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Cynthia A Wong - One of the best experts on this subject based on the ideXlab platform.

  • united states state level variation in the use of Neuraxial Analgesia during labor for pregnant women
    Anesthesiology, 2018
    Co-Authors: Alexander J Butwick, Cynthia A Wong, Jason Bentley, Jonathan M Snowden
    Abstract:

    Importance Neuraxial labor Analgesia is recognized as the most effective method of providing pain relief during labor. Little is known about variation in the rates of Neuraxial Analgesia across US states. Identifying the presence and extent of variation may provide insights into practice variation and may indicate where access to Neuraxial Analgesia is inadequate. Objective To test the hypothesis that variation exists in Neuraxial labor Analgesia use among US states. Design, Setting, and Participants Retrospective, population-based, cross-sectional analysis using US birth certificate data. Participants were 2 625 950 women who underwent labor in 2015. Main Outcomes and Measures State-specific prevalence of Neuraxial Analgesia per 100 women who underwent labor and variability in Neuraxial Analgesia use among states, assessed using multilevel multivariable regression modeling with the median odds ratio and the intraclass correlation coefficient to evaluate variation by state. Results In the study population of 2 625 950 women, 0.1% (n = 2010) were younger than 15 years, 7.0% (n = 183 546) were between the ages of 15 and 19 years, 23.6% (n = 620 118) were between the ages of 20 and 24 years, 29.6% (n = 777 957) were between the ages of 25 and 29 years, 26.0% (n = 683 656) were between the ages of 30 and 34 years, 11.4% (n = 298 237) were between the ages of 35 and 39 years, 2.2% (n = 57 130) were between the ages of 40 and 44 years, and 0.1% (n = 3296) were between the ages of 45 and 54 years. More than 90% were privately insured or insured with Medicaid. Neuraxial Analgesia was used by 73.1% (n = 1 920 368) of women. After adjustment for antepartum, obstetric, and intrapartum factors, Maine had the lowest Neuraxial Analgesia prevalence (36.6%; 95% CI, 33.2%-40.1%) and Nevada the highest (80.1%; 95% CI, 78.3%-81.7%). The adjusted median odds ratio was 1.5 (95% CI, 1.4-1.6), and the intraclass correlation coefficient was 5.4% (95% CI, 4.0%-7.9%). Conclusions and Relevance Results of this study suggest that a small portion of the overall variation in Neuraxial Analgesia use is explained by US states. Unmeasured patient-level and hospital-level factors likely account for a large portion of the variation between states. Efforts should be made to understand what the main reasons are for this variation and whether the variation influences maternal or perinatal outcomes.

  • maternal body mass index and use of labor Neuraxial Analgesia a population based retrospective cohort study
    Anesthesiology, 2018
    Co-Authors: Alexander J Butwick, Cynthia A Wong
    Abstract:

    WHAT WE ALREADY KNOW ABOUT THIS TOPIC: WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Neuraxial labor Analgesia may benefit obese women by optimizing cardiorespiratory function and mitigating complications related to emergency general anesthesia. We hypothesized that obese women have a higher rate of Neuraxial Analgesia compared with nonobese parturients. METHODS: Using U.S. natality data, our cohort comprised 17,220,680 deliveries, which accounts for 61.5% of 28 million births in the United States between 2009 and 2015. We examined the relationships between body mass index class and Neuraxial labor Analgesia, adjusting for sociodemographic, antenatal, pregnancy, and peripartum factors. RESULTS: The study cohort comprised 17,220,680 women; 0.1% were underweight, 12.7% were normal body mass index, 37% were overweight, and 28.3%, 13.5%, and 8.4% were obesity class I, II, and III, respectively. Rates of Neuraxial Analgesia by body mass index class were as follows: underweight, 59.7% (9,030/15,128); normal body mass index, 68.1% (1,487,117/2,182,797); overweight, 70.3% (4,476,685/6,368,656); obesity class I, 71.8% (3,503,321/4,881,938); obesity class II, 73.4% (1,710,099/2,330,028); and obesity class III, 75.6% (1,089,668/1,442,133). Compared to women with normal body mass index, the likelihood of receiving Neuraxial Analgesia was slightly increased for overweight women (adjusted relative risk, 1.02; 95% CI, 1.02 to 1.02), obese class I (adjusted relative risk, 1.04; 95% CI, 1.04 to 1.04), obese class II (adjusted relative risk, 1.05; 95% CI, 1.05 to 1.05), and obese class III (adjusted relative risk, 1.06; 95% CI, 1.06 to 1.06). CONCLUSIONS: Our findings suggest that the likelihood of receiving Neuraxial Analgesia is only marginally increased for morbidly obese women compared to women with normal body mass index.

