The Role of Anesthesiologists in Facilitating External Cephalic Versions

It is time to ensure that women have access to anesthesia services, both to potentially increase the likelihood of version success and also to ensure that women do not unnecessarily suffer during their procedure as Kim Kardashian West did.
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Anesthetist administering gas to patient
Anesthetist administering gas to patient

On Saturday, Kim Kardashian and Kanye West welcomed their baby boy to the world. Kardashian delivered vaginally after she underwent an external cephalic version, commonly known as a version. A version is a procedure in which a breech baby is manually turned to a vertex, or head down, position. She described the procedure as extremely painful, "perhaps more painful than childbirth." She stated that she was not given any pain medicine for the procedure.

The rising cesarean delivery rate in the United States (U.S.) is an area of public health concern. The cesarean delivery rate in the U.S. is now above 32 percent, a dramatic increase from 21 percent in 1996. The World Health Organization states the ideal cesarean delivery rate should be 10-15 percent, although this number has recently been called into question as being too low. The concern with cesarean deliveries is that they expose the mother and fetus to increased morbidity compared to vaginal deliveries. Another concern is that many women with a prior cesarean delivery will have repeat cesarean deliveries, which further increase the risk of complications for the mother.

A breech presentation is an indication for a cesarean delivery. Approximately 3-4 percent of all babies are in a breech position. Most obstetric providers will schedule a cesarean delivery, as opposed to attempting a vaginal delivery for a breech infant, because neonatal morbidity is lower when the baby is delivered via cesarean. Approximately 95 percent of all breech infants are delivered via cesarean, resulting in approximately 120,000 cesarean deliveries per year for this indication alone.

External cephalic version is the only clinical intervention with Level 1 evidence for reducing cesarean deliveries. During the procedure, one to two providers apply pressure to the abdomen until the baby rolls into a vertex position. The success rate is approximately 50-70 percent, with certain maternal factors being associated with increased success. Both the mother and infant are monitored during the procedure, but potential rare risks to the fetus include: inducing labor, placental abruption, uterine rupture, or fetal distress, which may result in a cesarean delivery.

There are many reasons that women with a breech infant may not have a version performed. In one qualitative study where pregnant women and healthcare providers were interviewed about attitudes and preferences towards versions, many patients had negative attitudes about the procedure. There were concerns about the procedure itself, risks to the fetus, as well as concerns about the pain associated with the procedure. Providers that were interviewed reported counseling women to use versions; however, a study of gynecologists and midwives in the Netherlands found that not all providers counseled patients about the option of a version, and the likelihood of recommending a version varied with the providers' perceived ability to perform the technique.

Anesthesiologists may have a role in increasing the success of external cephalic versions. While people often associate epidural pain relief with labor, epidurals may also be used to facilitate versions. A meta-analysis of randomized controlled trials that compared neuraxial anesthesia (spinal, epidural, or combined spinal-epidural anesthesia) to no anesthesia (or intravenous pain medications alone), found that using anesthesia increased the likelihood of version success. The likelihood of success further increased with increasing density of the block (i.e. a dose that was considered a surgical anesthetic was more likely to result in a successful version than analgesic doses, doses that only removed pain). Neuraxial anesthesia provides patient comfort while the obstetricians attempt to manipulate the baby's position. Furthermore, the use of neuraxial anesthesia is cost-effective, as the cost of the anesthesia service is less than the cost of a cesarean delivery.

The Council on Patient Safety in Women's Health Care is comprised of organizations that work together to improve healthcare for all women. The Council has created several bundles that contain evidence-based recommendations intended to improve patient outcomes. In the recently released patient safety bundle entitled, "Safe Reduction of Primary Cesarean Births: Supporting Intended Vaginal Births," it is recommended that hospitals have protocols and providers available with the expertise to facilitate external cephalic versions. Certainly, having obstetricians with expertise in the versions is a must, but also having anesthesiologists to facilitate neuraxial anesthesia should be necessary.

To be sure, not all mothers will want a version. Everyone with a breech infant should have a discussion with their obstetrician to see whether or not they are a candidate for a version; learn the risks and benefits of a version versus those of a scheduled cesarean delivery; and then make an informed decision about how they want to proceed. However, encouraging women to undergo versions is a good first step towards reducing the number of cesarean deliveries in the United States. It is time to ensure that women have access to anesthesia services, both to potentially increase the likelihood of version success and also to ensure that women do not unnecessarily suffer during their procedure as Kim Kardashian West did.

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