Systematic review of the effectiveness of remifentanil in term breech pregnancies undergoing external cephalic version

Abstract

Background: External cephalic version (ECV) is a moderately painful procedure used to turn a fetus from a non-vertex to cephalic position. This systematic review and meta-analysis compared intravenous remifentanil with other analgesia or no analgesia or placebo on the success rate and associated pain of ECV.

Methods: Systematic searches for randomised controlled trials using remifentanil during ECV for non-cephalic term singleton pregnancies were conducted in EMBASE, MEDLINE and the Cochrane Library to October 2021. The primary outcomes were successful ECV and maternal pain; secondary outcomes included mode of delivery and adverse effects. The Cochrane Risk of Bias tool was used and meta-analysis undertaken if there were ≥2 comparable studies.

Results: Four trials were identified, three placebo-controlled and one vs no analgesia, totalling 482 participants. Comparisons against nitrous oxide or neuraxial anaesthesia were not analysed. Two studies had a low overall risk of bias, and two had some concern for bias. Remifentanil compared with placebo increased the success of ECV by 43% (risk ratio [RR] 1.43; 95% confidence interval [CI] 1.14 to 1.78). Pain scores (0-10) were lower (mean difference -1.97; 95% CI -2.49 to -1.46) whilst there was no impact on caesarean delivery rate (RR 0.97; 95% CI 0.81 to 1.17). Adverse events were rare, with fetal bradycardia observed less often with remifentanil than placebo.

Conclusions: Remifentanil increases the procedural success of ECV and reduces pain compared with placebo. Trials were at low risk of bias and contained a sufficient number of participants to have reasonable confidence in this finding.

Keywords: Analgesia; Breech presentation; Extracephalic version; Meta-analysis; Remifentanil.