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external cephalic version:a role for anaesthesia?
Neil MuchatutaConsultant Anaesthetist
St Michael’s Hospital, Bristol, UK
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What is external cephalic version (ECV)?
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Breech is now a major cause of CS
Labour arrestMacrosomiaMalpresentationMaternal-fetalMaternal requestMultiple gestationNon-ressuring CTGOther obstetric indicationsPre-eclampsia
Lundsberg 2011. Obstet Gynecol; 118: 29–38
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Hannah 2000. Lancet; 356: 1375–83
n = 2,083
0
1
2
3
4
5
6
Vaginal breech birth Caesarean birth
Risk
of s
ever
e ne
onat
al h
arm
/dea
th (%
)
RR = 0.33
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Changes in CS frequency since Term Breech Study
Martin 2013. Natl Vital Stat Rep; 62: 1–90
Caesarean delivery rate
Primary caesarean delivery rate
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Ris
k of
com
plic
atio
ns (e
.g. C
S, p
raev
ia, a
ccre
ta)
number of caesarean sections
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Ris
k of
com
plic
atio
ns (e
.g. C
S, p
raev
ia, a
ccre
ta)
number of vaginal births
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What do
women want
?
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ECV success rates
RCOG 2017. BJOG: Int J Obstet Gy; 124: e178–92.
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Based on 1,000 ECVsInternally and externally validate
ECV success rates
Burgos 2012. Aust N Z J Obstet Gynaecol; 52: 59–61.
1 2 3 4
Parity P1 P2 P3+
Placental location Anterior Fundal
Lateral Posterior
Type of breech
Frank incomplete Complete Double
footling
Amniotic fluid volume Low Normal Abundant
31%
57%
77%
0
20
40
60
80
100
4–6 7–8 9–14
ECV
succ
ess
rate
(%)
ECV predictive index
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Do eligible women have ECV?
n > 32,000
67%of eligible women did not have ECV
Bin 2017. BMC Preg Childbirth; 17: 244–81
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ContraindicationsLack of trainingTendency to perform caesareansLack of awareness/service/resourcBreech not diagnosed
Why don’t women have ECV?
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Why don’t women have ECV?
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Risks of ECV
Collaris 2004. Acta Obstet Gynecol Scand; 83: 511–8
Transient CTG abnormalities 5.7%Vaginal bleeding 0.5%Emergency caesarean 0.4%Abruption 0.1%Perinatal mortality 0.2%
Why don’t women have ECV?
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Why don’t women have ECV?
Yogev 2002. Int J Gynaecol Obstet; 79: 221–4.
53% 54%
0
10
20
30
40
50
60
70
1995
% o
f wom
en
Aware of ECVWilling to have ECV
73%
24%
0
10
20
30
40
50
60
70
2001
% o
f wom
en
1995 2001
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Why don’t women have ECV?
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Why don’t women have ECV?
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Why don’t women have ECV?
Fok 2005. Acta Obstet Gynecol Scand; 84: 748–51.
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Analgesia for ECV
Better pain relief and higher satisfactionNo improvement in ECV success
Cluver 2015. Cochrane Database Syst Rev: CD000184.
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Regional analgesia for ECV
Magro-Malosso 2016. Am J Obstet Gynecol; 215: 276–86.
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Regional analgesia for ECV
Magro-Malosso 2016. Am J Obstet Gynecol; 215: 276–86.
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Regional analgesia for ECV
Goetzinger 2011. Obstet Gynecol; 118: 1137–44.
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Regional analgesia for ECV
Goetzinger 2011. Obstet Gynecol; 118: 1137–44.
‘The chance of a successful ECV was almost 2-fold higher with epidural anesthesia compared to
1.5-fold higher with spinal anesthesia.’
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Regional analgesia for ECV
Lavoie 2010. Can J Anesth; 57: 408–14.
‘analgesicdose’
motor blockspinal bupivacaine 7.5 mgepidural lidocaine 2%/240 mblock to T6
‘anaestheticdose’
spinal bupivacaine 2.5 mgepidural lidocaine 45 mg
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Regional analgesia for ECV
Lavoie 2010. Can J Anesth; 57: 408–14.
‘analgesicdose’
‘anaestheticdose’
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Magro-Malosso 2016. Am J Obstet Gynecol; 215: 276–86.
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Magro-Malosso 2016. Am J Obstet Gynecol; 215: 276–86.
0
15
30
45
60
75
Without CNB With CNB
ECV
succ
ess
rate
(%)
ECV success rate
NNT = 6.5
ECV success rateRR= 1.44 (1.27–1.64)
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Magro-Malosso 2016. Am J Obstet Gynecol; 215: 276–86.
NNT = 11
Vaginal birth rateRR = 1.21 (1.04–1.41)
0
13.5
27
40.5
54
67.5
Without CNB With CNBVa
gina
l birt
h ra
te (%
)
NVD rate
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dose
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Chalifoux 2017. Anesthesiol; 127: 625–32.
Regional analgesia for ECV
Rat
e of
suc
cess
ful E
CV
(%)
Intrathecal bupivacaine (mg)
‘analgesicdose’
‘anaestheticdoses’
All blocks ≥ T6
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What about the downsides?
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USA figures
Regional anaesthesia cost-effective if ECV success improves 11%
Carvalho 2013. Anesth Analg; 117: 155–9.
higher success rate with regional anaesthesia44%
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Suen 2012. J Mat Fet Neo Med; 25: 719–22 .
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Parry 2012. Int J Obstet Anaesth; 21: S46.George & Yentis. 2014. Int J Ostet Anaesth; 23, 4–7.
96% of UK units don’t offer
anaesthesia for ECV
Lack of awareness of evidenceLack of resourcesCost effectiveness in local contextResistance to change in complex syste
How common is ECV under regional anaesthesia?
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Logistics
where? which women?
timingwhat dose?
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1. Do all ECVs under regional anaesthesia?
Potential choices:
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2. Use regional anaesthesia in failed ECV?
Potential choices:
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Khaw 2015. Br J Anaesth; 114: 944–50.
Spinal Remi Control
Spinal
Remi
vs vs unsuccessful?
success/notsuccess/not success
vs
Phase 1
Phase 2
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Khaw 2015. Br J Anaesth; 114: 944–50.
Phase 1
83%
64% 64%
0
10
20
30
40
50
60
70
80
90
Spinal Remi Control
ECV
succ
ess
rate
(%)
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Khaw 2015. Br J Anaesth; 114: 944–50.
Phase 2 78% agreed to participate
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Khaw 2015. Br J Anaesth; 114: 944–50.
Phase 2 78%
successful ECV
0%successful
ECV
RemiSpinal
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RCOG 2017. BJOG: Int J Obstet Gy; 124: e178–92.
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3. Use regional in selected cases (e.g. more tricky,
wanting large family)?
Potential choices:
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4. Do ECV under regional before caesarean?
(could include failed ECVs)
Potential choices:
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Massalha 2017. Int J Gynecol Obstet; 139: 324–8.
retrospective studyn = 213
unsuccessful? Spinal
> 38 weeks37–38 weeks
2/3 consented
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Massalha 2017. Int J Gynecol Obstet; 139: 324–8.
Phase 1 Phase 2 Overall
68%successful
ECV
39%successful
ECV
73%successful
ECV
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Massalha 2017. Int J Gynecol Obstet; 139: 324–8.
Phase 1 Phase 2 Overall
68%successful
ECV
39%successful
ECV
73%successful
ECV
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Panda 2018. BMC Preg Childbirth;18: 377.
belief in normal birth
belief in normal birth
team-basedapproach
women’s involvement in decision-
making
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Summary