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External cephalic version: new interest and old concerns
International Journal of Obstetric Anesthesia (2001) 10, 263–266 ° C 2001 Harcourt Publishers Ltd doi:10.1054/ijoa.2001.0901, available online http://www.idealibrary.com on
EDITORIAL
External cephalic version: new interest and old concerns
Breech presentation occurs in 3–4% of term pregnancies. Until recently, there was considerable debate about the optimal mode of delivery of a fetus in the breech position. Perinatal morbidity and mortality were thought to be greater following vaginal breech delivery than with caesarean delivery but there was insufficient scientific evidence to support this general view. Publication of the Term Breech Trial (TBT) in October 2000 in the Lancet has finally provided us with this evidence.1 This was a multicentre (121 centres in 26 countries) trial in 2088 women with singleton fetus in frank or complete breech presentation at term (≥37 weeks’ gestation) who were allocated randomly to either planned caesarean section or planned vaginal birth. Perinatal and neonatal mortality at 28 days was significantly higher in the group delivered vaginally (1.3%) than in the group delivered by caesarean section (0.3%). There were 13 babies who died in the vaginal delivery group and 3 in the caesarean section group. Six deaths in the vaginal group were associated with difficult vaginal delivery and four with fetal heart rate abnormalities during labour. Neonatal morbidity was also greater in the vaginal delivery group (3.8%) than in the caesarean section group (1.4%). Significant neonatal morbidity included birth trauma, seizures in the first 24 hours, hypotonia, abnormal level of consciousness, low Apgar scores, abnormal cord blood pH (<7.00) and base deficit (≥15 mmol · L−1 ), ventilation for greater than 24 hours and care in the neonatal intensive care unit for more than four days. Serious maternal morbidity was 3.6% overall, and similar in the two groups. The TBT is the first large, randomised study to provide evidence that caesarean section was safer than planned vaginal birth for the term fetus in breech presentation. It now seems likely that with clinical governance issues and pressure to practice evidence-based medicine, it will be difficult for clinicians to advocate that patients have planned vaginal breech deliveries and most, if not all, breech presentation babies will be delivered by caesarean section. Although the findings of the TBT are welcome in some respects, it is inevitable that questions will be
raised on the long-term effects of loss of clinical skills in vaginal breech delivery by both midwives and obstetricians. Furthermore, the validity of some of the findings has already been questioned. Inadequate assessment of the pelvis may have led to a higher incidence of fetopelvic disproportion and failure of labour. Five of the deaths in the vaginal delivery group may not be truly attributed to the mode of delivery. Two babies may have died before their mothers were recruited to the study; one baby had congenital anomalies, one baby died at home from diarrhoea and vomiting, and one baby died during sleep. A surprising finding in the study was that caesarean delivery did not protect the breech babies from serious trauma. In two cases in the planned caesarean section group, spinal cord injury and basal skull fractures occurred. Although it may be possible to follow the recommendations of the TBT in western countries, there may be some reluctance by clinicians in less developed countries because of significant financial restraints. The performance of elective caesarean sections in all breech babies would add a major financial burden. The recommendations of the TBT will add additional challenges to obstetricians who are already under pressure to reduce the caesarean delivery rates. Surgical delivery may be avoided however, by reducing the incidence of breech presentations using external cephalic version. This technique is regarded as a safe method of reducing the prevalence of breech presentation in labour and hence reducing the number of caesarean sections and their related maternal risks. Recent guidelines from the Royal College of Obstetricians and Gynaecologists recommend that all women with uncomplicated breech presentation at term should be offered external cephalic version.2 External cephalic version comprises external manipulation of the fetus to rotate it from a breech to a cephalic presentation. It has apparently been practised since the time of Aristotle (384–322 BC) who stated that many of his fellow physicians advised midwives confronted with a breech presentation to place the head so that it presents 263
