Difference between revisions of "External cephalic version"

From WikiAnesthesia
VisualWikitext
(page creation)
 
 
(6 intermediate revisions by the same user not shown)
Line 3: Line 3:
| airway = Natural
| airway = Natural
| lines_access = 1 PIV
| lines_access = 1 PIV
| monitors = Standard ASA monitors
| monitors = Standard OB bedside monitors (EKG, pulse ox, NIBP, fetal HR monitoring)
| considerations_preoperative =  
| considerations_preoperative = Rule out thrombocytopenia/coagulopathy if neuraxial is used
| considerations_intraoperative =  
| considerations_intraoperative = Fetal distress is common, may result in aborting procedure, or require urgent C section
| considerations_postoperative =  
| considerations_postoperative =  
}}
}}


An '''external cephalic version''' is a maneuver performed by obstetric physicians to rotate a baby into vertex position in preparation for vaginal delivery.
An '''external cephalic version''' is a maneuver performed by obstetric physicians to rotate a baby into vertex position in preparation for vaginal delivery. It may be done without any anesthesia, or with neuraxial (epidural, spinal, combined spinal epidural) depending on patient and provider preference. The success rate of ECV varies from 45% to 65%.<ref>{{Cite journal|last=Svensson|first=Emelie|last2=Axelsson|first2=Daniel|last3=Nelson|first3=Marie|last4=Nevander|first4=Sofia|last5=Blomberg|first5=Marie|date=2021-10-08|title=Success rate of external cephalic version in relation to the woman’s body mass index and other factors—a population‐based cohort study|url=http://dx.doi.org/10.1111/aogs.14270|journal=Acta Obstetricia et Gynecologica Scandinavica|volume=100|issue=12|pages=2260–2267|doi=10.1111/aogs.14270|issn=0001-6349}}</ref>


== Overview ==
== Overview ==
Line 30: Line 30:
|-
|-
|Airway
|Airway
|
|Airway edema is common in pregnant women near term
|-
|-
|Neurologic
|Neurologic
Line 45: Line 45:
|-
|-
|Hematologic
|Hematologic
|
|Thrombocytopenia is common and must be considered if neuraxial is required
|-
|-
|Renal
|Renal
Line 58: Line 58:


=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===
=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===
* CBC
** In particular, evaluate platelet count if neuraxial anesthesia will be used


=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===
=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===
The ECV is often performed in a labor room or PACU area, where neuraxial anesthesia can be provided if needed, and in close proximity to the operating room in case of fetal distress requiring urgent [[Cesarean section]]. Having an operating room on standby and ready to use is prudent.


=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
Generally not needed


=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===
=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===
* An epidural or combined spinal epidural (CSE) can be offered for patients who wish to have analgesia, as the pressure applied to the abdomen can be quite significant and may prevent success of the maneuver.
** Yoshida ''et al.'' reported a 78.8% success rate in patients who received an epidural compared to 55.9% success rate in patients who did not (OR: 1.75; 95% CI: 1.26 to 2.44).<ref>{{Cite journal|last=Yoshida|first=M|last2=Matsuda|first2=H|last3=Kawakami|first3=Y|last4=Hasegawa|first4=Y|last5=Yoshinaga|first5=Y|last6=Hayata|first6=E|last7=Asai|first7=K|last8=Kawashima|first8=A|last9=Furuya|first9=K|date=2010-05-20|title=Effectiveness of epidural anesthesia for external cephalic version (ECV)|url=http://dx.doi.org/10.1038/jp.2010.61|journal=Journal of Perinatology|volume=30|issue=9|pages=580–583|doi=10.1038/jp.2010.61|issn=0743-8346}}</ref>
* Spinal dose: bupivacaine ~7.5 mg intrathecally (~1 mL bupivacaine 0.75%)
** CSE can be used to titrate up to effect
* Epidural dose: lidocaine 2% ~10 mL
*Reaching a T6 level is generally adequate


== Intraoperative management ==
== Intraoperative management ==


=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
* EKG
* pulse oximetry
* NIBP
* fetal HR monitoring


=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
Natural airway, oxygen (nasal cannula or mask) can be used for comfort if needed


=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
* Supine


=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
 
If an epidural is used, additional titration may be needed to tolerate the procedure. Careful observation of blood pressure is important as hypotension is common. Maintaining uterine artery blood flow is critical to avoiding fetal distress.
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===


== Postoperative management ==
== Postoperative management ==


=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
Generally, the fetus is monitored for several hours. If neuraxial anesthesia is used, patient must regain motor and sensory function.


