• Anesthesiology · Oct 2017

    Randomized Controlled Trial

    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, and John T Sullivan.
    • From the Department of Anesthesiology (L.A.C., J.R.B., N.H., P.T., F.M.P., J.F., R.J.M., J.T.S.) and Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology (S.E.G.), Northwestern University Feinberg School of Medicine, Chicago, Illinois; Current Position: Anesthesia Practice Consultants, Grand Rapids, Michigan (L.A.C.).
    • Anesthesiology. 2017 Oct 1; 127 (4): 625-632.

    BackgroundBreech 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.MethodsWe 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.ResultsA 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).ConclusionsA 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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