264
International Journal of Obstetric Anesthesia
at birth.3,4 During the early part of the last century, enthusiasm for external cephalic version fluctuated, but in the 1960s it became popular because of growing demand for a non-interventional approach to childbirth. Its popularity declined in the 1970s because of uncertainty regarding the effectiveness of the procedure, concerns about its safety and the high spontaneous version rates. However by the 1980s, it had again become fashionable, particularly in the USA, and this interest has continued to grow. In the UK, enthusiasm has lagged a little behind that in the USA but there has also been a recent resurgence of interest. It is important for mothers undergoing external cephalic version to be well informed about the associated benefits and risks. The value of external cephalic version is that it may reduce the incidence of breech delivery six-fold and hence reduce the associated neonatal complications.3 It reduces caesarean deliveries for breech presentation by 50–60%,3,5 and thereby reduces maternal morbidity and also cost of delivery. The safety of external cephalic version has improved immensely by better selection of patients, improved training of obstetricians and the use of ultrasound and cardiotocography (CTG) during the procedure. There appears to be some variability between units in the contraindications to external cephalic version, but the following appear to be the generally accepted absolute contraindications: multiple pregnancy, antepartum haemorrhage, placenta praevia, established labour, premature rupture of membranes, severe pregnancy-induced hypertension, maternal cardiac disease, previous uterine surgery (apart from caesarean section) and cases in which caesarean section is anyway necessary. Relative contraindications to external cephalic version include previous caesarean section, diabetes, hypertension, impaired fetal growth, obesity, fetal and uterine anomalies. Ideally, external cephalic version should be carried out only at term in order to reduce the incidence of preterm birth if immediate delivery is required as a complication of the external cephalic version. A high fetal death rate (1%) was reported in 1985 when external cephalic version was carried out without ultrasound or CTG monitoring and in preterm babies (33 to 36 weeks).6 In this study, external cephalic version was carried out in 310 patients. There were two fetal deaths (placental abruption) and one neonatal death (a preterm baby at 33 weeks who died of respiratory distress syndrome). Despite the recent improved safety record of external cephalic version, complications may still occur. Serious complications such as placental abruption, uterine rupture and perinatal death are rare. Less serious complications include fetal bradycardia, entanglement of the umbilical cord, preterm labour and premature rupture of membranes. Fetal bradycardia is the commonest complication; it occurs in about 10% of external cephalic
versions but resolves spontaneously in most cases.3 The underlying mechanism may be transient fetal hypoxia caused by impaired maternal blood flow to the placenta during the period of increased uterine pressure from the manipulation.7 Although the overall complication rate is not high (1–2%), immediate delivery by caesarean section may be required.8 Hellstrom and colleagues performed two emergency caesareans after carrying out 300 external cephalic versions5 and Norchi and colleagues carried out two emergency caesarean sections amongst 160 women who had external cephalic version.9 In all four cases, the indication for caesarean section was antepartum haemorrhage. Thus, external cephalic version was associated with a 0.9% risk of requiring an emergency caesarean section. Operating theatre facilities and staff must therefore be immediately available. Because there is a risk of emergency caesarean section, it may be advocated that all mothers undergoing external cephalic version should be starved for six hours, receive two doses of ranitidine and have intravenous access. Such precautions seem to be observed; in studies reported in the literature, there was a general trend towards starving patients for six hours before the procedure. It may be advisable that if regional analgesia is planned for external cephalic version, patients are starved. Although obstetric