  • interscapular pain associated with Neuraxial labour Analgesia a case series
    Canadian Journal of Anaesthesia-journal Canadien D Anesthesie, 2016
    Co-Authors: Cynthia A Wong, Paloma Toledo, Thomas T Klumpner, Jason Farrer
    Abstract:

    Purpose Some labouring women with Neuraxial labour Analgesia experience severe upper back pain, typically between the scapulae. This pain may complicate management of Neuraxial Analgesia/anesthesia, and it may also have important implications for the mode of delivery. This case series describes the clinical course and management of three patients who developed interscapular pain associated with Neuraxial labour Analgesia.

  • a qualitative analysis of parturients perspectives on Neuraxial labor Analgesia
    International Journal of Obstetric Anesthesia, 2013
    Co-Authors: Paloma Toledo, Cynthia A Wong, Feyce Peralta, William A Grobman, Romana Hasnainwynia
    Abstract:

    Abstract Background The decision to use, or not use, Neuraxial Analgesia is complex and likely multi-factorial. The objectives of this study were to understand parturients' concerns about Neuraxial Analgesia, and the reasons for not anticipating the use of Neuraxial Analgesia using qualitative methodology. Methods English-speaking, term parturients, who had not requested or received labor Analgesia, were recruited for this mixed-methods study. In addition to a quantitative survey, the results of which have been published elsewhere, women were asked open-ended questions regarding concerns about Neuraxial Analgesia and reasons for not anticipating its use. Answers were recorded verbatim and analyzed using qualitative methodology. Results Interviews were conducted with 509 women. Thirty-nine percent of patients expressed some concern about Neuraxial Analgesia. These concerns were thematically represented by misunderstandings about Neuraxial Analgesia, general fears about the procedure, and lack of trust in providers. Many of the concerns were misunderstandings that were not supported by the medical literature. Of the 129 patients who did not anticipate using Neuraxial Analgesia, 23% stated that this was because they desired a natural childbirth and/or control over their labor experience, whereas 46% cited concerns about the procedure and its complications as the basis for their decision. Conclusion Many women who anticipate not using Neuraxial Analgesia may be basing their decision on an inaccurate understanding of the risks of the procedure. Improved patient education and counseling that target specific areas of concern may address these misunderstandings.

  • racial and ethnic disparities in Neuraxial labor Analgesia
    Anesthesia & Analgesia, 2012
    Co-Authors: Paloma Toledo, Cynthia A Wong, William A Grobman, Joe Feinglass, Romana Hasnainwynia
    Abstract:

    BACKGROUND:Racial and ethnic disparities in the treatment of pain have been well documented, and there is evidence of such disparities in Neuraxial Analgesia use. Our objectives of this study were to analyze racial/ethnic disparities in Neuraxial Analgesia use, as well as anticipated use, among labo

Vincenzo Berghella - One of the best experts on this subject based on the ideXlab platform.

