Neuraxial anesthesia and External Cephalic Version

ACOG: If Your Baby is Breech

What is an external cephalic version?


Wikipedia: external cephalic version

Randomized trial of anaesthetic interventions in external cephalic version for breech presentation. British Journal of Anaesthesia 114 (6): 944–50 (2015)

  • Conclusions: Spinal Anesthesia (SA: hyperbaric bupivacaine 9mg + fentanyl 15mcg) increased the success rate and reduced pain for both primary and re-attempts of External Cephalic Version (ECV), whereas IV Anesthesia (IVA) using remifentanil infusion (0.1mcg/kg/min) only reduced the pain. There was no significant increase in the incidence of fetal bradycardia or emergency CS, with ECV performed under anaesthetic interventions. Relaxation of the abdominal muscles from SA appears to underlie the improved outcomes for ECV.
  • Editor’s key points: There is no consensus on best anaesthetic technique for external cephalic version (ECV).  In this study, success at ECV was higher using spinal anaesthesia compared with remifentanil infusion or no intervention.  Pain was also reduced in the remifentanil group but success at ECV was no different to the no intervention group.  The effect of spinal anaesthesia in ECV may relate to relaxation of the abdominal musculature.

Neuraxial blockade for external cephalic version: Cost analysis. J Obstet Gynaecol Res. 2015 Jul; 41(7): 1023–1031.

  • Neuraxial blockade is associated with minimal hospital and insurer cost changes in the setting of external cephalic version, while reducing the cesarean delivery rate.

External cephalic version with or without spinal anesthesia: a cost-effectiveness analysis.  American Journal of Obstetrics and Gynecology, January 2016Volume 214, Issue 1, Supplement, Pages S206–S207.  

  • It is both effective and cost-effective to utilize spinal anesthesia to perform ECV in term, nulliparous women with breech fetuses. Translation of this potentially impactful approach into broad obstetric practice should be undertaken.

Effect of Regional Anesthesia on the Success Rate of External Cephalic Version: A Systematic Review and Meta-Analysis. Obstet Gynecol. 2011 Nov; 118(5): 1137–1144.

  • Six RCTs met criteria for study inclusion. Regional anesthesia was associated with a higher external cephalic version success rate compared to intravenous or no analgesia (59.7% vs. 37.6%; pooled RR 1.58, 95% confidence interval [CI] 1.29-1.93). This significant association persisted when the data was stratified by type of regional anesthesia (spinal vs. epidural). The number needed to treat with regional anesthesia to achieve one additional successful ECV was 5. There was no evidence of statistical heterogeneity (p=0.32, I2=14.9%) or publication bias (Harbord test p=0.78). There was no statistically significant difference in the risk of cesarean delivery comparing regional anesthesia to intravenous or no analgesia (48.4% vs. 59.3%; pooled RR 0.80, 95% CI 0.55-1.17). Adverse events were rare and not significantly different between the two groups.

Does Regional Anesthesia for External Cephalic Version Increase the Risk of Emergent Cesarean Delivery? Obstetrics & Gynecology: May 2016

  • Neuraxial Anesthesia (NA) for External Cephalic Version (ECV) increased the risk of emergent cesarean delivery (CD) without impacting ECV success. These findings differ from previous randomized controlled trials (RCTs). The increased risk and decreased success of our ECVs compared to ECVs performed in the context of RCTs could be explained by patient selection, variation in operator experience or technique, or variation in anesthetic management.  Future studies should further evaluate the risk of NA for ECV in true practice scenarios outside of RCTs.

Clinical outcomes after external cephalic version with spinal anesthesia after failure of a first attempt without anesthesia.  International Journal of Obstetrics & Gynecology. Volume139, Issue3. December 2017: 324-328.

  • Repeat ECV with spinal anesthesia after a failed first attempt without spinal anesthesia increased vertex presentation at birth and decreased the rate of cesarean delivery.

Effect of Intrathecal Bupivacaine Dose on the Success of External Cephalic Version for Breech Presentation: A Prospective, Randomized, Blinded Clinical Trial. Anesthesiology 10 2017, Vol.127, 625-632.