anaesthetists may prefer patients to be starved, it is unclear if all obstetricians regard this as an acceptable precaution. In our hospital, some obstetricians believe that it is inappropriate to starve women before external cephalic version and discussions are required between all the professionals involved in care of these patients on what are the most appropriate precautions required. In order to clarify this situation, we hope to carry out a national survey to see what guidelines, if any, are adopted in units throughout the UK. There is considerable variation in the success rate of external cephalic version. Immediate success rates range from 25%10 to 83%11 with an average rate of 58%.12,13 A fetus may turn, however, from breech to cephalic presentation at any stage during the pregnancy. Spontaneous cephalic version has been reported to be as high as 57% after 32 weeks and 25% after 36 weeks of pregnancy.14 After successful external cephalic version, 10% of fetuses revert to breech presentation15 giving an average final cephalic presentation at birth of 48% after attempted external cephalic version. Following successful external cephalic version, labour does not progress as well as that with primary cephalic presentation. A study by Lau and colleagues showed that the risk of both dystocic labour and fetal distress was higher leading to a caesarean section rate twice that of matched controls.16 Caesarean section rates as high as 30% have been reported in patients after successful external cephalic version.17 There are several ways in which the success rates of external cephalic version may be improved. The
Editorial use of tocolytics is one (68% vs 28%) especially in nulliparous women and where doctors are learning the technique.18 The tocolytics used include infusion of ritodrine, single dose of terbutaline or intravenous salbutamol. Although enhancement of fetal movement with vibro-acoustic stimulation15 has been shown to increase the success rate of external cephalic version, further studies are required before this may be recommended. Regional analgesia has also been used in an attempt to improve the success rate, with conflicting results. A significantly greater success rate of version was found in three studies when epidural analgesia was used but all had flaws in study design. In two there were unusually low success rates for version (33% and 32%) in the control groups and the success rate in the epidural groups (59% and 69%) have been achieved in groups in which women had no epidural analgesia.19,20 In the third study there was a failure of randomization and epidural analgesia was used according to physicians’ and patients’ preferences.21 In another study, epidural analgesia was given to patients in whom previous version attempts failed;22 the success rate was increased from 57% to 73% with epidurals, but there were two complications: one woman had a dural puncture that required treatment with a blood patch, and another had moderate antepartum haemorrhage requiring delivery one day after external cephalic version. Spinal anaesthesia (1 mL of 0.25% bupivacaine and 10 µg of sufentanil) was found to have no effect on external cephalic version success rate compared with controls12 and general anaesthesia should be avoided as it has been associated with fetal deaths. In a review of the literature relating to 1975–1977, there were four deaths among 474 fetuses of women who received general anaesthesia or Entonox, (a fetal mortality of almost 1%) but none among the fetuses of 477 mothers who did not receive these drugs.23 The reason why general anaesthesia or Entonox were associated with poor outcomes is not clear. Therefore, on the information available, there is not enough evidence to recommend the routine use of regional analgesia as a means of improving the success rate of external cephalic version. It should be noted, however, that external cephalic version does cause discomfort to the mother. Mahomed and colleagues found that 13% of their patients reported moderate and 28% mild discomfort during external cephalic version11 although 59% had no symptoms. The clear advantage of regional anaesthesia is that it does make the procedure of external cephalic version more comfortable and anaesthetists may therefore increasingly be required to provide analgesia for external cephalic version. If regional analgesia is offered to patients, it is important that they are well informed of the risks and benefits so that they may make an informed decision to consent to such techniques.
