Effect of regional anesthesia on the success rate of external cephalic version: a systematic review and meta-analysis

Abstract

Objective: To estimate whether the use of regional anesthesia is associated with increased success of external cephalic version.

Data sources: We searched MEDLINE, EMBASE, the Cochrane Library, and clinical trial registries.

Methods of study selection: Electronic databases were searched from 1966 through April 2011 for published, randomized controlled trials in the English language comparing regional anesthesia with no regional anesthesia for external cephalic version. The primary outcome was external cephalic version success. Secondary outcomes included cesarean delivery, maternal discomfort, and adverse events. Pooled risk ratios (relative risk) were calculated using a random-effects model. Heterogeneity was assessed using the Cochran's Q statistic and quantified using the I Z method.

Tabulation, integration, and results: Six randomized controlled trials met criteria for study inclusion. Regional anesthesia was associated with a higher external cephalic version success rate compared with intravenous or no analgesia (59.7% compared with 37.6%; pooled relative risk 1.58; 95% confidence interval [CI] 1.29-1.93). This significant association persisted when the data were stratified by type of regional anesthesia (spinal compared with epidural). The number needed to treat with regional anesthesia to achieve one additional successful external cephalic version was five. There was no evidence of statistical heterogeneity (P=.32, I Z=14.9%) or publication bias (Harbord test P=.78). There was no statistically significant difference in the risk of cesarean delivery comparing regional anesthesia with intravenous or no analgesia (48.4% compared with 59.3%; pooled relative risk 0.80; 95% CI 0.55-1.17). Adverse events were rare and not significantly different between the two groups.

Conclusion: Regional anesthesia is associated with a higher success rate of external cephalic version.

Figure 1

Flow diagram of studies included in meta-analysis.

Figure 2

Forest plot of the outcome of successful external cephalic version comparing regional anesthesia to intravenous or no anesthesia. Pooled risk ratio is 1.58 (95% CI 1.29-1.93), I²=14.9%.

Figure 3

Begg funnel plot of the primary outcome of successful external cephalic version comparing regional to intravenous or no anesthesia. This is a plot of the logarithm of the risk ratio (log_RR) against the standard errors of the log_RRs with pseudo 95% confidence intervals. Visual inspection suggests the absence of publication bias.

Figure 4

Forest plot of the outcome of cesarean delivery comparing regional anesthesia to intravenous or no anesthesia. Pooled risk ratio is 0.80 (95% CI 0.55-1.17), I²=76.5%.