A randomized controlled trial of the effect of combined spinal-epidural analgesia on the success of external cephalic version for breech presentation.
BACKGROUND
Improving the success of external cephalic version (ECV) for breech presentation may help avoid some cesarean deliveries. The results of randomized trials comparing the success of ECV with neuraxial analgesia compared to control are inconsistent. We hypothesized that combined spinal-epidural (CSE) analgesia would increase the success of ECV when compared with systemic opioid analgesia.


METHODS
Parturients with singleton breech presentation (n=96) were randomized to receive CSE analgesia with bupivacaine 2.5mg and fentanyl 15 microg (CSE group) or intravenous fentanyl 50 microg (SYS group) before ECV attempt. The primary outcome was ECV success.


RESULTS
The success rate of ECV was 47% with CSE and 31% in the SYS group (P=0.14). Subsequent vaginal delivery was 36% for CSE and 25% for SYS (P=0.27). Median [IQR] visual analog pain scores (0-100mm scale) were lower with CSE (3 [0-12]) compared to SYS analgesia (36 [16 to 54]) (P<0.005) and patient satisfaction (0-10 scale) was higher (CSE 10 [9 to 10] versus SYS 7 [4 to 9]) (P<0.005). There were no differences in fetal heart rate patterns, but median time to return to fetal heart rate reactivity after analgesia was shorter with CSE (13 [IQR 9-21] min) compared to the SYS group (39 [IQR 23-51] min) (P=0.02).


CONCLUSIONS
There was no difference in the rate of successful ECV or vaginal delivery with CSE compared to intravenous fentanyl analgesia. Pain scores were lower and satisfaction higher with CSE analgesia, and median time to fetal heart rate reactivity was shorter in the CSE group.
Sullivan
J T
JT
Departments of Anesthesiology and Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, 251 E. Huron Street, F5-704, Chicago, IL 60611, USA. sullivan@northwestern.edu
Grobman
W A
WA
Bauchat
J R
JR
Scavone
B M
BM
Grouper
S
S
McCarthy
R J
RJ
Wong
C A
CA
D000328:Adult; D015360:Analgesia, Epidural; D016362:Analgesia, Obstetrical; D000775:Anesthesia, Spinal; D001946:Breech Presentation / Q000628:therapy*; D036861:Delivery, Obstetric; D005260:Female; D006439:Hemodynamics / Q000502:physiology; D006801:Humans; D007231:Infant, Newborn; D010147:Pain Measurement; D020250:Postoperative Nausea and Vomiting / Q000453:epidemiology; D011247:Pregnancy; D018401:Sample Size; D016896:Treatment Outcome; D014710:Version, Fetal