265
In summary, interest in the use of external cephalic version has fluctuated over past decades but currently there is a resurgence in its popularity because of the need to reduce the rate of caesarean delivery, fuelled by the results of the Term Breech Trial. Obstetric anaesthetists should be involved early in the planned management of patients undergoing external cephalic version. There is also a need for further research in this area, particularly in the role of regional analgesia for external cephalic version. The questions that need addressing are: should regional analgesia be reserved for women who have failed previous version attempts or should it be offered to all women, and also what is the most appropriate form of regional analgesia for these women? Mary Mushambi Leicester Royal Infirmary, Leicester, UK REFERENCES 1. Hannah M E, Hannah W J, Hewson S A, Hodnett E D, Saigal S, Willan A R. Planned Caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet 2000; 356: 1375–1383. 2. Royal College of Obstetricians and Gynaecologists. Setting standards to improve women’s health. The management of breech presentation. 1999; Guideline 20: p 1. 3. MacParland P, Farine D. External cephalic version. Does it have a role in modern obstetric practice? Can Fam Physician 1996; 42: 693–698. 4. Jordan B. External Cephalic Version as an alternative to breech delivery and Caesarean section. Soc Sci Med 1984; 18: 637–651. 5. Hellstrom A, Nilsson B, Stange L, Nylund L. When does external cephalic version succeed? Acta Obstet Gynecol Scand 1990; 69: 281–285. 6. Kasule J, Chimbira T H, Brown I M. Controlled trial of external cephalic version. Br J Obstet Gynaecol 1985; 92: 14–18. 7. Hofmeyr G J, Sonnendecker E W W. Cardiotocographic changes after external cephalic version. Br J Obstet Gynaecol 1983; 90: 914–918. 8. Coco A S, Silverman S D. External Cephalic Version. Am Fam Physician 1998; 58: 731–738. 9. Norchi S, Tenore A C, Lovotti M, Merati R, Teatini A, Belloni C. Efficacy of external cephalic version performed at term. Eur J Obstet Gynecol Reprod Biol 1998; 76: 161–163. 10. Van Veelen A J, Van Cappellen A W, Flu P K, Straub M J P F, Wallenburg H C S. Effect of external cephalic version in late pregnancy on presentation at delivery: a randomised controlled trial. Br J Obstet Gynaecol 1989; 96: 916–921. 11. Mahomed K, Seeras R, Coulson R. External Cephalic Version at term. A randomised controlled trial using tocolysis. Br J Obstet Gynaecol. 1991; 98: 8–13. 12. Dugoff L, Stamm C A, Jones O W, Mohling S I, Hawkins J L. The effect of spinal anesthesia on the success rate of external cephalic version: a randomised trial. Obstet Gynecol 1999; 93: 345–349. 13. American College of Obstetricians and Gynecologists. Clinical Management guidelines for obstetricians – gynecologists. External Cephalic Version. ACOG Practice Bulletin February 2000; 13: 1–7. 14. Westgren M, Edvall H, Nordstrom L, Svalenius E, Ranstam J. Spontaneous cephalic version of breech presentation in the last trimester. Br J Obstet Gynaecol 1985; 92: 19–22. 15. Annapoorna V, Arulkumaran S, Anandakumar C, Chua S, Montan S, Ratnam S S. External cephalic version at term with tocolysis and vibroacoustic stimulation. Int J Gynecol Obstet 1997; 59: 13–18. 16. Lau T K, Lo K W K, Rogers M. Pregnancy outcome after successful external cephalic version for breech presentation at term. Am J Obstet Gynecol 1997; 176: 218–223.
266
International Journal of Obstetric Anesthesia
17. Laros R K Jr, Flanagan T A, Kilpatrick S J. Management of term breech presentation: a protocol of external cephalic version and selective trial of labor. Am J Obstet Gynecol 1995; 172: 1916–1923. 18. Chung T, Neale E, Lau T K, Rodgers M. A randomised, double blind, controlled trial of tocolysis to assist external cephalic version in late pregnancy. Acta Obstet Gynecol Scand 1996; 75: 720–724. 19. Mancuso K M, Yancey M K, Murphy J A, Markenson G R. Epidural analgesia for cephalic version: a randomized trial. Obstet Gynecol 2000; 95: 648–651. 20. Schorr S J, Speights S E, Ross E L, et al. A randomized trial of
epidural anesthesia to improve external cephalic version success. Am J Obstet Gynecol 1997; 177: 1133–1137. 21. Carlan S J, Marshall Dent J, Huckaby T, Whittington E C, Shaefer D. The effect of epidural anesthesia on safety and success of external cephalic version at term. Anesth Analg 1994; 79: 525–528. 22. Rozenberg P, Goffinet F, de Spirlet M, et al. External cephalic version with epidural anaesthesia after failure of a first trial with beta-mimetics. Br J Obstet Gynaecol 2000; 107: 406–410. 23. Hofmeyr G J. Effect of external cephalic version in late pregnancy on breech presentation and Caesarean section rate: a controlled trial. Br J Obstet Gynaecol 1983; 90: 392–399.
