Key Takeaways:
- Research suggests spinal or epidural anesthesia can make external cephalic version (ECV), a procedure used to turn breech babies head-down before labor, nearly 40% more likely to succeed.
- Babies in the breech position — feet or bottom first — are more likely to be delivered by cesarean delivery (C-section) because vaginal birth has unique risks for breech babies.
- The American Society of Anesthesiologists (ASA) recommends women undergoing ECV be offered anesthesia to improve comfort and increase the likelihood of a successful procedure.
CHICAGO — Women carrying breech babies have a better chance of avoiding a cesarean delivery (C-section) when spinal or epidural anesthesia is used during external cephalic version (ECV), a procedure used to turn the baby head-down before labor, according to the American Society of Anesthesiologists (ASA).
Research suggests anesthesia can make ECV nearly 40% more likely to succeed. Yet, access to anesthesia support for ECV remains inconsistent across hospitals and care teams, ASA's statement reports.
At 37 weeks of pregnancy, 3% to 4% of babies remain in the breech position, meaning they are feet- or bottom-first in the uterus rather than head-down. A C-section is often recommended for breech babies because vaginal delivery may carry a higher risk of complications for the baby. To help reduce the need for C-section – a major surgery that carries risks for mothers, such as infection, significant blood loss and blood clots, and babies, such as breathing problems or surgical injury – the American College of Obstetricians and Gynecologists recommends offering ECV to eligible patients before labor begins.
During ECV, a physician uses pressure on the mother's abdomen to encourage the baby to turn to the head-down position while the baby is closely monitored. Although ECV typically takes only a few minutes, it can be uncomfortable and often requires more than one attempt.
"Most patients would benefit from anesthesia during ECV and are good candidates for it," said Rachel Kacmar, M.D., FASA, chair of the ASA Committee on Obstetric Anesthesia. "It can help patients better tolerate the procedure, increasing the likelihood of success. Anesthesia may also relax the abdominal muscles, making it easier for physicians to reposition the baby."
For Amber Watters, M.D., M.S., ASA's recommendation reflects both her clinical experience and her own birth story. As an obstetrician, Dr. Watters has performed many ECVs. But when her second daughter was still in the breech position at 37 weeks of pregnancy, she became the patient.
"I knew I wanted to try everything possible to avoid a cesarean delivery," she said. "The ECV was challenging and took two physicians working very hard to turn my daughter, who was clearly settled in. Because I had a combination spinal-epidural, I was better able to tolerate the procedure. When it finally worked, I was so relieved." Two weeks later, her daughter Juniper was delivered vaginally.
ASA's statement notes that providing spinal or epidural anesthesia for ECV is cost-effective because it may reduce the need for C-section. ECV should be performed in a hospital setting with the staff and resources necessary to provide an emergency C-section, if needed.
While some breech babies can be delivered vaginally, breech birth carries a higher risk of complications than a head-first vaginal birth, including the baby's head becoming trapped in the birth canal, reduced oxygen supply due to umbilical cord compression and other birth injuries, such as fractures or nerve damage.
Patients whose babies remain in the breech position later in pregnancy should ask their obstetrician whether ECV is an option and whether epidural or spinal anesthesia is available. They should discuss anesthesia options with an anesthesiologist before undergoing the procedure, the statement notes.
THE AMERICAN SOCIETY OF ANESTHESIOLOGISTS
Founded in 1905, the American Society of Anesthesiologists (ASA) is an educational, research and scientific society with more than 60,000 members organized to advance the medical practice of anesthesiology and secure its future. ASA is committed to ensuring anesthesiologists evaluate and supervise the medical care of all patients before, during, and after surgery. ASA members also lead the care of critically ill patients in intensive care units, as well as treat pain in both acute and chronic settings.
