Anesthesia for external cephalic version

[pgg]

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What are you all doing for versions?

As a resident, women presenting for versions nearly always had some form of neuraxial anesthesia. One of our more senior obstetricians was adamant that attempting one without anesthesia or on the soft laboring beds dramatically reduced odds of success.

In most cases, for a patient at term, we'd do these in the OR. Occasionally in a laboring room, but they preferred the hard OR beds. Combined spinal epidural with a dense surgical block from the intrathecal dose. If successful, membranes were ruptured, and she already had an epidural in place for laboring (with the flavor-of-the-day dilute LA/narcotic solution). If unsuccessful, or if anything bad happened, she was in the OR with a surgical block and a section could proceed.

For patients not at term, we'd do straight spinals, obviously with no subsequent induction of labor.


But here I am now, out of the academic world. At both the .mil gig and the civilian gig, obstetricians appear to be in the habit of attempting versions without anesthesia (or tocolytics). They seem to fail a lot.

I know ACOG guidelines favor doing versions, and there's plenty of data showing that success increases with anesthesia. I'm just surprised at the local OB practices. I did talk with one of the OBs today, and he's not opposed to anesthesia, just seemed sort of surprised that I was willing to get involved. Maybe this is the norm out of academics? Is it not worth what you can bill for the spinal?


So, two part question.

Are you guys routinely involved with versions? How about for patients not at term, who aren't going to need your services afterward?

If you are involved, are you doing surgical blocks or something less dense? I've always done surgical blocks via the spinal route, but the patients sometimes griped that they didn't like being stump-numb for the first 1-2 hours of labor after a successful version.

 

[Mman]

I will admit that in both residency and real world, I have never been involved in a version. As a resident we'd go eyeball the patients ahead of time and consent them for anesthesia in case of need for emergency c-section. That's the extent of any involvement I have ever had.

I imagine you wouldn't need surgical anesthesia. Maybe just some epidural chloroprocaine?

 

[proman]

I will admit that in both residency and real world, I have never been involved in a version. As a resident we'd go eyeball the patients ahead of time and consent them for anesthesia in case of need for emergency c-section. That's the extent of any involvement I have ever had.

I imagine you wouldn't need surgical anesthesia. Maybe just some epidural chloroprocaine?

Ditto. I bet the OBs who do them have a very low threshold for section (and I mean, super low, because most OBs have a low threshold to begin with).

 

[rsgillmd]

The ones I did during residency, we put in a CSE. Spinal dose was Bupivacaine 2.5 mg + Fentanyl 15 mcg. We did them in both the OR and in an observation area. The ones in the OR tended to succeed -- I don't know if that was because of the bed, or because the surgeons that did them in the OR were really trying to succeed. If the patients needed anything supplemental, we would use the epidural -- usually Lidocaine.

I've heard of two attempted versions at my current institution with anesthesia involvement -- I believe one was a success and another was a failure. I was not there for them so I don't know exactly what was given.

I've heard of a couple of more attempts without us involved. So I don't think your colleagues are alone -- just surprised at the low to no involvement that you seem to be describing.

There did not seem to be a good reason for when they involved us and when they didn't at my current institution.

I know it's not the best of answers, but I hope it helped to give you a different perspective.

 

[periopdoc]

It would probably be most effective with a little volatile inhaled (uterine relaxation). So what's a little aspiration risk?


- pod

 

[Bertelman]

Like Mman, we pre-op them but don't provide our services.

 

[Idiopathic]

ive done epidurals and ive done remifentanil with a little IV nitro, both were equally annoying

 

[dhb]

I've never provided analgesia for a version we are just made aware that it's happening and that they could end up in the OR for a c-section.
I believe most work since the rate of sections for traverse lie is smaller than the versions. Maybe it's the difference in BMI?

 

[IN2B8R]

The less exposure I have to OBs and their antics, the better I sleep.... Interpret that at will.

What are you all doing for versions?

As a resident, women presenting for versions nearly always had some form of neuraxial anesthesia. One of our more senior obstetricians was adamant that attempting one without anesthesia or on the soft laboring beds dramatically reduced odds of success.

