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Effectiveness of Epidural Anesthesia for External Cephalic Version (ECV)

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Effectiveness of Epidural Anesthesia for External Cephalic Version (ECV) Journal of Perinatology (2010) 30, 580–583 r 2010 Nature America, Inc. All rights reserved. 0743-8346/10 www.nature.com/jp ORIGINAL ARTICLE Effectiveness of epidural anesthesia for external cephalic version (ECV) M Yoshida, H Matsuda, Y Kawakami, Y Hasegawa, Y Yoshinaga, E Hayata, K Asai, A Kawashima and K Furuya Department of Obstetrics and Gynecology, National Defense Medical College, Saitama, Japan Journal of Perinatology (2010) 30, 580–583; doi:10.1038/jp.2010.61; Objective: The Cochrane review conducted in 2001 re-established the published online 20 May 2010 usefulness of external cephalic version (ECV). The success rate for ECV using epidural anesthesia or spinal anesthesia is reported to be 35 to 86%. Keywords: breech presentation; external cephalic version; epidural In this study, we examined the effectiveness of epidural anesthesia for ECV. anesthesia Study Design: A retrospective cohort study was conducted of pregnant women who were at 35 to 36 weeks of gestation between 2001 and June 2009, with a single fetus, non-cephalic presentation and without non- Introduction reassuring fetal status. The subjects were ultrasonographically examined Breech presentation at term occurs in 3 to 4% of all pregnancies.1 for placental location, presence/absence of nuchal cord and amniotic fluid In case of breech presentation, it has been shown that selective volume. Those with placenta previa, early rupture of membranes, uterine cesarean delivery provides a better perinatal prognosis for anomaly or severe fetal anomaly and those in whom delivery was initiated children than vaginal delivery.2–4 The Cochrane review in 2001 were excluded from the study. The study protocol was approved by the re-established the usefulness of external cephalic version (ECV). institutional ethics committee, and written informed consent was obtained The American Congress of Obstetricians and Gynecologists for all procedures described in the protocol. The success rate for ECV was Committee has also recommended reducing breech presentation.3 compared between the anesthesia and non-anesthesia groups. Analysis was On the basis of these suggestions, we are proposing to our patients also performed to identify factors contributing to successful ECV. the use of ECV as the third option, in addition to the choice of Result: There were 86 women with non-cephalic presentation who either trial breech delivery or selective cesarean delivery. 5 underwent ECV during the study period. The non-anesthesia group Mancuso et al. have reported the effectiveness of epidural consisted of 34 women in whom ritodrine hydrochloride, a tocolytic agent, anesthesia for ECV for breech presentation in late pregnancy. The was administered alone, and 52 women in whom a tocolytic agent and success rate of ECV with epidural anesthesia was 59.2%. We began epidural anesthesia were used constituted the anesthesia group. There using epidural anesthesia for ECV since 2003. This study intends to were no significant differences between the two groups in terms of age, examine its effectiveness for success of ECV. parity, body mass index and placental location. The success rate for ECV was 55.9% (19/34 patients) in the non-anesthesia group and 78.8% (41/52 patients) in the anesthesia group, showing a significant difference Methods between the two groups (odds ratio 1.75, 95% confidence interval 1.26 to The study was carried out at National Defense Medical College 2.44). Analysis was also performed to identify factors determining Hospital between 1 January 2001 and 30 June 2009. The study successful ECV other than epidural anesthesia from among age, parity, protocol was approved by the institutional ethics committee, and body mass index, placental location, presence/absence of uterine myoma, written informed consent was obtained for all procedures described nuchal code and previous cesarean delivery; however, none of the factors in the protocol. Pregnant women meeting the following criteria identified was found to be a significant determinant factor. were selected as the study subjects: 35 to 36 weeks of gestation, Conclusion: The use of epidural anesthesia significantly increases the breech or transverse presentation, single pregnancy, aged X18 success rate for ECV for breech presentation. years, showing a reassuring fetal status pattern in the non-stress test and estimated fetal weight of 2000 to 4000 g. The subjects were Correspondence: Dr M Yoshida, Department of Obstetrics and Gynecology, National Defense hospitalized and ultrasonographically examined for placental Medical College, 3-2, Namiki, Tokorozawa, Saitama, 359-8513 Japan. location, umbilical insertion site, presence/absence of uterine E-mail: [email protected] Received 18 September 2009; revised 15 March 2010; accepted 11 April 2010; published online myoma, anomaly and nuchal