of spinal analgesia significantly increased the rate of successful ECV among multiparae at term with increased patient comfort.
Introduction
Almost 90% of women in developed countries with a breech-presenting fetus at term are delivered by Caesarean section because of concerns about fetal safety. This exposes women to risks such as uterine rupture and placenta accreta during subsequent deliveries. Furthermore, maternal and fetal morbidity is lower with vertex vaginal delivery than with Caesarean section. Since women with a breech-presenting fetus are more likely to have a breech-presenting fetus during a subsequent pregnancy, it becomes important to succeed with external cephalic version (ECV) in each individual pregnancy in order to avoid unnecessary Caesarean sections with their cumulative risk.
Neuraxial analgesia significantly increases the chance of successful ECV among nulliparae, thus an otherwise mandatory Caesarean delivery can potentially be avoided. The success rate of ECV among multiparae is known to be higher (57–67%) than among nulliparae; therefore, neuraxial analgesia may not have the same positive impact on the success rate of ECV among multiparae.
The primary aim of this randomized prospective controlled trial was to examine the effect of spinal analgesia on the success rate of ECV performed among multiparae at term.
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