EDITORIAL
External cephalic version: new interest and old concerns
Breech presentation occurs in 3–4% of term pregnancies. Until recently, there was considerable debate about the optimal mode of delivery of a fetus in the breech position. Perinatal morbidity and mortality were thought to be greater following vaginal breech delivery than with caesarean delivery but there was insufficient scientific evidence to support this general view. Publication of the Term Breech Trial (TBT) in October 2000 in the Lancet has finally provided us with this evidence.1 This was a multicentre (121 centres in 26 countries) trial in 2088 women with singleton fetus in frank or complete breech presentation at term (≥37 weeks’ gestation) who were allocated randomly to either planned caesarean section or planned vaginal birth. Perinatal and neonatal mortality at 28 days was significantly higher in the group delivered vaginally (1.3%) than in the group delivered by caesarean section (0.3%). There were 13 babies who died in the vaginal delivery group and 3 in the caesarean section group. Six deaths in the vaginal group were associated with difficult vaginal delivery and four with fetal heart rate abnormalities during labour. Neonatal morbidity was also greater in the vaginal delivery group (3.8%) than in the caesarean section group (1.4%). Significant neonatal morbidity included birth trauma, seizures in the first 24 hours, hypotonia, abnormal level of consciousness, low Apgar scores, abnormal cord blood pH (<7.00) and base deficit (≥15 mmol · L−1 ), ventilation for greater than 24 hours and care in the neonatal intensive care unit for more than four days. Serious maternal morbidity was 3.6% overall, and similar in the two groups. The TBT is the first large, randomised study to provide evidence that caesarean section was safer than planned vaginal birth for the term fetus in breech presentation. It now seems likely that with clinical governance issues and pressure to practice evidence-based medicine, it will be difficult for clinicians to advocate that patients have planned vaginal breech deliveries and most, if not all, breech presentation babies will be delivered by caesarean section. Although the findings of the TBT are welcome in some respects, it is inevitable that questions will be
raised on the long-term effects of loss of clinical skills in vaginal breech delivery by both midwives and obstetricians. Furthermore, the validity of some of the findings has already been questioned. Inadequate assessment of the pelvis may have led to a higher incidence of fetopelvic disproportion and failure of labour. Five of the deaths in the vaginal delivery group may not be truly attributed to the mode of delivery. Two babies may have died before their mothers were recruited to the study; one baby had congenital anomalies, one baby died at home from diarrhoea and vomiting, and one baby died during sleep. A surprising finding in the study was that caesarean delivery did not protect the breech babies from serious trauma. In two cases in the planned caesarean section group, spinal cord injury and basal skull fractures occurred. Although it may be possible to follow the recommendations of the TBT in western countries, there may be some reluctance by clinicians in less developed countries because of significant financial restraints. The performance of elective caesarean sections in all breech babies would add a major financial burden. The recommendations of the TBT will add additional challenges to obstetricians who are already under pressure to reduce the caesarean delivery rates. Surgical delivery may be avoided however, by reducing the incidence of breech presentations using external cephalic version. This technique is regarded as a safe method of reducing the prevalence of breech presentation in labour and hence reducing the number of caesarean sections and their related maternal risks. Recent guidelines from the Royal College of Obstetricians and Gynaecologists recommend that all women with uncomplicated breech presentation at term should be offered external cephalic version.2 External cephalic version comprises external manipulation of the fetus to rotate it from a breech to a cephalic presentation. It has apparently been practised since the time of Aristotle (384–322 BC) who stated that many of his fellow physicians advised midwives confronted with a breech presentation to place the head so that it presents 263
264