In most cases, for a patient at term, we'd do these in the OR. Occasionally in a laboring room, but they preferred the hard OR beds. Combined spinal epidural with a dense surgical block from the intrathecal dose. If successful, membranes were ruptured, and she already had an epidural in place for laboring (with the flavor-of-the-day dilute LA/narcotic solution). If unsuccessful, or if anything bad happened, she was in the OR with a surgical block and a section could proceed.

For patients not at term, we'd do straight spinals, obviously with no subsequent induction of labor.


But here I am now, out of the academic world. At both the .mil gig and the civilian gig, obstetricians appear to be in the habit of attempting versions without anesthesia (or tocolytics). They seem to fail a lot.

I know ACOG guidelines favor doing versions, and there's plenty of data showing that success increases with anesthesia. I'm just surprised at the local OB practices. I did talk with one of the OBs today, and he's not opposed to anesthesia, just seemed sort of surprised that I was willing to get involved. Maybe this is the norm out of academics? Is it not worth what you can bill for the spinal?


So, two part question.

Are you guys routinely involved with versions? How about for patients not at term, who aren't going to need your services afterward?

If you are involved, are you doing surgical blocks or something less dense? I've always done surgical blocks via the spinal route, but the patients sometimes griped that they didn't like being stump-numb for the first 1-2 hours of labor after a successful version.

 

[gaspasser2004]

I place an epidural. In addition to the test dose (3 cc of 1.5% lido with epi) I give 100 mcg of fentanyl and 10 cc of 2% lido with epi). This gets the patient comfortable enough for the version and you are halfway to C-section dosing. If the version is successful, there is plenty of time for the motor block to wear off for her to push later on.

 

[Idiopathic]

the problem with that in my experience is we do them before they get to term, typically, like at 37 weeks, and then they go home. is this atypical?

 

[proman]

37 is full term. No concerns about delivering at that age.

 

[oldbearprofessor]

37 is full term. No concerns about delivering at that age.

37 weeks is full-term, but multiple recent studies (see March 2010 Am J Obstet Gynecol for several articles about this) suggest that elective induction/C-section has a greater morbidity at 37 and 38 weeks compared to 39 weeks. I can't quote the whole editorial here, but Macones summarizes this (Am J Obstet Gynecol. March 2010, page 208) with this sentence:

"Taken together, these 3 excellent articles suggest that not only do elective deliveries < 39 weeks lead to worse neonatal outcomes, but that there are likely interventions to change this practice."

So, from a neonatal perspective, we prefer waiting until 39 weeks to get the babies. I have no comment otherwise about this, just wanted to let you guys know about our current view on this topic.

 

[proman]

37 weeks is full-term, but multiple recent studies (see March 2010 Am J Obstet Gynecol for several articles about this) suggest that elective induction/C-section has a greater morbidity at 37 and 38 weeks compared to 39 weeks. I can't quote the whole editorial here, but Macones summarizes this (Am J Obstet Gynecol. March 2010, page 208) with this sentence:

"Taken together, these 3 excellent articles suggest that not only do elective deliveries < 39 weeks lead to worse neonatal outcomes, but that there are likely interventions to change this practice."

So, from a neonatal perspective, we prefer waiting until 39 weeks to get the babies. I have no comment otherwise about this, just wanted to let you guys know about our current view on this topic.

Thanks!👍

 

[oldbearprofessor]

Thanks!👍

You're welcome, I like to post on this forum every few years when the topic warrants a neonatologist.😛

Really though, this is one of those things where very well done epidemiological data all come to the same conclusion that flies in the face of decades of personal bias by lots of folks and the desire of families to have the baby sooner once "term" has been reached. Now, how do we make practice fall in line with the evidence?

