Practice Guide for Anesthetic Management of the Parturient Undergoing External Cephalic Version (ECV)

Abstract

Despite the World Health Organization’s recommendation that cesarean delivery (CD) rates not exceed 15%, one in three women in the United States have a CD. This is a 50% increase since the mid 1990’s. The Term Breech Trial resulted in a perceived prohibition of elective vaginal delivery (VD) for breech presentation (BP). BP of the fetus occurs in 3-4% of all pregnancies, accounts for 6-8% of primary CD, and 87-98% of all BPs result in CD. “…The most important determinant of the overall cesarean rate is the primary cesarean rate” (Branch & Silver, 2012, p.946). The American College of Obstetricians and Gynecologists (ACOG) recommends offering external cephalic version (ECV) to all parturients that are determined to be acceptable candidates. ECV presents a statistically safe alternative to CD for fetal BP at term when VD is desired (Collaris & Oei, 2004). Fear of pain frequently results in refusal of ECV and pain is a frequent reason for termination of ECV attempts. In addition to alleviating pain, central neuraxial blockade (CNB) reduces abdominal muscle tone leading to an increased success rate of ECV. Naval Hospital Camp Lejeune (NHCL) has no standard practice for involving anesthesia in the pre-procedural counseling and management of ECV candidates. The goal of this project is the development of an agency clinical practice protocol based on best evidence to guide the care of patients undergoing ECV at NHCL. Following an extensive literature review, an agency clinical practice protocol is developed and formally presented to stakeholders for future implementation based on an interprofessional care model.