Success of External Cephalic Version Study

Study Overview
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Brief Summary
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The purpose of this study is to determine the best way to optimize the success of external cephalic version (turning the baby from the outside). Attempting to turn babies in-utero is recommended because it may decrease the risk of needing a cesarean section for abnormal presentation. While the study team knows that this procedure can be effective, the study team still has some un-answered questions as to the best way to perform this procedure to increase the chance of success. Many prior studies have shown that using spinal anesthesia (a shot of medication placed in your back to numb and relax the abdomen) can increase the success rate of a version. This ultimately has led to the finding that using this anesthesia can decrease the rate of cesarean section. However, there have been only a small number of studies assessing the success rate if spinal anesthesia is used only in the event that without it fails. Therefore the study team is going to compare patients who receive spinal anesthesia with those who only receive spinal anesthesia if the procedure to turn the baby (ECV) fails without it.

Detailed Description
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Breech presentation occurs in approximately 3-4% of term pregnancies and leads to one of the most common indications for cesarean delivery. Attempting an external cephalic version (ECV) significantly increases the chance of cephalic presentation at time of delivery and reduces the chance of cesarean section. Since ECV does in fact reduce the rate of cesarean section, many studies have sought to determine the best method to perform the procedure to optimize the chance of success. A recent meta-analysis concluded that administration of neuraxial analgesia significantly increases the success rate of ECV and also increases the incidence of vaginal delivery. However, there have been only 2 prospective studies and no randomized trials that evaluated the success of ECV using neuraxial analgesia only when initial attempt without it has failed. Therefore, the study team designed a randomized controlled trial with two groups: Group 1- patients receiving spinal anesthesia immediately versus Group 2- patients attempting ECV without spinal anesthesia with reattempt using a spinal if first attempt fails. This study will be conducted on labor and delivery at Mount Sinai West hospital. Patients who present to labor and delivery at term for ECV will be approached for enrollment and those who consent to be part of the study would be randomized into a group. ECV will then be attempted and delivery and neonatal outcomes will be collected. Patients will likely be enrolled in the study from time of version (approximately 37 weeks) until postpartum. This study will take approximately 1-2 years given the ECV rate.

Official Title
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Success of External Cephalic Version With Immediate Spinal Anesthesia Versus Spinal Anesthesia When Attempt Without Anesthesia Has Failed: A Randomized Controlled Trial

Conditions
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External Cephalic Version

Intervention / Treatment
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* Drug: Bupivacaine
* Drug: Terbutaline


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients included are those with singleton pregnancies of at least 37 weeks gestation in nonvertex presentation with no contraindication for a vaginal delivery. Membranes must be intact with a minimum of a 2x2 pocket and Category 1 non-stress test. Exclusion Criteria: All patients with a contraindication for a vaginal delivery will be excluded from the study. Patients with gross fetal anomalies or uterine malformations. Patients with contraindications to neuraxial anesthesia or allergies to any of the study medications will also be excluded.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 60 Years

Sexes Eligible for Study
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Female

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Spinal anesthesia immediately for ECV.<br>The patient will have a spinal administered by the on call anesthesiologist using standard protocol (intrathecal bupivacaine 7.5 mg). The patient will then be administered 0.25 mg Terbutaline subcutaneously and the ECV will be attempted. Under ultrasound guidance the provider will attempt to lift the breech upward from the pelvis with one hand and guide the head with the other hand to produce a forward roll. If forward roll fails, a backward roll somersault may be attempted. ECV attempt will be abandoned if there is significant fetal bradycardia, discomfort to the patient, or if the procedure cannot be completed easily with these maneuvers. Once attempt is complete, whether successful or not, the patient will be monitored for a minimum of 30 minutes, and will be discharged once they are able to walk, void, and tolerate PO intake, only if fetal and maternal status is reassuring. | Drug: Bupivacaine<br>* intrathecal bupivacaine 7.5 mg<br>Drug: Terbutaline<br>* 0.25 mg Terbutaline subcutaneously<br>|
| Experimental: Spinal anesthesia if no intervention fails for ECV.<br>The patient will be administered terbutaline 0.25 mg subcutaneously and the version will be attempted using the same procedure as above. If successful, the patient will be monitored for 30 minutes and discharged if fetal and maternal status is reassuring. If the attempt fails, the patient will be administered spinal anesthesia as above and the same maneuvers will be attempted. Once attempt is complete, whether successful or not, the patient will be monitored for a minimum of 30 minutes, and will be discharged once they are able to walk, void, and tolerate PO intake, only if fetal and maternal status is reassuring. | Drug: Bupivacaine<br>* intrathecal bupivacaine 7.5 mg<br>Drug: Terbutaline<br>* 0.25 mg Terbutaline subcutaneously<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of Participants With Success Rate of External Cephalic Version to Cephalic Presentation. | Success rate will be measured by comparing the percentage of successful external cephalic versions in each group. | Day 1 | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Time From Procedure to Delivery. | Number of days from procedure to delivery. | up to day 42 | 
| Number of Participants With Various Mode of Delivery | Mode of delivery as incidence of spontaneous vaginal delivery, operative vaginal delivery, or cesarean section. | up to day 42 | 
| Numeric Rating Scale (NRS-11) | Patient discomfort rated with NRS-11. Total scale from 0-10, with higher score indicating more pain. | Day 1 | 
| Number of Adverse Events During Procedure | Number of total specific adverse events such as: fetal bradycardia, emergent cesarean section, or abruption. | Day 1 | 
| Newborn Birth Weight | Newborn birth weight in grams. | Day 1 of delivery | 
| Number of Participants With Newborns With Apgar Score 7 or 9 | Newborns with Apgar Score 7 or 9 at 5 minutes after delivery. The Apgar score is based on a total score of 1 to 10. The higher the score, the better the baby is doing after birth. A score of 7, 8, or 9 is normal and is a sign that the newborn is in good health. | 7 minutes and 9 minutes after delivery | 
| Cord pH | Arterial cord pH level | Day 1 | 
| Number of NICU Admission | Number of patients whose neonate was admitted to the NICU in each group. | Day 1 | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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External Cephalic Version, neuraxial analgesia