Does the use of a tocolytic agent affect the success rate of external cephalic version? Tocolysis in term breech external cephalic version. The effect of spinal anesthesia on the success rate of external cephalic version: a randomized trial. A randomized trial of epidural anesthesia to improve external cephalic version success. Tocolysis for repeat external cephalic version in breech presentation at term: a randomised, double-blinded, placebo-controlled trial. External cephalic version for breech presentation with or without spinal analgesia in nulliparous women at term: a randomized controlled trial. Fetal acoustic stimulation, an adjunct to external cephalic version: a blinded, randomized crossover study. Intravenous nitroglycerin for external cephalic version: a randomized controlled trial. External cephalic version at term: is a tocolytic necessary? A randomized controlled trial of the effect of combined spinal-epidural analgesia on the success of external cephalic version for breech presentation. Randomized comparison of intravenous nitroglycerin and subcutaneous terbutaline for external cephalic version under tocolysis. A randomized placebo-controlled evaluation of terbutaline for external cephalic version. A prospective randomised controlled trial of external cephalic version comparing two methods of uterine tocolysis with a non-tocolysis group. Intravenous salbutamol for external cephalic version. Oral nifepidine versus subcutaneous terbutaline tocolysis for external cephalic version: a double-blind randomised trial. Randomized, double blind, placebo controlled comparison of ritodrine and hexoprenaline for tocolysis prior to external cephalic version at term. Nifedipine as a uterine relaxant for external cephalic version: a randomized controlled trial. Epidural analgesia for cephalic version: a randomized trial. A randomized, double blind, controlled trial of tocolysis to assist external cephalic version in late pregnancy. Sublingual nitroglycerin versus placebo as a tocolytic for external cephalic version: a randomized controlled trial in parous women. Double-blind randomised controlled trial of glyceryl trinitrate spray for external cephalic version. Randomized controlled trial of external cephalic version in term multiparae with or without spinal analgesia.
Our purpose was to study the effect of ritodrine tocolysis on the success rate of external cephalic version at > or = 36 weeks' gestation.
                This was a prospective, double-blinded, randomized study. All patients were > or = 36 weeks' gestation, confirmed by early ultrasonography. External cephalic version assessment included nonstress testing before and after external cephalic version and ultrasonographic evaluation of type of breech, estimated fetal weight, position of placenta and fetal spine, and amniotic fluid index. Patients were excluded if the breech was not mobile or if they had any contraindications to tocolysis or external cephalic version. After randomization 283 patients received either ritodrine (111 micrograms/min) or identical placebo by intravenous infusion for > or = 20 minutes. Up to three attempts at external cephalic version under ultrasonographic surveillance were performed. With an alpha error of 0.05 and a beta of 0.2, 264 patients were required to complete this study.
                There were no differences between study groups in maternal age, body mass index, gestational age, amniotic fluid index, position of fetal spine, and placental location. Statistical analysis controlled for parity because parity had a major influence on success rates. There was a higher success rate in the group receiving ritodrine tocolysis (52% vs 42%, p = 0.028). Ritodrine improved success rates in nulliparous patients (43% vs 25%, p = 0.026) but not in parous subjects (66% vs 58%, p = 0.385).
                Ritodrine tocolysis improves the success rate of external cephalic version performed at > or = 36 weeks in nulliparous patients. To study the effect of ritodrine tocolysis on the success of external cephalic version (ECV) and to assess the role of ECV in breech presentation at our centre.
                A prospective randomized double-blind-controlled trial comparing ritodrine and placebo in ECV of singleton term breech pregnancy at a tertiary hospital.
                Among the 60 patients who were recruited, there was a success rate of 36.7%. Ritodrine tocolysis significantly improved the success rate of ECV (50% vs. 23%; P=0.032). There was a marked effect of ritodrine tocolysis on the ECV success in nulliparae (36.4% vs. 13.0%) and multiparae (87.5% vs. 57.1%). External cephalic version has shown to reduce the rate of cesarean section for breech presentation by 33.5% in our unit.
                External cephalic version significantly reduced the rate of cesarean section in breech presentation, and ritodrine tocolysis improved the success of ECV and should be offered to both nulliparous and parous women in the case of term breech presentation. To identify the effect of spinal anesthesia on the success rate of external cephalic version after 36 weeks' gestation.
                Women with singleton breech presentations after 36 weeks' gestation were offered enrollment. Those who agreed were randomized to receive spinal anesthesia or no anesthesia. Up to four attempts were made using ultrasound surveillance. External cephalic version was terminated with patient discomfort or fetal heart decelerations. Statistical analysis based on intent-to-treat was performed using chi2, Student t tests, and multivariate analysis. Sample size projection based on 20% difference in success rate from a baseline of 50% indicated a need for 50 women in each group.
                One hundred two women were entered in the study from October 1993 to August 1997. There were no differences between groups in parity, maternal age, amniotic fluid index, gestational age, birth weight, placental location, type of breech presentation, maternal weight, or gestational age at delivery. Forty-four external cephalic versions were successful. Fifty (49%) women received spinal anesthesia, and 52 (51%) did not; there was no difference in the overall success rate between groups (44% spinal versus 42% no spinal). Spontaneous version occurred before external cephalic version was attempted in four patients in the spinal group (after the spinal was given) and one patient in the no-spinal group. These patients were included in the analysis.
                Spinal anesthesia does not increase the external cephalic version success rate in singleton pregnancies with breech presentations after 36 weeks' gestation. This study was designed to determine whether epidural anesthesia would improve external cephalic version success in a safe and effective manner.
                All women > 37 weeks' gestation with breech presentation scheduled for external cephalic version at the medical center from Dec. 1, 1993, to July 31, 1996, were randomized to receive an epidural or no epidural anesthesia. Under ultrasonographic guidance up to three version attempts were performed.
                Sixty-nine women were randomized to receive epidural (n = 35) versus no epidural (n = 34) anesthesia for external cephalic version. There were no statistically significant differences in maternal age, parity, maternal weight, gestational age, estimated fetal weight, or station of the presenting part. The success rate was better for the epidural group (relative risk 2.12, 95% confidence interval 1.24 to 3.62). Neither anterior placentation or oligohydramnios affected the success rate.
                Epidural anesthesia increases success of external cephalic version without any apparent detrimental effect on the maternal-fetal unit. External cephalic version (ECV) reduces the incidence of breech presentation at term and caesarean section for non-cephalic births. Tocolytics may improve success rates, but are time consuming, may cause side effects and have not been proven to alter caesarean section rates. The aim of this trial was to determine whether tocolysis should be used if ECV is being re-attempted after a failed attempt.
                To determine whether tocolysis should be used if ECV is being re-attempted after a failed attempt.
                Randomised, double-blinded, placebo-controlled trial.
                UK teaching hospital.
                One hundred and twenty-four women with a breech presentation at term who had undergone an unsuccessful attempt at ECV.
                Relative risks with 95% confidence intervals for categorical variables and a t test for continuous variables. Analysis was by intention to treat.
                Incidence of cephalic presentation at delivery. Secondary outcomes were caesarean section and measures of neonatal and maternal morbidity.
                The use of tocolysis for a repeat attempt at ECV significantly increases the incidence of cephalic presentation at delivery (RR 3.21; 95% CI 1.23-8.39) and reduces the incidence of caesarean section (RR 0.33; 95% CI 0.14-0.80). The effects were most marked in multiparous women (RR for cephalic presentation at delivery 9.38; 95% CI 1.64-53.62). Maternal and neonatal morbidity remain unchanged.
                The use of tocolysis increases the success rate of repeat ECV and reduces the incidence of caesarean section. A policy of only using tocolysis where an initial attempt has failed leads to a relatively high success rate with minimum usage of tocolysis. To compare the success of external cephalic version using spinal analgesia with no analgesia among nulliparas.
                A prospective randomized controlled trial was performed in a tertiary referral center delivery suite. Nulliparous women at term requesting external cephalic version for breech presentation were randomized to receive spinal analgesia (7.5 mg bupivacaine) or no analgesia before the external cephalic version. An experienced obstetrician performed the external cephalic version. Primary outcome was successful conversion to vertex presentation.
                Seventy-four women were enrolled, and 70 analyzed (36 spinal, 34 no analgesia). Successful external cephalic version occurred among 24 of 36 (66.7%) women randomized to receive spinal analgesia compared with 11 of 34 (32.4%) without, P=.004 (95% confidence interval [CI] of the difference: 0.0954-0.5513). External cephalic version with spinal analgesia resulted in a lower visual analog pain score, 1.76+/-2.74 compared with 6.84+/-3.08 without, P<.001. A secondary analysis logistic regression model demonstrated that the odds of external cephalic version success was 4.0-fold higher when performed with spinal analgesia P=.02 (95% CI, odds ratio [OR] 1.2-12.9). Complete breech presentation before attempting external cephalic version increased the odds of success 8.2-fold, P=.001 (95% CI, OR 2.2-30.3). Placental position, estimated fetal weight, and maternal weight did not contribute to the success rate when spinal analgesia was used. There were no cases of placental abruption or fetal distress.
                Administration of spinal analgesia significantly increases the success rate of external cephalic version among nulliparous women at term, which allows possible normal vaginal delivery.
                ClinicalTrials.gov, www.clinicaltrials.gov, NCT00119184
                I. Our purpose was to determine whether fetal acoustic stimulation can improve the chance of successful external cephalic version in patients at 36 to 38 weeks' gestation with fetal midline spine position.
                A randomized, blinded crossover trial was performed. In this "N of 1" study, the patient served as her own control.
                Twenty-six patients were enrolled in the study, and three were excluded due to engagement of the fetal breech. In the initial trial with fetal acoustic stimulation to the maternal abdomen, 12 of 12 (100%) changed position to spine lateral and 11 of 12 (92%) were successfully verted. In the control group (fetal acoustic stimulation to nurse's arm), none of 11 (0%) changed position to spine lateral and one of 11 (9%) were successfully verted (p < 0.0001). In the crossover trial eight of 10 (80%) of the original placebo (control) patients were successfully verted after fetal acoustic stimulation to the maternal abdomen and none of 1 (0%) from the original treatment group were successfully verted after placebo fetal acoustic stimulation (p < 0.0001). Combined data from the original and crossover trials indicates 19 of 22 (86%) successful versions after fetal acoustic stimulation to maternal abdomen compared with one of 12 (8%) that had successful external cephalic version after placebo fetal acoustic stimulation.
                Fetal acoustic stimulation shifts fetal position to spine lateral, which increases successful version of fetuses with midline fetal spine presentations. To estimate whether treatment with intravenous nitroglycerin for uterine relaxation increases the chance of successful external cephalic version.
                Two double-blind, randomized clinical trials were undertaken: one in nulliparous women and a second in multiparous women. Women presenting for external cephalic version at term were eligible to participate. The primary outcome was immediate success of external cephalic version. Other outcomes were presentation at delivery, cesarean delivery rate, and side effects and complications. Sample size calculations were based on a 100% increase in success of external cephalic version with a one-sided analysis and alpha=0.05 (80% power).
                In total, 126 women were recruited-82 in the nulliparous trial and 44 in the multiparous trial. Seven patients did not have external cephalic version before delivery but were included in the analysis of success of external cephalic version. One patient was lost to follow-up. The external cephalic version success rate for nulliparous patients was 24% (10 of 42) in patients who received nitroglycerin compared with 8% (3 of 40) in those who receive placebo (P=.04, one-sided Fisher exact test, odds ratio 3.85, lower bound 1.22). In multiparous patients, the external cephalic version success rate did not differ significantly between groups: 44% (10 of 23) in the nitroglycerin group compared with 43% (9 of 21) in the placebo group (P=.60).
                Treatment with intravenous nitroglycerin increased the rate of successful external cephalic version in nulliparous, but not in multiparous, women. Treatment with intravenous nitroglycerin appeared to be safe, but our numbers were too small to rule out rare serious adverse effects.
                I. This prospective investigation evaluates the benefit of a beta-mimetic tocolytic for external cephalic version. From July 1, 1984 to May 15, 1987, 58 patients who had breech presentations between 37-41 weeks' gestation were considered for external cephalic version. The patients were randomly assigned to one of two groups: tocolytic or no tocolytic. An ultrasound examination, serum alpha-fetoprotein (AFP), Kleihauer-Betke test, and nonstress test (NST) were performed before and after the attempt at version. A version was not attempted if there was evidence of intrauterine growth retardation (IUGR), oligohydramnios, or a nonreactive NST. Patients in the tocolytic group received 200 micrograms/minute of ritodrine hydrochloride for 20 minutes via continuous intravenous infusion before a version was attempted. Twenty of the 30 patients (66.7%) in the tocolytic group and 19 of the 28 patients (67.8%) in the no-tocolytic group had successful versions, a nonsignificant difference. The nine patients with unsuccessful version attempts in the group without a tocolytic then received intravenous ritodrine and underwent a second attempt. Only one of these nine attempts was successful. There were no serious maternal or fetal complications associated with the attempts at version. In our patient population, use of a tocolytic did not significantly increase the probability of a successful version. Improving the success of external cephalic version (ECV) for breech presentation may help avoid some cesarean deliveries. The results of randomized trials comparing the success of ECV with neuraxial analgesia compared to control are inconsistent. We hypothesized that combined spinal-epidural (CSE) analgesia would increase the success of ECV when compared with systemic opioid analgesia.
                Parturients with singleton breech presentation (n=96) were randomized to receive CSE analgesia with bupivacaine 2.5mg and fentanyl 15 microg (CSE group) or intravenous fentanyl 50 microg (SYS group) before ECV attempt. The primary outcome was ECV success.
                The success rate of ECV was 47% with CSE and 31% in the SYS group (P=0.14). Subsequent vaginal delivery was 36% for CSE and 25% for SYS (P=0.27). Median [IQR] visual analog pain scores (0-100mm scale) were lower with CSE (3 [0-12]) compared to SYS analgesia (36 [16 to 54]) (P<0.005) and patient satisfaction (0-10 scale) was higher (CSE 10 [9 to 10] versus SYS 7 [4 to 9]) (P<0.005). There were no differences in fetal heart rate patterns, but median time to return to fetal heart rate reactivity after analgesia was shorter with CSE (13 [IQR 9-21] min) compared to the SYS group (39 [IQR 23-51] min) (P=0.02).
                There was no difference in the rate of successful ECV or vaginal delivery with CSE compared to intravenous fentanyl analgesia. Pain scores were lower and satisfaction higher with CSE analgesia, and median time to fetal heart rate reactivity was shorter in the CSE group. The purpose of this study was to compare the efficacy and safety of intravenous nitroglycerin with that of subcutaneous terbutaline as a tocolytic agent for external cephalic version at term.
                We performed a prospective randomized trial. Patients between 37 and 42 weeks of gestation were assigned randomly to receive either 200 microg of intravenous nitroglycerin therapy or 0.25 mg of subcutaneous terbutaline therapy for tocolysis during external cephalic version. The rate of successful external cephalic version and side effects were compared between groups.
                Of 59 randomly assigned patients, 30 patients received intravenous nitroglycerin, and 29 patients received subcutaneous terbutaline. The overall success rate of external cephalic version in the study was 39%. The rate of successful external cephalic version was significantly higher in the terbutaline group (55% vs 23%; P = .01). The incidence of palpitations was significantly higher in patients who received terbutaline therapy (17.2% vs 0%; P = .02), as was the mean maternal heart rate at multiple time periods.
                Compared with intravenous nitroglycerin, subcutaneous terbutaline was associated with a significantly higher rate of successful external cephalic version at term. To evaluate the efficacy of subcutaneous terbutaline therapy on the success rate of external cephalic version in term gestation.
                Women with singleton noncephalic gestations were assigned randomly to receive either terbutaline (0.25 mg) or placebo. Physicians were blinded to the assignment. Fifteen to 30 minutes after the study drug was administered, external cephalic version was attempted. It was discontinued after three attempts, for patient discomfort, for fetal heart rate decelerations, or when successful. Patients were discharged home after the procedure and allowed to enter spontaneous labor. Primary outcomes evaluated included initial success of version, presentation in labor, and route of delivery.