International Journal of Obstetric Anesthesia
at birth.3,4 During the early part of the last century, enthusiasm for external cephalic version fluctuated, but in the 1960s it became popular because of growing demand for a non-interventional approach to childbirth. Its popularity declined in the 1970s because of uncertainty regarding the effectiveness of the procedure, concerns about its safety and the high spontaneous version rates. However by the 1980s, it had again become fashionable, particularly in the USA, and this interest has continued to grow. In the UK, enthusiasm has lagged a little behind that in the USA but there has also been a recent resurgence of interest. It is important for mothers undergoing external cephalic version to be well informed about the associated benefits and risks. The value of external cephalic version is that it may reduce the incidence of breech delivery six-fold and hence reduce the associated neonatal complications.3 It reduces caesarean deliveries for breech presentation by 50–60%,3,5 and thereby reduces maternal morbidity and also cost of delivery. The safety of external cephalic version has improved immensely by better selection of patients, improved training of obstetricians and the use of ultrasound and cardiotocography (CTG) during the procedure. There appears to be some variability between units in the contraindications to external cephalic version, but the following appear to be the generally accepted absolute contraindications: multiple pregnancy, antepartum haemorrhage, placenta praevia, established labour, premature rupture of membranes, severe pregnancy-induced hypertension, maternal cardiac disease, previous uterine surgery (apart from caesarean section) and cases in which caesarean section is anyway necessary. Relative contraindications to external cephalic version include previous caesarean section, diabetes, hypertension, impaired fetal growth, obesity, fetal and uterine anomalies. Ideally, external cephalic version should be carried out only at term in order to reduce the incidence of preterm birth if immediate delivery is required as a complication of the external cephalic version. A high fetal death rate (1%) was reported in 1985 when external cephalic version was carried out without ultrasound or CTG monitoring and in preterm babies (33 to 36 weeks).6 In this study, external cephalic version was carried out in 310 patients. There were two fetal deaths (placental abruption) and one neonatal death (a preterm baby at 33 weeks who died of respiratory distress syndrome). Despite the recent improved safety record of external cephalic version, complications may still occur. Serious complications such as placental abruption, uterine rupture and perinatal death are rare. Less serious complications include fetal bradycardia, entanglement of the umbilical cord, preterm labour and premature rupture of membranes. Fetal bradycardia is the commonest complication; it occurs in about 10% of external cephalic
versions but resolves spontaneously in most cases.3 The underlying mechanism may be transient fetal hypoxia caused by impaired maternal blood flow to the placenta during the period of increased uterine pressure from the manipulation.7 Although the overall complication rate is not high (1–2%), immediate delivery by caesarean section may be required.8 Hellstrom and colleagues performed two emergency caesareans after carrying out 300 external cephalic versions5 and Norchi and colleagues carried out two emergency caesarean sections amongst 160 women who had external cephalic version.9 In all four cases, the indication for caesarean section was antepartum haemorrhage. Thus, external cephalic version was associated with a 0.9% risk of requiring an emergency caesarean section. Operating theatre facilities and staff must therefore be immediately available. Because there is a risk of emergency caesarean section, it may be advocated that all mothers undergoing external cephalic version should be starved for six hours, receive two doses of ranitidine and have intravenous access. Such precautions seem to be observed; in studies reported in the literature, there was a general trend towards starving patients for six hours before the procedure. It may be advisable that if regional analgesia is planned for external cephalic version, patients are starved. Although obstetric anaesthetists may prefer patients to be starved, it is unclear if all obstetricians regard this