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The critical role of neuraxial anesthesia in external cephalic version

We read with much interest the article written by Anand et al., “Development and validation of a clinical score to predict the probability of successful procedure in women undergoing external cephalic version”. A validated scoring system to improve success rates of external cephalic version (ECV) is of great clinical utility, as it could increase the frequency with which ECV is both offered and accepted. Breech presentation is a common indication for cesarean delivery, even more so since publication of the Term Breech trial in 2000 [1,2]. The risks of cesarean delivery include hemorrhage, cardiac arrest, renal failure, venous thromboembolism, and infection, and after a primary cesarean delivery, the likelihood of repeat cesarean delivery is estimated to be over 90% [3]. The complications of abnormal placentation in this setting are well described and associated with significant maternal morbidity and mortality [4]. Thus, external cephalic version – when successful – offers the opportunity to achieve a vertex presentation and reduce the rate of cesarean deliveries [5]. Despite this, ECV is frequently not performed [6]. Anand et al. propose the low acceptance rate among women to undergo ECV might be attributed to concerns about the safety and efficacy of the procedure [7]. They therefore developed an individualized scoring system to predict chances of procedure success. They incorporated a number of clinical and ultrasound parameters into their final model, ranging from parity and placental location to uterine tone [7]. Their model had good discrimination with an AUC of 0.782; however, a glaring omission to their model is the presence or absence of neuraxial anesthesia. Pain is a known consequence of ECV [8], and could be a deterrent to maternal acceptance of the procedure. Furthermore, it is well known that neuraxial anesthesia improves the success rate of ECV [9–14]. One study suggests that epidural anesthesia be considered in women with a previously failed ECV due to increased success in the same women when performed with an epidural [10]. It is theorized that pain relief reduces guarding and aids relaxation of the abdominal wall, which in one study was associated with decreased force applied during the ECV performed under spinal anesthesia [11]. Although neither the type of neuraxial anesthesia nor the optimal dose has been determined, the role of neuraxial anesthesia in successful ECV cannot and should not be ignored as it can increase both its safety and efficacy [5]. Any tool to increase both the frequency with which ECV is performed and its success rate could prove invaluable in reducing the number of cesarean deliveries. Anand et al. should be recognized for their development of an easy to use, inexpensive, and accessible scoring system that could target this goal. Future models should incorporate presence or absence of neuraxial anesthesia, a known predictor of successful ECV, to improve the validity and applicability of the model.