                One hundred three women were enrolled in the study between January 1994 and June 1995, of whom 52 were assigned to terbutaline and 51 to placebo. External cephalic version was successful in 27 of 52 (52%) women receiving terbutaline compared with 14 of 51 (27%) of those receiving placebo (P = .019). This comparison yielded a relative risk (RR) of 1.9 (95% confidence interval [CI] 1.3, 6.5). Four of the 27 (15%) successful versions in the terbutaline group and three of the 14 (21%) successful versions in the placebo group spontaneously reverted to breech presentation. Ultimately, in labor there were 24 (46%) cephalic presentations in the terbutaline group and 13 (25%) in the placebo group (P = .048, RR 1.84, 95% CI 1.1, 5.8). Cesarean delivery rates were 11 of 41 (27%) for women with successful versions and 58 of 62 (94%) among those with failed versions (P < .001).
                Terbutaline (0.25 mg) administered subcutaneously before an attempted version in women at term with noncephalic presentations significantly increased the initial success rate of version and the rate of cephalic presentations in labor while decreasing the rate of cesarean delivery. The use of tocolvtic agents to enhance uterine relaxation and facilitate external cephalic version (ECV) has come under recent debate. We studied 90 breech presentations in late pregnancy who did not have contra-indications to ECV. The patients were randomised into 3 groups of 30 patients each: one was administered oral salbutamol 4 mg t.d.s.; another had intravenous salbutamol infused until the maternal heart rate rose above 100 bpm for 30 mins; and the last served as a control group. All patients in each group were matched for parity and gestation, and each had an intravenous line, thereby masking the treatment group from the 2 doctors who performed half the number of ECVs each. There was no significant difference in the success of ECV between the treatment and control groups (46.6% vs 50.0% vs 46.6%). The gestational age, the placental site, the attitude of the breech, the abdominal girth, and the maternal weight and fetal birth weights did not seem to influence results. On the other hand, there was a significant difference in successful ECV between nullipara (26%) and multipara (75%) (p less than 0.001). There were no cases of abruptio placenta or foetal distress, and one patient entered labour one day after the ECV at 39 weeks gestation. There were 2 cases of spontaneous version after failed ECV, and one case of spontaneous reversion to breech after successful ECV. We conclude that the use of salbutamol does not increase the incidence of successful ECV, but multiparity predicts for a successful outcome. To evaluate the success of external cephalic version (ECV) using an adjusted bolus dose of intravenous salbutamol compared with no tocolysis.
                An open-label randomized study of 114 women with a term breech fetus randomized to receive either an intravenous bolus dose of 0.1 mg salbutamol with further boluses every 5 minutes, as required, before commencing ECV, or no tocolysis. Primary outcomes were successful ECV and rate of cesarean delivery.
                Salbutamol tocolysis resulted in a higher rate of successful ECV compared with no tocolysis (70.2% [40/57] vs 36.8% [21/57]; RR 1.9, 95% CI 1.3-2.8; P<0.001). Cesarean delivery rate was lower in the salbutamol group compared with the control group (31.6% [18/57] vs 63.2% [36/57]; RR 0.5, 95% CI 0.3-0.8; P=0.001). Salbutamol dose ranged from 0.1-0.4 mg and outcome was not related to dose.
                Adjusted dose intravenous salbutamol tocolysis prior to ECV increases its success rate and reduces the cesarean delivery rate. To evaluate oral nifedipine versus subcutaneous terbutaline tocolysis for external cephalic version (ECV).
                A double-blind randomised trial.
                A university hospital in Malaysia.
                Non-labouring women with a term singleton fetus in breech presentation or transverse lie suitable for elective ECV.
                Participants were randomised to either 10 mg oral nifedipine tablet and subcutaneous saline placebo or oral placebo tablet and 250 microgram bolus terbutaline subcutaneously. Participants and providers were blinded. Ultrasound assessment and cardiotocogram were performed prior to ECV. ECV was commenced 20-30 minutes after treatment. A maximum of two ECV attempts were permitted. Elective caesarean delivery or a repeat ECV attempt at a later date was offered to participants following failed ECV. After successful ECV, management was expectant.
                Primary outcomes were successful ECV (cephalic presentation immediately after ECV) and caesarean delivery.