  • delayed versus immediate pushing in the second stage of labor in women with Neuraxial Analgesia a systematic review and meta analysis of randomized controlled trials
    American Journal of Obstetrics and Gynecology, 2020
    Co-Authors: Gabriele Saccone, Daniele Di Mascio, F Bellussi, Huda B Alkouatly, Roberto Brunelli, Pierluigi Benedetti Panici, Marco Liberati, F Dantonio, Vincenzo Berghella
    Abstract:

    Abstract Objective The aim of this systematic review and meta-analysis of randomized controlled trials (RCTs) was to evaluate the effect of delayed versus immediate pushing in the second stage of labor on mode of delivery and other outcomes in women with Neuraxial Analgesia. Data sources The research was conducted using MEDLINE, EMBASE, Web of Sciences, Scopus, ClinicalTrial.gov, OVID and Cochrane Library as electronic databases, from the inception of each database to August 2019. No restrictions for language or geographic location were applied. Study eligibility criteria Selection criteria included only RCTs of pregnant women randomized to either delayed or immediate pushing during the second stage of labor. Study appraisal and synthesis methods The primary outcome was mode of delivery. The summary measures were reported as relative risk (RR) or as mean difference (MD) with 95% confidence intervals (CI) using the random effects model of DerSimonian and Laird. I-squared (Higgins I2) greater than 0% was used to identify heterogeneity. Results Twelve RCTs, including 5,445 women with Neuraxial Analgesia randomized to delayed versus immediate pushing during the second stage of labor were included in the meta-analysis. Of the 5,445 women included in the meta-analysis, 2,754 were randomized to the delayed pushing group and 2,691 to the immediate pushing group. No significant difference between delayed and immediate pushing was found for spontaneous vaginal delivery (80.9% vs 78.3%; RR 1.05, 95% CI 1.00 to 1.10; 12 RCTs, 5,540 women), operative vaginal delivery (12.8% vs 14.6%; RR 0.89, 95% CI 0.75 to 1.08; 11 RCTs, 5,395 women), and cesarean delivery (6.9% vs 7.9%; RR 0.89, 95% CI 0.73 to 1.07; 11 RCTs; 5,395 women). Women randomized to the delayed pushing group had a significantly shorter length of active pushing (MD -27.54 minutes; 95% CI -43.04 to -12.04; 7 RCTs, 4,737 women) at the expense of a significantly longer overall duration of the second stage of labor (MD 46.17 minutes; 95% CI 32.63 to 59.71; 8 studies; 4,890 women). The incidence of chorioamnionitis (9.1% vs 6.6%; RR 1.37, 95% CI 1.04 to 1.81; 1 RCT, 2,404 women) and low umbilical cord pH (2.7% vs 1.3%; RR 2.00, 95% CI 1.30 to 3.07; 5 RCTs, 4,549 women) were significantly higher in the delayed pushing group. Conclusions In women with spontaneous or induced labor at term with Neuraxial Analgesia, delayed pushing in the second stage does not affect the mode of delivery, although it reduces the time of active pushing at the expense of a longer second stage. This prolongation of labor was associated with a higher incidence of chorioamnionitis and low umbilical cord pH. Based on these findings, delayed pushing cannot be routinely advocated for the management of the second stage.

  • Neuraxial Analgesia to Increase the Success Rate of External Cephalic Version: A Systematic Review and Meta-Analysis of Randomized Controlled Trials
    Obstetric Anesthesia Digest, 2017
    Co-Authors: Elena Rita Magro-malosso, Gabriele Saccone, Mariarosaria Di Tommaso, Michele Mele, Vincenzo Berghella
    Abstract:

    (Am J Obstet Gynecol. 2016;215(3):276–286)The objective of this study was to gauge the effectiveness of Neuraxial Analgesia in increasing the success rate of external cephalic version. Breech or transverse presentations of the fetus is one of the most common causes for the increased cesarean deliver

  • Neuraxial Analgesia to increase the success rate of external cephalic version a systematic review and meta analysis of randomized controlled trials
    American Journal of Obstetrics and Gynecology, 2016
    Co-Authors: Elena Rita Magromalosso, Gabriele Saccone, Mariarosaria Di Tommaso, Michele Mele, Vincenzo Berghella
    Abstract:

    Background External cephalic version is a medical procedure in which the fetus is externally manipulated to assume the cephalic presentation. The use of Neuraxial Analgesia for facilitating the version has been evaluated in several randomized clinical trials, but its potential effects are still controversial. Objective The objective of the study was to evaluate the effectiveness of Neuraxial Analgesia as an intervention to increase the success rate of external cephalic version. Data Sources Searches were performed in electronic databases with the use of a combination of text words related to external cephalic version and Neuraxial Analgesia from the inception of each database to January 2016. Study Eligibility Criteria We included all randomized clinical trials of women, with a gestational age ≥36 weeks and breech or transverse fetal presentation, undergoing external cephalic version who were randomized to Neuraxial Analgesia, including spinal, epidural, or combined spinal-epidural techniques (ie, intervention group) or to a control group (either intravenous Analgesia or no treatment). Study Appraisal and Synthesis Methods The primary outcome was the successful external cephalic version. The summary measures were reported as relative risk or as mean differences with a 95% confidence interval. Tabulation, Integration, and Results Nine randomized clinical trials (934 women) were included in this review. Women who received Neuraxial Analgesia had a significantly higher incidence of successful external cephalic version (58.4% vs 43.1%; relative risk, 1.44, 95% confidence interval, 1.27–1.64), cephalic presentation in labor (55.1% vs 40.2%; relative risk, 1.37, 95% confidence interval, 1.08–1.73), and vaginal delivery (54.0% vs 44.6%; relative risk, 1.21, 95% confidence interval, 1.04–1.41) compared with those who did not. Women who were randomized to the intervention group also had a significantly lower incidence of cesarean delivery (46.0% vs 55.3%; relative risk, 0.83, 95% confidence interval, 0.71–0.97), maternal discomfort (1.2% vs 9.3%; relative risk, 0.12, 95% confidence interval, 0.02–0.99), and lower pain, assessed by the visual analog scale pain score (mean difference, –4.52 points, 95% confidence interval, –5.35 to 3.69) compared with the control group. The incidences of emergency cesarean delivery (1.6% vs 2.5%; relative risk, 0.63, 95% confidence interval, 0.24–1.70), transient bradycardia (11.8% vs 8.3%; relative risk, 1.42, 95% confidence interval, 0.72–2.80), nonreassuring fetal testing, excluding transient bradycardia, after external cephalic version (6.9% vs 7.4%; relative risk, 0.93, 95% confidence interval, 0.53–1.64), and abruption placentae (0.4% vs 0.4%; relative risk, 1.01, 95% confidence interval, 0.06–16.1) were similar. Conclusion Administration of Neuraxial Analgesia significantly increases the success rate of external cephalic version among women with malpresentation at term or late preterm, which then significantly increases the incidence of vaginal delivery.

David J Birnbach - One of the best experts on this subject based on the ideXlab platform.

  • magnetic resonance imaging findings after uneventful continuous infusion Neuraxial Analgesia a prospective study to determine whether epidural infusion produces pathologic magnetic resonance imaging findings
    Anesthesia & Analgesia, 2010
    Co-Authors: Elyad M Davidson, Evelyn Sklar, Rita Bhatia, Lester Garcia, Kristopher L Arheart, Yehuda Ginosar, David J Birnbach
    Abstract:

    BACKGROUND: Magnetic resonance imaging (MRI) is considered the preferred diagnostic tool to determine whether postepidural neurologic symptoms are due to hematoma or abscess. However, there is currently no published information regarding the normal appearance of a MRI after a continuous epidural infusion. In this prospective cohort study, we defined the characteristic appearance of MRI findings after uneventful epidural Analgesia. METHODS: Thirty women were prospectively enrolled to undergo a lumbar MRI after labor and delivery. The study group consisted of 15 women who received Neuraxial Analgesia with a combined spinal epidural technique followed by continuous epidural infusion, whereas the control group included 15 women who delivered without receiving Neuraxial Analgesia. All patients received a MRI within 12 h of delivery via a 1.5T scanner. MRIs were reviewed by two neuroradiologists who were blinded to the patient's study group allocation and asked to document the presence or absence of fluid collection, air collection, or soft tissue abnormalities. RESULTS: There were no radiologically significant fluid collections, hematomas, or mass effects noted on the thecal sac of any of the 30 MRI studies. A small amount of epidural air was seen in 77% of MRI studies after epidural Analgesia, but there was no indention on the thecal sac. CONCLUSIONS: The lack of significant collections or mass effects seen in the MRIs of our patients after continuous infusion of epidural Analgesia suggests that the presence of these findings in a patient with new neurologic symptoms after administration of epidural Analgesia should be considered pathologic and warrant immediate attention.