  • Results: A total of 240 subjects were enrolled, and 239 received the intervention. External cephalic version was successful in 123 (51.5%) of 239 patients. Compared with bupivacaine 2.5 mg, the odds (99% CI) for a successful version were 1.0 (0.4 to 2.6), 1.0 (0.4 to 2.7), and 0.9 (0.4 to 2.4) for bupivacaine 5.0, 7.5, and 10.0 mg, respectively (P = 0.99). There were no differences in the cesarean delivery rate (P = 0.76) or indication for cesarean delivery (P = 0.82). Time to discharge was increased 60 min (16 to 116 min) with bupivacaine 7.5 mg or higher as compared with 2.5 mg (P = 0.004).
  • Conclusions: A dose of intrathecal bupivacaine greater than 2.5 mg does not lead to an additional increase in external cephalic procedural success or a reduction in cesarean delivery.





Walking labor epidurals

What is an epidural?

What is a “walking” epidural?

Anesthesiology 2 2000, Vol.92, 387. Walking with Labor Epidural Analgesia: The Impact of Bupivacaine Concentration and a Lidocaine–Epinephrine Test Dose.

MJAFI, Vol. 63, No. 1, 2007. Walking Epidural : An Effective Method of Labour Pain Relief. 

Int J Women’s Health, 2009, 1: 139-154. Advances in labor analgesia.

R. Can J Anesth/J Can Anesth (2010) 57: 103. Walking epidurals for labour analgesia: do they benefit anyone?

MOBILIZATION IN LABOUR AFTER REGIONAL ANALGESIA. Euroanesthesia May 2005. Royal Free Hospital. London, UK.

Impact of first-stage ambulation on mode of delivery among women with epidural analgesia. Australian and New Zealand Journal of Obstetrics and Gynaecology 2004; 44: 489–494

From WebMD

Walking Epidural with Low Dose Bupivacaine Plus Tramadol on Normal Labour in Primipara. Journal of the College of Physicians and Surgeons Pakistan 2010, Vol. 20 (5): 295-298.

Clinical Guidelines: Labour Analgesia. Jan 2017. King Edward Memorial Hospital, Australia.

BJOG, Feb 2015. Neuraxial analgesia effects on labor progression: facts, fallacies, uncertainties and the future.

Position in the second stage of labour for women with epidural anaesthesia. Cochrane Database of Systematic Reviews. Feb 2017.

Ambulatory Epidural Analgesia in Obstetrics: Clinical Effectiveness, Safety, and Guidelines. Canadian Agency for Drugs and Technologies in Health. Rapid Response Reports. Nov 2010.

Contin Educ Anaesth Crit Care Pain (2004) 4 (4): 114-117. Epidural analgesia in labor.

CSE for Labour Analgesia. 


From the ASA 2017 (October in Boston):

  • CSE: 1 cc 0.25% bupi + 15mcg fentanyl (good for primip)
  • 25g Dural Puncture without dosing sometimes (primips)

OB Anesthesia

Today, I’m on call covering OB.

MGH: OB anesthesia Q&A for patients

BWH: OB anesthesia Q&A for patients

IARS 2010: OB anesthesia in the 21st century

IARS 2011: OB anesthesia update

A&A 2013: A Randomized Controlled Comparison of Epidural Analgesia and Combined Spinal-Epidural Analgesia in a Private Practice Setting: Pain Scores During First and Second Stages of Labor and at Delivery

Indian J Anesthesia 2006: Acute Pain – Labour Analgesia

Presentation on mobile epidural


June 2011: Update on rural OB anesthesia

Oct 2013: Presentation on Labor analgesia. Epidural vs CSE, bolus v infusions

To epidural or not to epidural. That is the question.

My Reddit Comment

A great YouTube video on what an epidural is and what it will feel like.

YouTube vid of a real epidural placement ** Needles are involved in this one**

Lately, I’ve been changing my regimen for pain control with PCEA.  It seems most of my partners use a 10ml/hr basal rate, 5ml bolus dose, 10 minute lockout, and 30 ml/hr max.

My current strategy for PCEA (0.0625% bupi + 2mcg/ml fentanyl):

  • 5ml/hr basal rate
  • 10ml bolus
  • 20 minute lockout
  • 35 ml/hr max

Anesth Analges 2007: A Comparison of a Basal Infusion with Automated Mandatory Boluses in Parturient-Controlled Epidural Analgesia During Labor.

ASA Nov 2001: PCEA during labor

Br J Anaesth 2010:Labour analgesia and obstetric outcomes.

Effect of Intrathecal Bupivacaine Dose on the Success of External Cephalic Version for Breech Presentation: A Prospective, Randomized, Blinded Clinical Trial

Neuraxial anesthesia in the non-pregnant patient

Anesthesiology Research and Practice 2012: Recent advances in epidural analgesia.

Br J Anaesth 2012: Failed epidural: causes and management.

From my blog: