We aim to answer the clinical question: Does combined spinal-epidural analgesia improve the
success rate of external cephalic version? We hypothesize that neuraxial analgesia (spinal
or epidural analgesia) during version for breech presentation increases successful fetal
rotation and decreases the incidence of Cesarean delivery for malpresentation.
At term 2 to 3% of singleton pregnancies are in breech presentation. Many of these
deliveries are managed by cesarean delivery due to higher neonatal morbidity associated with
vaginal breech delivery. Cesarean delivery, the safer option for the baby, however, is
associated with a higher incidence of maternal complications for both the current and
subsequent pregnancies. External cephalic version is a procedure commonly used to attempt
to manually rotate the fetus into vertex position. This facilitates vaginal delivery and
thus avoids higher maternal and/or neonatal complications.
Obstetricians perform versions after 36 weeks gestational age with a reportable success rate
of 30-80%. The most common technique involves external manipulation of the fetal position
preceded by pharmacologic uterine relaxation. Pain relief is most commonly provided in the
form of intravenous opioids such as fentanyl. A more efficacious form of analgesia is the
use of neuraxial opioids and local anesthetics (neuraxial analgesia), a technique commonly
used for labor and delivery analgesia.
Although the use of neuraxial analgesia and anesthesia techniques improve maternal pain and
satisfaction, there is conflicting evidence if they improve the success rate of version
procedures. The American College of Obstetricians and Gynecologists (ACOG) has stated,
"Currently there is not enough evidence to make a recommendation favoring or opposing
anesthesia during ECV (external cephalic version) attempts."
We propose to conduct a prospective, single blinded, randomized clinical trial to assess the
impact of combined spinal-epidural analgesia on the success rate of external version for
breech fetal position and the subsequent incidence of vaginal vs. Cesarean delivery as a
- 18-55 years of age
- Breech Presentation
- Greater than 36 Weeks gestation
- Version Procedure
- Under 18 or over 55 years of age