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Listen to the patient: A Successful External Cephalic Version (ECV) under Neuraxial Anesthesia and Subsequent Vaginal Birth After Cesarean Delivery (VBAC) in a Grand-Multiparous Patient
Abstract Number: F4C-8
Abstract Type: Case Report/Case Series
Studies support the use of neuraxial anesthesia as safe and effective to improve the success of external cephalic version (ECV).1 Recent literature is abundant on ECV outcomes and models to predict ECV success and ultimately vaginal delivery (VD) have emerged.
We report here the case of a grand-multipara scheduled for a 3rd cesarean delivery (CD) in the context of breech presentation who insisted on having an ECV attempted.
A 42 yo G13P11 at 38 weeks for fetal monitoring of variable decelerations during an office non-stress test, who was scheduled for a 3rd CD (breech) the following week. Upon admission, irregular contractions with 1cm cervical dilation, anterior placenta, amniotic-fluid index (AFI) 16, and fetus in breech position were noted. She had 3 normal VD (1996/97/99), 1 CD in 2000, 1 VBAC 2002, 1 CD 2004, 1 VBAC 2006, SAB 2007 (twins), and 4 VBAC (2008/10/12/13). With her most recent VD, after induction of labor (IOL) for oligohydramnios, a postpartum hemorrhage (PPH) required blood products. The 2 CD were for breech presentation, without attempted ECVs.
This time, the patient requested the possibility of an ECV, and after review of all possible complications (uterine rupture, placental abruption, fetal compromise, increased risk for PPH) an ECV was agreed upon with a plan for IOL if successful, and immediate CD if unsuccessful. A combined spinal-epidural (CSE) was placed for ECV (spinal hyperbaric bupivacaine 7.5mg and fentanyl 15mcg), to follow with PCEA analgesia if IOL or anesthesia if CD. A T8 dermatomal level was observed prior to 1st ECV attempt. Additional epidural dosing (lidocaine 2% 5ml) with improved tolerance to the abdominal manipulation, resulted in successful ECV with vertex presentation after 2nd attempt. IOL with oxytocin and artificial rupture of membranes followed, and the patient delivered vaginally within 8 hours. No post-partum complications were noted.
Neuraxial anesthesia plays a key role in improving ECV success rates, although a recent study demonstrated a 'goldilocks' effect with higher doses not necessarily providing better outcomes.2,3 We opted for a relatively high spinal dose, anticipating a possible urgent CD which would require rapid conversion to surgical anesthesia. Indeed, while placental abruption or uterine rupture are always possible, ECV with neuraxial analgesia was recently shown to result in higher risk for urgent CD.4
Multiparity has been shown to be the single most important factor associated with success.5 In this highly grand-multipara, placental location, AFI and anesthesia clearly increased the odds for ECV success. Of note, recent literature encourages ECV in women with previous CD if otherwise eligible for a trial of labor.6
1. Am J Obstet Gynecol 2016;215:276-86
2. Anesthesiol 2017;127:625-32
3. Anesthesiol 2017;127:596-8
4. Int J Obstet Anesth 2017;31:57-62
5. Obstet Gynecol Int 2017:3028398
6. Int J Gynaecol Obstet 2017:138:79-83