A prospective randomized trial of the use of epidural anesthesia during external cephalic version.

Objective: To determine if the use of epidural anesthesia improves the success rate of external cephalic version (ECV).Design: Women identified with a singleton fetus in a breech or transverse presentation at a gestational age of >/=37 weeks gestation were offered enrollment in this prospective randomized trial. Inclusion criteria included maternal age of 18 years or older, a non-vertex presentation confirmed by ultrasound, a reactive fetal non-stress test, and an estimated fetal weight of 2,000-4,000 g. A 1:1 randomization was accomplished through a computer-generated random numbers table with group assignments sealed in sequentially numbered opaque envelopes. Women in the epidural ECV group had a lumbar epidural catheter inserted through which 2% lidocaine and 100 µg of fentanyl were infused.Results: There were no statistically significant differences between the two groups in gestational age at ECV, placental location, fetal lie, gravidity or parity, estimated fetal weight, or amniotic fluid index. The ECV was successful in 26 of 45 (58%) women with epidural anesthesia compared to 16 of 48 (33%) with no anesthesia (relative risk 1.7, 95% confidence interval 1.1-2.8, P <.05). Fetal bradycardia resulting in discontinuation of the version efforts occurred in two patients in the epidural group and three women in the control population, a non-statistically significant difference. There were no maternal complications noted in the study population related to the epidural anesthesia.Conclusions: The use of epidural anesthesia increases the success rate of external cephalic version.

Prelabor Rupture of Membranes at Term: Induce or Wait?

Rupture of the fetal membranes prior to the onset of labor is a common event. With its occurrence, the risk is increased for serious maternal and fetal infections, dysfunctional labor, and the need for operative delivery. Fortunately, for most women with prelabor rupture of membranes (PROM) at term, labor begins spontaneously in the hours following membrane rupture. If spontaneous labor does not commence shortly after PROM at term, and the patient's cervix is favorable, labor induction should be initiated. Women with uncomplicated gestations who have an unfavorable cervical score may be managed expectantly, undergo immediate labor induction, or be observed for an arbitrary time period and then undergo labor induction. Recent clinical trials have shown that immediate labor induction for women with PROM at term and an unfavorable cervical score is preferable in the context of maternal and neonatal outcome, cost-effectiveness, and patient satisfaction.