cord. Those with placenta previa, 20 May 2010 early rupture of membranes, uterine anomaly or severe fetal Does ECV need epidural anesthesia? M Yoshida et al 581 anomaly and those in whom delivery was initiated were excluded Table 1 Study characteristics from the study. Anesthesia Non-anesthesia P-value Before ECV, each subject was intravenously administered 500 ml group group of hydroxyethylated starch for the expansion of circulating plasma (n ¼ 52) (n ¼ 34) volume and continuously administered ritodrine hydrochloride as a tocolytic agent at a rate of 67 mg min–1. In the anesthesia group, Age (years) 31.9±4.7 29.5±5.1 0.168 an epidural catheter was inserted at the L1/L2 intervertebral space, Nullipara 21 (40.4%) 13 (38.2%) 0.662 –2 followed by the administration of 3 ml of 0.25% bupivacaine. After BMI (kg m ) 25.4±3.8 23.8±2.0 0.112 confirming the absence of adverse reactions such as a decrease in Placental location blood pressure, another 10 ml of 0.25% bupivacaine was infused. Anterior 29 (55.8%) 21 (61.8%) 0.449 Blood pressure was monitored every 1 min during the first 10 min Posterior 23 (44.2%) 13 (38.2%) after drug administration, then every 2 min for another 10 min Uterine myoma 2 (3.8%) 2 (5.9%) 0.572 and every 5 min thereafter. Each subject was placed in the Nucal cord 2 (3.8%) 1 (2.9%) 0.324 Trendelenburg position after the level of anesthesia reached T10. Gestational week at ECV (weeks)a 36.2±0.6 35.8±0.9 0.112 An obstetrician stood on the right-hand side of a subject when Estimated fetal body weight at ECV (g)a 2436±264 2451±251 0.812 performing ECV. ECV was basically performed by forward rotation, Gestational week at birth (weeks)a 38.8±1.7 38.8±1.6 0.426 and if it failed, by backward rotation. No limitation was set on the Birth weight (g)a 2969±442 2882±452 0.168 procedural time. We did not perform a transvaginal fetus-lifting Apgar score (5 min)a 9.4±0.9 9.5±0.6 0.334 procedure in any of the patients. When a resident physician was to Abbreviations: BMI, body mass index; ECV, external cephalic version. perform ECV, he or she was supervised by a senior attending aMean±s.d. physician. After completion of ECV, the mother and fetus were evaluated for approximately 4 h. Fetal well-being was evaluated using (41/52 patients) in the anesthesia group, showing a significant the non-stress test before and after ECV. If ECV failed, cesarean difference between the two groups (odds ratio 1.75, 95% confidence delivery was then scheduled for approximately 38 weeks of gestation. interval 1.26 to 2.44). There was no case of non-reassuring fetal From 2001 to 2003, we used just the tocolytic agent in the status immediately after ECV in either of the groups. In the setting of ECV. Subsequent to 2003, we began using epidural non-anesthesia group, 1 of the 19 patients with successful ECV anesthesia, and this constituted the primary difference between our developed uterine infection and thus underwent cesarean delivery. two groups. The anesthesia and non-anesthesia groups were In the anesthesia group, 6 of the 41 patients with successful compared in terms of the rate of vaginal delivery, overall rate of ECV underwent cesarean delivery. The reasons included cesarean delivery and rate of neonatal asphyxia. occipitoposterior presentation during delivery in four patients, Statistical analyses were performed using Student’s t-test and the non-reassuring fetal status during delivery in one patient and w2 test. Logistic regression was used for multivariate analysis to adjust recurrence of breech presentation in one patient. The overall rate for potential confounding factors (Statview, version 5.0, SAS Institute of cesarean delivery as a measure of delivery outcome was 50.0% Inc., Cary, NC, USA). P<0.05 was statistically significant. Because of (17/34 patients) in the non-anesthesia group and 32.7% the natural experiment nature of this study with a specific convenience (17/52 patients) in the anesthesia group, not indicating a sample, we did not conduct any apriorisample size calculations. significant contribution of ECV to the reduction of cesarean delivery (odds ratio 0.49, 95% confidence interval 0.23 to 1.18). There was no case of neonatal asphyxia during delivery or transient Results tachypnea of the newborn after delivery in either of the groups. During the study period, 86 women with non-cephalic presentation Univariate analysis of the potential effect of different variables were eligible for ECV and were included in the study. The non- on success rates of ECV is shown in Table 3. Maternal age, parity, anesthesia group consisted of 34 women who underwent ECV body mass index, placental location and epidural anesthesia were between January 2001 and March 2003, in whom ritodrine significant at P<0.05. Multivariate analysis found that none of the hydrochloride, a tocolytic agent, was administered alone, and 52 factors had statistically significant effects of ECV success rates women who underwent ECV between April 2003 and June 2009, in except for epidural anesthesia (Table 4).
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