Effect of Intrathecal Bupivacaine Dose on the Success of External Cephalic Version for Breech Presentation

A Prospective, Randomized, Blinded Clinical Trial

Laurie A. Chalifoux, Jeanette R. Bauchat, Nicole Higgins, Paloma Toledo, Feyce M. Peralta, Jason Farrer, Susan E. Gerber, Robert J. McCarthy, John T. Sullivan*

*Corresponding author for this work

Research output: Contribution to journalArticle

2 Citations (Scopus)

Abstract

Background: Breech presentation is a leading cause of cesarean delivery. The use of neuraxial anesthesia increases the success rate of external cephalic version procedures for breech presentation and reduces cesarean delivery rates for fetal malpresentation. Meta-analysis suggests that higher-dose neuraxial techniques increase external cephalic version success to a greater extent than lower-dose techniques, but no randomized study has evaluated the dose-response effect. We hypothesized that increasing the intrathecal bupivacaine dose would be associated with increased external cephalic version success. Methods: We conducted a randomized, double-blind trial to assess the effect of four intrathecal bupivacaine doses (2.5, 5.0, 7.5, 10.0 mg) combined with fentanyl 15 μg on the success rate of external cephalic version for breech presentation. Secondary outcomes included mode of delivery, indication for cesarean delivery, and length of stay. 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.

Original languageEnglish (US)
Pages (from-to)625-632
Number of pages8
JournalAnesthesiology
Volume127
Issue number4
DOIs
StatePublished - Oct 1 2017

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Fetal Version
Breech Presentation
Bupivacaine
Randomized Controlled Trials
Labor Presentation
Fentanyl
Meta-Analysis
Length of Stay
Anesthesia
Head

ASJC Scopus subject areas

  • Anesthesiology and Pain Medicine

Cite this

@article{14de2770184a4fe49b4c71ee323d4c7c,
title = "Effect of Intrathecal Bupivacaine Dose on the Success of External Cephalic Version for Breech Presentation: A Prospective, Randomized, Blinded Clinical Trial",
abstract = "Background: Breech presentation is a leading cause of cesarean delivery. The use of neuraxial anesthesia increases the success rate of external cephalic version procedures for breech presentation and reduces cesarean delivery rates for fetal malpresentation. Meta-analysis suggests that higher-dose neuraxial techniques increase external cephalic version success to a greater extent than lower-dose techniques, but no randomized study has evaluated the dose-response effect. We hypothesized that increasing the intrathecal bupivacaine dose would be associated with increased external cephalic version success. Methods: We conducted a randomized, double-blind trial to assess the effect of four intrathecal bupivacaine doses (2.5, 5.0, 7.5, 10.0 mg) combined with fentanyl 15 μg on the success rate of external cephalic version for breech presentation. Secondary outcomes included mode of delivery, indication for cesarean delivery, and length of stay. 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.",
author = "Chalifoux, {Laurie A.} and Bauchat, {Jeanette R.} and Nicole Higgins and Paloma Toledo and Peralta, {Feyce M.} and Jason Farrer and Gerber, {Susan E.} and McCarthy, {Robert J.} and Sullivan, {John T.}",
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language = "English (US)",
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journal = "Anesthesiology",
issn = "0003-3022",
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Effect of Intrathecal Bupivacaine Dose on the Success of External Cephalic Version for Breech Presentation : A Prospective, Randomized, Blinded Clinical Trial. / Chalifoux, Laurie A.; Bauchat, Jeanette R.; Higgins, Nicole; Toledo, Paloma; Peralta, Feyce M.; Farrer, Jason; Gerber, Susan E.; McCarthy, Robert J.; Sullivan, John T.

In: Anesthesiology, Vol. 127, No. 4, 01.10.2017, p. 625-632.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Effect of Intrathecal Bupivacaine Dose on the Success of External Cephalic Version for Breech Presentation

T2 - A Prospective, Randomized, Blinded Clinical Trial

AU - Chalifoux, Laurie A.

AU - Bauchat, Jeanette R.

AU - Higgins, Nicole

AU - Toledo, Paloma

AU - Peralta, Feyce M.

AU - Farrer, Jason

AU - Gerber, Susan E.

AU - McCarthy, Robert J.

AU - Sullivan, John T.

PY - 2017/10/1

Y1 - 2017/10/1

N2 - Background: Breech presentation is a leading cause of cesarean delivery. The use of neuraxial anesthesia increases the success rate of external cephalic version procedures for breech presentation and reduces cesarean delivery rates for fetal malpresentation. Meta-analysis suggests that higher-dose neuraxial techniques increase external cephalic version success to a greater extent than lower-dose techniques, but no randomized study has evaluated the dose-response effect. We hypothesized that increasing the intrathecal bupivacaine dose would be associated with increased external cephalic version success. Methods: We conducted a randomized, double-blind trial to assess the effect of four intrathecal bupivacaine doses (2.5, 5.0, 7.5, 10.0 mg) combined with fentanyl 15 μg on the success rate of external cephalic version for breech presentation. Secondary outcomes included mode of delivery, indication for cesarean delivery, and length of stay. 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.

AB - Background: Breech presentation is a leading cause of cesarean delivery. The use of neuraxial anesthesia increases the success rate of external cephalic version procedures for breech presentation and reduces cesarean delivery rates for fetal malpresentation. Meta-analysis suggests that higher-dose neuraxial techniques increase external cephalic version success to a greater extent than lower-dose techniques, but no randomized study has evaluated the dose-response effect. We hypothesized that increasing the intrathecal bupivacaine dose would be associated with increased external cephalic version success. Methods: We conducted a randomized, double-blind trial to assess the effect of four intrathecal bupivacaine doses (2.5, 5.0, 7.5, 10.0 mg) combined with fentanyl 15 μg on the success rate of external cephalic version for breech presentation. Secondary outcomes included mode of delivery, indication for cesarean delivery, and length of stay. 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.

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