From the Division of Anesthesiology, Geisinger Medical Center, Danville, Pennsylvania.
Department of Population Health Sciences, Geisinger Medical Center, Danville, Pennsylvania.
Anesth Analg. 2020 Dec;131(6):1800-1811. doi: 10.1213/ANE.0000000000004795.
External cephalic version (ECV) is a frequently performed obstetric procedure for fetal breech presentation to avoid cesarean delivery. Neuraxial, intravenous, and inhalational anesthetic techniques have been studied to reduce maternal discomfort caused by the forceful manipulation. This study compares the effects of these anesthetic techniques on ECV and incidence of cesarean delivery.
We conducted a comprehensive literature search for published randomized controlled trials (RCTs) or well-conducted quasi-randomized trials of ECV performed either without anesthesia or under neuraxial, intravenous, or inhalational anesthesia. Pairwise random-effects meta-analyses and network meta-analyses were performed to compare and rank the perinatal outcomes of the 3 anesthetic interventions and no anesthesia control, including the rate of successful version, cesarean delivery, maternal hypotension, nonreassuring fetal response, and adequacy of maternal pain control/satisfaction.
Eighteen RCTs and 1 quasi-randomized trial involving a total of 2296 term parturients with a noncephalic presenting singleton fetus were included. ECV under neuraxial anesthesia had significantly higher odds of successful fetal version compared to control (odds ratio [OR] = 2.59; 95% confidence interval [CI], 1.88-3.57), compared to intravenous anesthesia (OR = 2.08; 95% CI, 1.36-3.16), and compared to inhalational anesthesia (OR = 2.30; 95% CI, 1.33-4.00). No association was found between anesthesia interventions and rate of cesarean delivery. Neuraxial anesthesia was associated with higher odds of maternal hypotension (OR = 9.33; 95% CI, 3.14-27.68). Intravenous anesthesia was associated with significantly lower odds of nonreassuring fetal response compared to control (OR = 0.36; 95% CI, 0.16-0.82). Patients received neuraxial anesthesia reported significantly lower visual analog scale (VAS) of procedure-related pain (standardized mean difference [SMD] = -1.61; 95% CI, -1.92 to -1.31). The VAS scores of pain were also significantly lower with intravenous (SMD = -1.61; 95% CI, -1.92 to -1.31) and inhalational (SMD = -1.19; 95% CI, -1.58 to -0.8) anesthesia. The VAS of patient satisfaction was significantly higher with intravenous anesthesia (SMD = 1.53; 95% CI, 0.64-2.43).
Compared to control, ECV with neuraxial anesthesia had a significantly higher successful rate; however, the odds of maternal hypotension increased significantly. All anesthesia interventions provided significant reduction of procedure-related pain. Intravenous anesthesia had significantly higher score in patient satisfaction and lower odds of nonreassuring fetal response. No evidence indicated that anesthesia interventions were associated with significant decrease in the incidence of cesarean delivery compared to control.
外倒转术（ECV）是一种常用于纠正胎臀位以避免剖宫产的产科操作。为减轻强力操作引起的产妇不适，已研究了椎管内、静脉内和吸入性麻醉技术。本研究比较了这些麻醉技术对 ECV 及剖宫产发生率的影响。
我们对已发表的 ECV 相关随机对照试验（RCT）或精心设计的准随机试验进行了全面文献检索，这些研究对象为不接受麻醉或接受椎管内、静脉内或吸入性麻醉的 ECV。采用两两随机效应荟萃分析和网络荟萃分析比较和排列 3 种麻醉干预措施与无麻醉对照组的围产结局，包括转胎位成功率、剖宫产率、产妇低血压、胎儿反应不佳和产妇疼痛控制/满意度。
纳入了 18 项 RCT 和 1 项准随机试验，共纳入 2296 例足月、非头位单胎产妇。与对照组相比，椎管内麻醉下 ECV 的胎儿转胎位成功率更高（比值比[OR] = 2.59；95%置信区间[CI]，1.88-3.57），与静脉内麻醉（OR = 2.08；95% CI，1.36-3.16）相比，与吸入性麻醉（OR = 2.30；95% CI，1.33-4.00）相比。麻醉干预与剖宫产率之间无关联。椎管内麻醉与产妇低血压发生率更高相关（OR = 9.33；95% CI，3.14-27.68）。与对照组相比，静脉内麻醉与胎儿反应不佳发生率更低相关（OR = 0.36；95% CI，0.16-0.82）。接受椎管内麻醉的患者报告的与操作相关的疼痛视觉模拟量表（VAS）评分明显更低（标准化均数差[SMD] = -1.61；95% CI，-1.92 至-1.31）。静脉内麻醉（SMD = -1.61；95% CI，-1.92 至-1.31）和吸入性麻醉（SMD = -1.19；95% CI，-1.58 至-0.8）的 VAS 疼痛评分也明显更低。静脉内麻醉的患者满意度 VAS 评分明显更高（SMD = 1.53；95% CI，0.64-2.43）。
与对照组相比，椎管内麻醉下 ECV 的成功率显著更高；然而，产妇低血压的几率显著增加。所有麻醉干预均显著减轻了与操作相关的疼痛。静脉内麻醉的患者满意度评分更高，胎儿反应不佳的几率更低。没有证据表明与对照组相比，麻醉干预可显著降低剖宫产率。