                Ninety women were randomised: 44 to nifedipine and 46 to terbutaline. Initial ECV success rate was 15/44 (34.1%) versus 24/46 (52.2%) (relative risk [RR] 0.7, 95% CI 0.4-1.1; P= 0.094), and caesarean delivery rate was 34/44 (77.3%) versus 26/46 (56.5%) (RR 1.4, 95% CI 1.01-1.85; numbers needed to treat to benefit 5, 95% CI 2.5-55; P= 0.046) for nifedipine and terbutaline groups, respectively. Neonatal outcome was not different.
                Bolus subcutaneous terbutaline tocolysis for ECV compared with oral nifedipine resulted in less caesarean deliveries. ECV success rate was not significantly higher. Larger studies are indicated. External cephalic versions in the study period were performed in a double blind design by 2 experienced practitioners. Sixty-three patients were allocated to treatment with either placebo, ritodrine or hexoprenaline. The main outcome measure studied was successful completion of external cephalic version. Hexoprenaline, but not ritodrine, was statistically more likely to be associated with successful version than placebo (p = 0.04 versus p = 0.22). To estimate the effectiveness of nifedipine as a uterine relaxant during external cephalic version to correct breech presentation.
                In this randomized, double-blind, placebo-controlled trial, women with a singleton fetus in breech presentation and a gestational age of 36 weeks or more were eligible for enrollment. Participating women received two doses of either nifedipine 10 mg or placebo, 30 and 15 minutes before the external cephalic version attempt. The primary outcome was a cephalic-presenting fetus immediately after the procedure. Secondary outcome measures were cephalic presentation at delivery, mode of delivery, and adverse events. A sample size of 292 was calculated to provide 80% power to detect a 17% improvement of the external cephalic version success rate, assuming a placebo group rate of 40% and alpha of .05.
                Outcome data for 310 of 320 randomly assigned participants revealed no significant difference in external cephalic version success rates between treatment (42%) and control group (37%) (relative risk 1.1, 95%; 95% confidence interval 0.85-1.5). The cesarean delivery rate was 51% in the treatment group and 46% in the control group (relative risk 1.1, 95% confidence interval 0.88-1.4).
                Nifedipine did not significantly improve the success of external cephalic version. Future use of nifedipine to improve the outcome of external cephalic version should be limited to large clinical trials. To determine if epidural analgesia improves the success rate of external cephalic version.
                Women with singleton fetuses in breech or transverse presentation of at least 37 weeks' gestation were offered enrollment in a randomized trial. Inclusion criteria included maternal age of 18 years or older, nonvertex presentation confirmed by ultrasound, intact membranes, reactive fetal nonstress test, and estimated fetal weight (EFW) between 2000 and 4000 g. Women in the epidural group had lumbar epidural catheters inserted, through which 2% lidocaine and 100 microg of fentanyl were infused. External cephalic version attempts were done with ultrasound guidance in a standard fashion for both groups. The primary outcome variable was the successful version of the fetus to a cephalic presentation.
                There were no statistically significant differences between groups in gestation at time of procedure, placental location, fetal lie, gravity, parity, EFW, or amniotic fluid index. External cephalic version was successful in 32 of 54 women (59%) with epidural anesthesia compared with 18 of 54 (33%) with no anesthesia (relative risk [RR] 1.8, 95% confidence interval [CI] 1.2, 2.8, P <.05). Vaginal delivery occurred in 29 of 54 women (54%) in the epidural group and 16 of 54 women (30%) in the control group (RR 1.9, 95% CI 1.2, 2.9, P <.05).
                Epidural analgesia increased the success rate of external cephalic version and the likelihood of subsequent vaginal delivery. External cephalic version at term is not always successful. This trial was done to ascertain whether tocolysis has any effect on the success rate.
                A randomized, double blind, controlled trial, with continuous paired sequential analysis. Fifty-one consecutive patients with a singleton fetus in a breech presentation between 36 and 38 weeks gestation, external version being attempted on each. Ritodrine infusion or placebo was infused before attempt at external cephalic version.
                A university teaching hospital with 8000 confinements annually.