as an acceptable precaution. In our hospital, some obstetricians believe that it is inappropriate to starve women before external cephalic version and discussions are required between all the professionals involved in care of these patients on what are the most appropriate precautions required. In order to clarify this situation, we hope to carry out a national survey to see what guidelines, if any, are adopted in units throughout the UK. There is considerable variation in the success rate of external cephalic version. Immediate success rates range from 25%10 to 83%11 with an average rate of 58%.12,13 A fetus may turn, however, from breech to cephalic presentation at any stage during the pregnancy. Spontaneous cephalic version has been reported to be as high as 57% after 32 weeks and 25% after 36 weeks of pregnancy.14 After successful external cephalic version, 10% of fetuses revert to breech presentation15 giving an average final cephalic presentation at birth of 48% after attempted external cephalic version. Following successful external cephalic version, labour does not progress as well as that with primary cephalic presentation. A study by Lau and colleagues showed that the risk of both dystocic labour and fetal distress was higher leading to a caesarean section rate twice that of matched controls.16 Caesarean section rates as high as 30% have been reported in patients after successful external cephalic version.17 There are several ways in which the success rates of external cephalic version may be improved. The
Editorial use of tocolytics is one (68% vs 28%) especially in nulliparous women and where doctors are learning the technique.18 The tocolytics used include infusion of ritodrine, single dose of terbutaline or intravenous salbutamol. Although enhancement of fetal movement with vibro-acoustic stimulation15 has been shown to increase the success rate of external cephalic version, further studies are required before this may be recommended. Regional analgesia has also been used in an attempt to improve the success rate, with conflicting results. A significantly greater success rate of version was found in three studies when epidural analgesia was used but all had flaws in study design. In two there were unusually low success rates for version (33% and 32%) in the control groups and the success rate in the epidural groups (59% and 69%) have been achieved in groups in which women had no epidural analgesia.19,20 In the third study there was a failure of randomization and epidural analgesia was used according to physicians’ and patients’ preferences.21 In another study, epidural analgesia was given to patients in whom previous version attempts failed;22 the success rate was increased from 57% to 73% with epidurals, but there were two complications: one woman had a dural puncture that required treatment with a blood patch, and another had moderate antepartum haemorrhage requiring delivery one day after external cephalic version. Spinal anaesthesia (1 mL of 0.25% bupivacaine and 10 µg of sufentanil) was found to have no effect on external cephalic version success rate compared with controls12 and general anaesthesia should be avoided as it has been associated with fetal deaths. In a review of the literature relating to 1975–1977, there were four deaths among 474 fetuses of women who received general anaesthesia or Entonox, (a fetal mortality of almost 1%) but none among the fetuses of 477 mothers who did not receive these drugs.23 The reason why general anaesthesia or Entonox were associated with poor outcomes is not clear. Therefore, on the information available, there is not enough evidence to recommend the routine use of regional analgesia as a means of improving the success rate of external cephalic version. It should be noted, however, that external cephalic version does cause discomfort to the mother. Mahomed and colleagues found that 13% of their patients reported moderate and 28% mild discomfort during external cephalic version11 although 59% had no symptoms. The clear advantage of regional anaesthesia is that it does make the procedure of external cephalic version more comfortable and anaesthetists may therefore increasingly be required to provide analgesia for external cephalic version. If regional analgesia is offered to patients, it is important that they are well informed of the risks and benefits so that they may make an informed decision to consent to such techniques.
