title: Neuraxial analgesia to increase the success rate of external cephalic version: a systematic review and meta-analysis of randomized controlled trials.
abstract: BACKGROUND
  External cephalic version is a medical procedure in which the fetus is externally manipulated to assume the cephalic presentation. The use of neuraxial analgesia for facilitating the version has been evaluated in several randomized clinical trials, but its potential effects are still controversial.
  
  
  OBJECTIVE
  The objective of the study was to evaluate the effectiveness of neuraxial analgesia as an intervention to increase the success rate of external cephalic version.
  
  
  METHODS
  Searches were performed in electronic databases with the use of a combination of text words related to external cephalic version and neuraxial analgesia from the inception of each database to January 2016.
  
  
  METHODS
  We included all randomized clinical trials of women, with a gestational age ≥36 weeks and breech or transverse fetal presentation, undergoing external cephalic version who were randomized to neuraxial analgesia, including spinal, epidural, or combined spinal-epidural techniques (ie, intervention group) or to a control group (either intravenous analgesia or no treatment).
  
  
  METHODS
  The primary outcome was the successful external cephalic version. The summary measures were reported as relative risk or as mean differences with a 95% confidence interval.
  
  
  RESULTS
  Nine randomized clinical trials (934 women) were included in this review. Women who received neuraxial analgesia had a significantly higher incidence of successful external cephalic version (58.4% vs 43.1%; relative risk, 1.44, 95% confidence interval, 1.27-1.64), cephalic presentation in labor (55.1% vs 40.2%; relative risk, 1.37, 95% confidence interval, 1.08-1.73), and vaginal delivery (54.0% vs 44.6%; relative risk, 1.21, 95% confidence interval, 1.04-1.41) compared with those who did not. Women who were randomized to the intervention group also had a significantly lower incidence of cesarean delivery (46.0% vs 55.3%; relative risk, 0.83, 95% confidence interval, 0.71-0.97), maternal discomfort (1.2% vs 9.3%; relative risk, 0.12, 95% confidence interval, 0.02-0.99), and lower pain, assessed by the visual analog scale pain score (mean difference, -4.52 points, 95% confidence interval, -5.35 to 3.69) compared with the control group. The incidences of emergency cesarean delivery (1.6% vs 2.5%; relative risk, 0.63, 95% confidence interval, 0.24-1.70), transient bradycardia (11.8% vs 8.3%; relative risk, 1.42, 95% confidence interval, 0.72-2.80), nonreassuring fetal testing, excluding transient bradycardia, after external cephalic version (6.9% vs 7.4%; relative risk, 0.93, 95% confidence interval, 0.53-1.64), and abruption placentae (0.4% vs 0.4%; relative risk, 1.01, 95% confidence interval, 0.06-16.1) were similar.
  
  
  CONCLUSIONS
  Administration of neuraxial analgesia significantly increases the success rate of external cephalic version among women with malpresentation at term or late preterm, which then significantly increases the incidence of vaginal delivery.
authors.affiliation: Department of Health Science, Division of Pediatrics, Obstetrics, and Gynecology, Careggi Hospital University of Florence, Florence, Italy.
authors.forename: Elena Rita
authors.initials: ER
authors.lastname: Magro-Malosso
authors.affiliation: Department of Neuroscience, Reproductive Sciences, and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy.
authors.forename: Gabriele
authors.initials: G
authors.lastname: Saccone
authors.affiliation: Department of Health Science, Division of Pediatrics, Obstetrics, and Gynecology, Careggi Hospital University of Florence, Florence, Italy.
authors.forename: Mariarosaria
authors.initials: M
authors.lastname: Di Tommaso
authors.affiliation: Department of Anesthesiology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA.
authors.forename: Michele
authors.initials: M
authors.lastname: Mele
authors.affiliation: Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA. Electronic address: vincenzo.berghella@jefferson.edu.
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Berghella
mesh_terms: D000698:Analgesia / Q000379:methods*; D015360:Analgesia, Epidural / Q000379:methods; D001946:Breech Presentation / Q000628:therapy*; D005260:Female; D006801:Humans; D059408:Pain Management / Q000379:methods; D011247:Pregnancy; D016032:Randomized Controlled Trials as Topic; D016896:Treatment Outcome; D014710:Version, Fetal / Q000379:methods*
keywords: anesthesia; breech; cesarean delivery; delivery; version; vertex