                Version was successful in 17 of the 25 patients given tocolysis, but in only eight of the 25 given placebo (p < 0.01). A positive benefit for tocolysis was shown after version had been completed in 10 pairs of patients. However the trial was continued until 25 pairs had been analyzed. The benefit deteriorated during analysis of the last 15 pairs suggesting that the initial benefit may reflect a learning curve for the procedure.
                Tocolysis is likely to improve the success rate of external cephalic version in late pregnancy, especially in nulliparous mothers or where doctors are learning the technique. The purpose of this study was to evaluate the efficacy of sublingual nitroglycerin as a tocolytic agent for external cephalic version in parous women.
                A double-blinded randomized controlled trial was performed. Patients with parity of >or=1 at 36 to 40 weeks of gestation who were eligible for external cephalic version were included. Patients were randomized to receive either two sublingual sprays of 400 mug of nitroglycerin or two sprays of placebo 3 minutes before the trial of external cephalic version. Rates of successful external cephalic version and side effects were compared between groups.
                Of 99 patients in the study, 50 patients received sublingual nitroglycerin, and 49 patients received placebo. There were no differences in maternal age, gestational age, estimated fetal weight, amniotic fluid index, and placental location between the two groups. The success rate of external cephalic version was 48% in the nitroglycerin group compared with 63% in the placebo group (P=.13). There was a higher incidence of headaches in the nitroglycerin group (42% vs 4%, P<.001).
                Sublingual nitroglycerin was associated with a higher rate of headache and did not improve the rate of successful external cephalic version. A placebo controlled trial of glyceryl trinitrate was carried out in women whose first attempt at external cephalic version without tocolysis had been unsuccessful. No significant differences between groups were found and no side effects were noted. It is recommended that a larger, possibly multicentre study, should be undertaken. Neuraxial analgesia significantly increases the success rate of external cephalic version (ECV) among nulliparae. The study objective was to compare ECV success among multiparae with and without spinal analgesia.
                Prospective randomized controlled trial performed over a pre-defined 6 yr period in a tertiary referral delivery suite. Healthy multiparae at term requesting ECV for breech presentation, without fetal or uterine anomaly, were enrolled after written informed consent. Women were randomized to receive either spinal analgesia (bupivacaine 7.5 mg) or no analgesia before the ECV. The primary outcome was successful conversion from breech to vertex presentation, confirmed by ultrasound. Visual analogue pain score and adverse outcomes (complications of anaesthesia or ECV) were recorded. Statistical analysis was performed according to intention to treat using two-sided tests.
                Among 265 multiparae who underwent ECV, 65 consented to enrol, one subsequently refused ECV; therefore, data from 64 women were analysed. ECV was successful in 27 of 31 patients (87.1%) receiving spinal analgesia vs 19 of 33 (57.5%) with no analgesia (P=0.009; 95% CI of difference: 0.075-0.48). ECV with spinal analgesia reduced visual analogue pain score, mean (sd) 1.7 (2.4) vs 5.5 (2.9) without (P<0.0001). Maternal hypotension was seen after spinal analgesia in 10 of 31 (32%) (P=0.0003) and easily treated without adverse outcome. No complications were noted after the ECV.
                Administration of spinal analgesia significantly increased the rate of successful ECV among multiparae at term with increased patient comfort. The trial was registered at the National Institute of Health Trials Registry, NCT00119184, www.clinicaltrials.gov.
Betastimulants, to facilitate ECV, increased cephalic presentation in labour and birth, and reduced the caesarean section rate in both nulliparous and multiparous women, but there were insufficient data on adverse effects. Calcium channel blockers and nitric acid donors had insufficient data to provide good evidence. At present we recommend betamimetics for facilitating ECV.
There is scope for further research. The possible benefits of tocolysis to reduce the force required for successful version and the possible risks of maternal cardiovascular side effects, need to be addressed further. Further trials are needed to compare the effectiveness of routine versus selective use of tocolysis, the role of regional analgesia, fetal acoustic stimulation, amnioinfusion and the effect of intravenous or oral hydration prior to ECV.
Although randomised trials of nitroglycerine are small, the results are sufficiently negative to discourage further trials.