265
In summary, interest in the use of external cephalic version has fluctuated over past decades but currently there is a resurgence in its popularity because of the need to reduce the rate of caesarean delivery, fuelled by the results of the Term Breech Trial. Obstetric anaesthetists should be involved early in the planned management of patients undergoing external cephalic version. There is also a need for further research in this area, particularly in the role of regional analgesia for external cephalic version. The questions that need addressing are: should regional analgesia be reserved for women who have failed previous version attempts or should it be offered to all women, and also what is the most appropriate form of regional analgesia for these women? Mary Mushambi Leicester Royal Infirmary, Leicester, UK REFERENCES 1. Hannah M E, Hannah W J, Hewson S A, Hodnett E D, Saigal S, Willan A R. Planned Caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet 2000; 356: 1375–1383. 2. Royal College of Obstetricians and Gynaecologists. Setting standards to improve women’s health. The management of breech presentation. 1999; Guideline 20: p 1. 3. MacParland P, Farine D. External cephalic version. Does it have a role in modern obstetric practice? Can Fam Physician 1996; 42: 693–698. 4. Jordan B. External Cephalic Version as an alternative to breech delivery and Caesarean section. Soc Sci Med 1984; 18: 637–651. 5. Hellstrom A, Nilsson B, Stange L, Nylund L. When does external cephalic version succeed? Acta Obstet Gynecol Scand 1990; 69: 281–285. 6. Kasule J, Chimbira T H, Brown I M. Controlled trial of external cephalic version. Br J Obstet Gynaecol 1985; 92: 14–18. 7. Hofmeyr G J, Sonnendecker E W W. Cardiotocographic changes after external cephalic version. Br J Obstet Gynaecol 1983; 90: 914–918. 8. Coco A S, Silverman S D. External Cephalic Version. Am Fam Physician 1998; 58: 731–738. 9. Norchi S, Tenore A C, Lovotti M, Merati R, Teatini A, Belloni C. Efficacy of external cephalic version performed at term. Eur J Obstet Gynecol Reprod Biol 1998; 76: 161–163. 10. Van Veelen A J, Van Cappellen A W, Flu P K, Straub M J P F, Wallenburg H C S. Effect of external cephalic version in late pregnancy on presentation at delivery: a randomised controlled trial. Br J Obstet Gynaecol 1989; 96: 916–921. 11. Mahomed K, Seeras R, Coulson R. External Cephalic Version at term. A randomised controlled trial using tocolysis. Br J Obstet Gynaecol. 1991; 98: 8–13. 12. Dugoff L, Stamm C A, Jones O W, Mohling S I, Hawkins J L. The effect of spinal anesthesia on the success rate of external cephalic version: a randomised trial. Obstet Gynecol 1999; 93: 345–349. 13. American College of Obstetricians and Gynecologists. Clinical Management guidelines for obstetricians – gynecologists. External Cephalic Version. ACOG Practice Bulletin February 2000; 13: 1–7. 14. Westgren M, Edvall H, Nordstrom L, Svalenius E, Ranstam J. Spontaneous cephalic version of breech presentation in the last trimester. Br J Obstet Gynaecol 1985; 92: 19–22. 15. Annapoorna V, Arulkumaran S, Anandakumar C, Chua S, Montan S, Ratnam S S. External cephalic version at term with tocolysis and vibroacoustic stimulation. Int J Gynecol Obstet 1997; 59: 13–18. 16. Lau T K, Lo K W K, Rogers M. Pregnancy outcome after successful external cephalic version for breech presentation at term. Am J Obstet Gynecol 1997; 176: 218–223.
266
International Journal of Obstetric Anesthesia
17. Laros R K Jr, Flanagan T A, Kilpatrick S J. Management of term breech presentation: a protocol of external cephalic version and selective trial of labor. Am J Obstet Gynecol 1995; 172: 1916–1923. 18. Chung T, Neale E, Lau T K, Rodgers M. A randomised, double blind, controlled trial of tocolysis to assist external cephalic version in late pregnancy. Acta Obstet Gynecol Scand 1996; 75: 720–724. 19. Mancuso K M, Yancey M K, Murphy J A, Markenson G R. Epidural analgesia for cephalic version: a randomized trial. Obstet Gynecol 2000; 95: 648–651. 20. Schorr S J, Speights S E, Ross E L, et al. A randomized trial of
epidural anesthesia to improve external cephalic version success. Am J Obstet Gynecol 1997; 177: 1133–1137. 21. Carlan S J, Marshall Dent J, Huckaby T, Whittington E C, Shaefer D. The effect of epidural anesthesia on safety and success of external cephalic version at term. Anesth Analg 1994; 79: 525–528. 22. Rozenberg P, Goffinet F, de Spirlet M, et al. External cephalic version with epidural anaesthesia after failure of a first trial with beta-mimetics. Br J Obstet Gynaecol 2000; 107: 406–410. 23. Hofmeyr G J. Effect of external cephalic version in late pregnancy on breech presentation and Caesarean section rate: a controlled trial. Br J Obstet Gynaecol 1983; 90: 392–399.