  • progress in Analgesia for labor focus on Neuraxial blocks
    International Journal of Women's Health, 2009
    Co-Authors: Sudharma J Ranasinghe, David J Birnbach
    Abstract:

    Neuraxial Analgesia is widely accepted as the most effective and the least depressant method of providing pain relief in labor. Over the last several decades Neuraxial labor Analgesia techniques and medications have progressed to the point now where they provide high quality pain relief with minimal side effects to both the mother and the fetus while maximizing the maternal autonomy possible for the parturient receiving Neuraxial Analgesia. The introduction of the combined spinal epidural technique for labor has allowed for the rapid onset of Analgesia with minimal motor blockade, therefore allowing the comfortable parturient to ambulate. Patient-controlled epidural Analgesia techniques have evolved to allow for more flexible Analgesia that is tailored to the individual needs of the parturient and effective throughout the different phases of labor. Computer integrated systems have been studied to provide seamless Analgesia from induction of Neuraxial block to delivery. New adjuvant drugs that improve the effectiveness of Neuraxial labor Analgesia while decreasing the side effects that may occur due to high dose of a single drug are likely to be added to future labor Analgesia practice. Bupivacaine still remains a popular choice of local anesthetic for labor Analgesia. New local anesthetics with less cardiotoxicity have been introduced, but their cost effectiveness in the current labor Analgesia practice has been questioned.

  • Anesthesia Complications in the Birthplace: Is the Neuraxial Block Always to Blame?
    Clinics in Perinatology, 2008
    Co-Authors: David J Birnbach, J. Sudharma Ranasinghe
    Abstract:

    This article highlights the common and some of the very serious complications that may occur following Neuraxial Analgesia for labor and delivery, including headache, backache, infection, hypotension, and hematoma. Total spinal and failed block also are discussed, as are complications unique to epidural anesthesia, such as the intravascular injection of large volumes of local anesthetic (causing seizure or cardiac arrest) and accidental dural puncture.

  • neurologic complications of Neuraxial Analgesia for labor
    Current Opinion in Anesthesiology, 2005
    Co-Authors: David J Birnbach, Marcelle Hernandez, Andre A J Van Zundert
    Abstract:

    Purpose of reviewIn today's anesthesia practice, provision of Neuraxial anesthesia and Analgesia is increasing. Along with the patient's fear of paralysis that accompanies placement of a needle near the spinal cord, any subsequent nerve deficit is usually blamed on the Neuraxial block provided. Know

Roshan Fernando - One of the best experts on this subject based on the ideXlab platform.

  • Neuraxial labor Analgesia a focused narrative review of the 2017 literature
    Current Opinion in Anesthesiology, 2018
    Co-Authors: Mitko Kocarev, Fouzia Khalid, Fatima Khatoon, Roshan Fernando
    Abstract:

    Purpose of reviewNeuraxial labor Analgesia remains the most effective and one of the most commonly utilized methods for pain relief during labor. This narrative review article is a summary of the literature published in 2017 on Neuraxial Analgesia for labor.Recent findingsFrom a total of 41 identifi

  • central Neuraxial Analgesia for labor an update of the literature
    Pain management, 2017
    Co-Authors: Serena Sodha, Alexandra Reeve, Roshan Fernando
    Abstract:

    : Numerous techniques are in use to provide Analgesia for labor, of which central Neuraxial block is widely considered superior to non-Neuraxial options. Central Neuraxial techniques have evolved over many years to provide greater efficacy, safety and maternal satisfaction. This narrative review focuses on the literature relating to central Neuraxial labor Analgesia from the past 5 years, from November 2010 to October 2015. We discuss the evidence related to the various central Neuraxial techniques used, the increasingly widespread use of ultrasound guidance and the evidence surrounding other novel methods of central Neuraxial block insertion. The timing of institution of central Neuraxial Analgesia in labor is considered, as are the advances in maintenance regimens for labor Analgesia.