=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
Generally, the procedure has minimal pain once completed. The epidural, if placed, can be titrated as needed


=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
 
There is imminent risk of fetal distress with the ECV, thus there should always be an available operating room for emergent [[Cesarean section]].  
== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==
 
{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Indications
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}


== References ==
== References ==


[[Category:Surgical procedures]]
[[Category:Surgical procedures]]

Latest revision as of 07:37, 24 May 2023

External cephalic version
Anesthesia type

None or epidural/CSE

Airway

Natural

Lines and access

1 PIV

Monitors

Standard OB bedside monitors (EKG, pulse ox, NIBP, fetal HR monitoring)

Primary anesthetic considerations
Preoperative

Rule out thrombocytopenia/coagulopathy if neuraxial is used

Intraoperative

Fetal distress is common, may result in aborting procedure, or require urgent C section

Postoperative
Article quality
Editor rating
Comprehensive
User likes
0

An external cephalic version is a maneuver performed by obstetric physicians to rotate a baby into vertex position in preparation for vaginal delivery. It may be done without any anesthesia, or with neuraxial (epidural, spinal, combined spinal epidural) depending on patient and provider preference. The success rate of ECV varies from 45% to 65%.[1]

Overview

Indications

  • Breech or transverse presentation
    • Ideally around 36-37 weeks gestation before the baby is too large

Surgical procedure

The maneuver can be performed at bedside using external force on the abdomen to rotate the baby. Ultrasound is used to confirm head position before, during, and after the maneuver. Fetal heart rate monitoring is used to closely monitor for fetal distress

Preoperative management

Patient evaluation

System Considerations
Airway Airway edema is common in pregnant women near term
Neurologic
Cardiovascular
Pulmonary
Gastrointestinal
Hematologic Thrombocytopenia is common and must be considered if neuraxial is required
Renal
Endocrine
Other

Labs and studies

  • CBC
    • In particular, evaluate platelet count if neuraxial anesthesia will be used

Operating room setup

The ECV is often performed in a labor room or PACU area, where neuraxial anesthesia can be provided if needed, and in close proximity to the operating room in case of fetal distress requiring urgent Cesarean section. Having an operating room on standby and ready to use is prudent.

Patient preparation and premedication

Generally not needed

Regional and neuraxial techniques

  • An epidural or combined spinal epidural (CSE) can be offered for patients who wish to have analgesia, as the pressure applied to the abdomen can be quite significant and may prevent success of the maneuver.
    • Yoshida et al. reported a 78.8% success rate in patients who received an epidural compared to 55.9% success rate in patients who did not (OR: 1.75; 95% CI: 1.26 to 2.44).[2]
  • Spinal dose: bupivacaine ~7.5 mg intrathecally (~1 mL bupivacaine 0.75%)
    • CSE can be used to titrate up to effect
  • Epidural dose: lidocaine 2% ~10 mL
  • Reaching a T6 level is generally adequate

Intraoperative management

Monitoring and access

  • EKG
  • pulse oximetry
  • NIBP
  • fetal HR monitoring

Induction and airway management

Natural airway, oxygen (nasal cannula or mask) can be used for comfort if needed

Positioning

  • Supine

Maintenance and surgical considerations

If an epidural is used, additional titration may be needed to tolerate the procedure. Careful observation of blood pressure is important as hypotension is common. Maintaining uterine artery blood flow is critical to avoiding fetal distress.

Postoperative management

Disposition

Generally, the fetus is monitored for several hours. If neuraxial anesthesia is used, patient must regain motor and sensory function.

Pain management

Generally, the procedure has minimal pain once completed. The epidural, if placed, can be titrated as needed

Potential complications

There is imminent risk of fetal distress with the ECV, thus there should always be an available operating room for emergent Cesarean section.

References

  1. ↑ Svensson, Emelie; Axelsson, Daniel; Nelson, Marie; Nevander, Sofia; Blomberg, Marie (2021-10-08). "Success rate of external cephalic version in relation to the woman's body mass index and other factors—a population‐based cohort study". Acta Obstetricia et Gynecologica Scandinavica. 100 (12): 2260–2267. doi:10.1111/aogs.14270. ISSN 0001-6349.
  2. ↑ Yoshida, M; Matsuda, H; Kawakami, Y; Hasegawa, Y; Yoshinaga, Y; Hayata, E; Asai, K; Kawashima, A; Furuya, K (2010-05-20). "Effectiveness of epidural anesthesia for external cephalic version (ECV)". Journal of Perinatology. 30 (9): 580–583. doi:10.1038/jp.2010.61. ISSN 0743-8346.

Top contributors: Tony Wang

Retrieved from "https://wikianesthesia.org/w/index.php?title=External_cephalic_version&oldid=15006"