 

[Idiopathic]

37 is full term. No concerns about delivering at that age.

that wasnt my point, if you were referring to my comment. im just saying thats typically why i dont place an epidural in those patients, since it isnt highly likely that they will stay for labor.

if they are difficult airway or enormous then i would do one just for the safety net of the block for the operating room, but otherwise ill just help with IV meds

 

[THP]

I'm an OB resident. We do versions usually without anesthesia but will on occasion depending on the patient. I think it works better with the epidural. We usually do them between 36 and 37 weeks. If you wait too long then it becomes less likely to be successful as the babies get big. If you do it too early not only do you risk having a preterm baby but also they may flip back. Patients usually go home after the procedure if it is successful and wait for spontaneous labor.

 

[dhb]

I'm an OB resident. We do versions usually without anesthesia but will on occasion depending on the patient. I think it works better with the epidural. We usually do them between 36 and 37 weeks. If you wait too long then it becomes less likely to be successful as the babies get big. If you do it too early not only do you risk having a preterm baby but also they may flip back. Patients usually go home after the procedure if it is successful and wait for spontaneous labor.

Why in your opinion is it more successful with an epidural? Is it because you can exert more pressure?

 

[THP]

Why in your opinion is it more successful with an epidural? Is it because you can exert more pressure?

The data is mixed on whether or not anesthesia is beneficial. Most of the randomized control trials show that it is beneficial but there were some problems with those studies. In my anecdotal experience I have been more successful with anesthesia for the reason you mentioned. It takes quite a bit of force and is very uncomfortable and if mom is fighting me by contracting her muscles and flinching it makes it that much more difficult.

Personally, if I were a woman and had a breech presentation I would opt for the c/s and take my chances with a VBAC in a future pregnancy. But we offer it to everyone and most want to give it a shot.

 

[narcusprince]

Ressurecting this post. This has become a daily part of my OB practice. Here the cocktail of choice is epidural with a surgical level of anesthesia IE T6-7 dosed with lidocaine/ Chloroprocaine. I had never done a version under regional in my residency. How exactly does providing a labor epidural increase the chances of succesful version. IE contractions stay the same or increase in tone and rate under epidural/spinal anesthesia. So a hypercontractile uterus is not the envirorment for a succesful version. Also, If the OB's want surgical anesthesia and we are dosing these as such their needs to be an anesthesia record filled out for these procedures with PACU recovery. Currently most dose the epidural/spinal and watch the OB's do the version and then leave (no record).

 

[pgg]

How exactly does providing a labor epidural increase the chances of succesful version.

It's a painful procedure. Having a good block lets the OBs really put some effort into it. I guess.

IE contractions stay the same or increase in tone and rate under epidural/spinal anesthesia.

That's what NTG is for. 🙂

So a hypercontractile uterus is not the envirorment for a succesful version. Also, If the OB's want surgical anesthesia and we are dosing these as such their needs to be an anesthesia record filled out for these procedures with PACU recovery. Currently most dose the epidural/spinal and watch the OB's do the version and then leave (no record).

All our current OBs want surgical anesthesia for these. I always insisted on doing mine in the OR. After someone had a bit of a misadventure with a high level in a labor room, now it's the dept policy that all versions getting surgical blocks get done in the OR.

 

[jwk]

Ressurecting this post. This has become a daily part of my OB practice. Here the cocktail of choice is epidural with a surgical level of anesthesia IE T6-7 dosed with lidocaine/ Chloroprocaine. I had never done a version under regional in my residency. How exactly does providing a labor epidural increase the chances of succesful version. IE contractions stay the same or increase in tone and rate under epidural/spinal anesthesia. So a hypercontractile uterus is not the envirorment for a succesful version. Also, If the OB's want surgical anesthesia and we are dosing these as such their needs to be an anesthesia record filled out for these procedures with PACU recovery. Currently most dose the epidural/spinal and watch the OB's do the version and then leave (no record).

No offense intended, but that's incredibly stupid on several different levels. Thankfully you at least realize the problem.

 

[Idiopathic]

yeah we dont do them this way, but the pain can induce labor, is my thought - block that out and you reduce the rate. ill search for it

 

[bullard]

Did many CSEs for version in residency, mostly successful. Always in a labor room, only had to crash c/s once. 2.5 mg of bupiv plus 15 mcg fentanyl. OB would often induce there and then if successful. Additional 2 percent lido (5 mL) is a good idea.