  • update on modern Neuraxial Analgesia in labour a review of the literature of the last 5 years
    Anaesthesia, 2011
    Co-Authors: C Loubert, A Hinova, Roshan Fernando
    Abstract:

    Summary Several strategies and alternative therapies have been used to provide Analgesia for labour pain. Over the last few years, a number of improvements have enhanced the efficacy and safety of Neuraxial Analgesia and ultimately have improved mothers’ satisfaction with their birth experience. As labour Analgesia is a field of obstetric anaesthesia that is rapidly evolving, this review is an update, from a clinical point of view, of developments over the last 5‐7 years. We discuss advantages and controversies related to combined spinal-epidural Analgesia, patient controlled epidural Analgesia and the integration of computer systems into analgesic modalities. We also review the recent literature on future clinical and research perspectives including ultrasound guided Neuraxial block placement, epidural adjuvants and pharmacogenetics. We finally look at the latest work with regards to epidural Analgesia and breastfeeding.

Gabriele Saccone - One of the best experts on this subject based on the ideXlab platform.

  • delayed versus immediate pushing in the second stage of labor in women with Neuraxial Analgesia a systematic review and meta analysis of randomized controlled trials
    American Journal of Obstetrics and Gynecology, 2020
    Co-Authors: Gabriele Saccone, Daniele Di Mascio, F Bellussi, Huda B Alkouatly, Roberto Brunelli, Pierluigi Benedetti Panici, Marco Liberati, F Dantonio, Vincenzo Berghella
    Abstract:

    Abstract Objective The aim of this systematic review and meta-analysis of randomized controlled trials (RCTs) was to evaluate the effect of delayed versus immediate pushing in the second stage of labor on mode of delivery and other outcomes in women with Neuraxial Analgesia. Data sources The research was conducted using MEDLINE, EMBASE, Web of Sciences, Scopus, ClinicalTrial.gov, OVID and Cochrane Library as electronic databases, from the inception of each database to August 2019. No restrictions for language or geographic location were applied. Study eligibility criteria Selection criteria included only RCTs of pregnant women randomized to either delayed or immediate pushing during the second stage of labor. Study appraisal and synthesis methods The primary outcome was mode of delivery. The summary measures were reported as relative risk (RR) or as mean difference (MD) with 95% confidence intervals (CI) using the random effects model of DerSimonian and Laird. I-squared (Higgins I2) greater than 0% was used to identify heterogeneity. Results Twelve RCTs, including 5,445 women with Neuraxial Analgesia randomized to delayed versus immediate pushing during the second stage of labor were included in the meta-analysis. Of the 5,445 women included in the meta-analysis, 2,754 were randomized to the delayed pushing group and 2,691 to the immediate pushing group. No significant difference between delayed and immediate pushing was found for spontaneous vaginal delivery (80.9% vs 78.3%; RR 1.05, 95% CI 1.00 to 1.10; 12 RCTs, 5,540 women), operative vaginal delivery (12.8% vs 14.6%; RR 0.89, 95% CI 0.75 to 1.08; 11 RCTs, 5,395 women), and cesarean delivery (6.9% vs 7.9%; RR 0.89, 95% CI 0.73 to 1.07; 11 RCTs; 5,395 women). Women randomized to the delayed pushing group had a significantly shorter length of active pushing (MD -27.54 minutes; 95% CI -43.04 to -12.04; 7 RCTs, 4,737 women) at the expense of a significantly longer overall duration of the second stage of labor (MD 46.17 minutes; 95% CI 32.63 to 59.71; 8 studies; 4,890 women). The incidence of chorioamnionitis (9.1% vs 6.6%; RR 1.37, 95% CI 1.04 to 1.81; 1 RCT, 2,404 women) and low umbilical cord pH (2.7% vs 1.3%; RR 2.00, 95% CI 1.30 to 3.07; 5 RCTs, 4,549 women) were significantly higher in the delayed pushing group. Conclusions In women with spontaneous or induced labor at term with Neuraxial Analgesia, delayed pushing in the second stage does not affect the mode of delivery, although it reduces the time of active pushing at the expense of a longer second stage. This prolongation of labor was associated with a higher incidence of chorioamnionitis and low umbilical cord pH. Based on these findings, delayed pushing cannot be routinely advocated for the management of the second stage.

