Difference between revisions of "External cephalic version"
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| lines_access = 1 PIV | | lines_access = 1 PIV | ||
| monitors = Standard OB bedside monitors (EKG, pulse ox, NIBP, fetal HR monitoring) | | 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 == | ||
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|- | |- | ||
|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 | ||
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=== 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. | |||
== 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]]. | |||
== References == | == References == | ||
[[Category:Surgical procedures]] | [[Category:Surgical procedures]] | ||
Latest revision as of 06:37, 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 | |
| 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
- ↑ 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.
- ↑ 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.
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