  • Neuraxial Analgesia to Increase the Success Rate of External Cephalic Version: A Systematic Review and Meta-Analysis of Randomized Controlled Trials
    Obstetric Anesthesia Digest, 2017
    Co-Authors: Elena Rita Magro-malosso, Gabriele Saccone, Mariarosaria Di Tommaso, Michele Mele, Vincenzo Berghella
    Abstract:

    (Am J Obstet Gynecol. 2016;215(3):276–286)The objective of this study was to gauge the effectiveness of Neuraxial Analgesia in increasing the success rate of external cephalic version. Breech or transverse presentations of the fetus is one of the most common causes for the increased cesarean deliver

  • Neuraxial Analgesia to increase the success rate of external cephalic version a systematic review and meta analysis of randomized controlled trials
    American Journal of Obstetrics and Gynecology, 2016
    Co-Authors: Elena Rita Magromalosso, Gabriele Saccone, Mariarosaria Di Tommaso, Michele Mele, Vincenzo Berghella
    Abstract:

    Background External cephalic version is a medical procedure in which the fetus is externally manipulated to assume the cephalic presentation. The use of Neuraxial Analgesia for facilitating the version has been evaluated in several randomized clinical trials, but its potential effects are still controversial. Objective The objective of the study was to evaluate the effectiveness of Neuraxial Analgesia as an intervention to increase the success rate of external cephalic version. Data Sources Searches were performed in electronic databases with the use of a combination of text words related to external cephalic version and Neuraxial Analgesia from the inception of each database to January 2016. Study Eligibility Criteria We included all randomized clinical trials of women, with a gestational age ≥36 weeks and breech or transverse fetal presentation, undergoing external cephalic version who were randomized to Neuraxial Analgesia, including spinal, epidural, or combined spinal-epidural techniques (ie, intervention group) or to a control group (either intravenous Analgesia or no treatment). Study Appraisal and Synthesis Methods The primary outcome was the successful external cephalic version. The summary measures were reported as relative risk or as mean differences with a 95% confidence interval. Tabulation, Integration, and Results Nine randomized clinical trials (934 women) were included in this review. Women who received Neuraxial Analgesia had a significantly higher incidence of successful external cephalic version (58.4% vs 43.1%; relative risk, 1.44, 95% confidence interval, 1.27–1.64), cephalic presentation in labor (55.1% vs 40.2%; relative risk, 1.37, 95% confidence interval, 1.08–1.73), and vaginal delivery (54.0% vs 44.6%; relative risk, 1.21, 95% confidence interval, 1.04–1.41) compared with those who did not. Women who were randomized to the intervention group also had a significantly lower incidence of cesarean delivery (46.0% vs 55.3%; relative risk, 0.83, 95% confidence interval, 0.71–0.97), maternal discomfort (1.2% vs 9.3%; relative risk, 0.12, 95% confidence interval, 0.02–0.99), and lower pain, assessed by the visual analog scale pain score (mean difference, –4.52 points, 95% confidence interval, –5.35 to 3.69) compared with the control group. The incidences of emergency cesarean delivery (1.6% vs 2.5%; relative risk, 0.63, 95% confidence interval, 0.24–1.70), transient bradycardia (11.8% vs 8.3%; relative risk, 1.42, 95% confidence interval, 0.72–2.80), nonreassuring fetal testing, excluding transient bradycardia, after external cephalic version (6.9% vs 7.4%; relative risk, 0.93, 95% confidence interval, 0.53–1.64), and abruption placentae (0.4% vs 0.4%; relative risk, 1.01, 95% confidence interval, 0.06–16.1) were similar. Conclusion Administration of Neuraxial Analgesia significantly increases the success rate of external cephalic version among women with malpresentation at term or late preterm, which then significantly increases the incidence of vaginal delivery.