Effectiveness of nitrous oxide in external cephalic version on success rate: A randomized controlled trial

Vincent Dochez, Julie Esbelin, Emilie Misbert, Chloé Arthuis, Anne Drouard, Virginie Badon, Olivier Fenet, Thibault Thubert, Norbert Winer, Vincent Dochez, Julie Esbelin, Emilie Misbert, Chloé Arthuis, Anne Drouard, Virginie Badon, Olivier Fenet, Thibault Thubert, Norbert Winer

Abstract

Introduction: Approximately 4% of singleton pregnancies at term are in breech presentation. External cephalic version (ECV) can reduce the risks of noncephalic birth and cesarean delivery, but this maneuver can be painful. Our aim was to analyze the effect of administering inhaled nitrous oxide for analgesia on the ECV success rate.

Material and methods: This prospective, randomized, single-blind, controlled trial included women with singleton pregnancies in breech presentation at term who were referred for ECV in a tertiary care center. Women were assigned according to a balanced (1:1) restricted randomization design to inhale either nitrous oxide (N2 O) in a 50:50 mix with oxygen or medical air during the procedure. The main outcomes reported are the ECV success rate, degree of pain, adverse event rate, and women's satisfaction.

Trial registration: ClinicalTrials.gov Identifier: NCT01948115.

Results: The study included 150 women (nitrous oxide group: n = 74; medical air: n = 76). Inhaled nitrous oxide was not associated with a higher ECV success rate than medical air (24.3 vs 19.7%, P = 0.51). Among parous women (n = 34 in each group), the ECV success rate appeared higher in the nitrous oxide group, respectively 47.1% (n = 16) vs 23.5% (n = 8) (P = 0.042). Neither the median pain level nor adverse event rates differed significantly in women with inhaled nitrous oxide compared with medical air.

Conclusions: Use of an equimolar mixture of oxygen and nitrous oxide during ECV appears safe. Although it does not seem to change the overall success rate, it may increase success in parous women.

Keywords: breech presentation; external cephalic version; nitrous oxide.

© 2019 Nordic Federation of Societies of Obstetrics and Gynecology.

References

REFERENCES

    1. Hofmeyr GJ, Kulier R, West HM. External cephalic version for breech presentation at term. Cochrane Database Syst Rev. 2015;(4):CD000083.
    1. Collaris RJ, Oei SG. External cephalic version: a safe procedure? A systematic review of version-related risks. Acta Obstet Gynecol Scand. 2004;83:511-518.
    1. Cephalic E. Version and reducing the incidence of term breech presentation: Green-top Guideline No. 20a. BJOG. 2017;124:e178-e192.
    1. Dochez V, Delbos L, Esbelin J, Volteau C, Winer N, Sentilhes L. Facteurs prédictifs de réussite d’une version par manœuvre externe: étude bicentrique.[Predictors of success of external cephalic version: Bi-center study]. In French. J Gynécol Obstét Biol Reprod. 2016;45:509-515.
    1. Collins M. Nitrous oxide utility in labor and birth: a multipurpose modality. J Perinat Neonatal Nurs. 2017;31:137-144.
    1. Rooks JP. Safety and risks of nitrous oxide labor analgesia: a review. J Midwifery Womens Health. 2011;56:557-565.
    1. van der Kooy J, De Graaf JP, Kolder ZM, et al. A newly developed scavenging system for administration of nitrous oxide during labour: safe occupational use. Acta Anaesthesiol Scand. 2012;56:920-925.
    1. Jones L, Othman M, Dowswell T, et al. Pain management for women in labour: an overview of systematic reviews. Cochrane Database Syst Rev. 2012;(3):CD009234.
    1. Klomp T, van Poppel M, Jones L, Lazet J, Di Nisio M, Lagro-Janssen ALM. Inhaled analgesia for pain management in labour. Cochrane Database Syst Rev. 2012;(9):CD009351.
    1. Pita CP, Pazmiño S, Vallejo M, et al. Inhaled intrapartum analgesia using a 50%-50% mixture of nitrous oxide-oxygen in a low-income hospital setting. Arch Gynecol Obstet. 2012;286:627-631.
    1. ACOG. Practice Bulletin No. 161: External Cephalic Version. Obstet Gynecol. 2016;127:e54-e61.
    1. Zhang J, Bowes WA, Fortney JA. Efficacy of external cephalic version: a review. Obstet Gynecol. 1993;82:306-312.
    1. Le Bret T, Grangé G, Goffinet F, Cabrol D. Version par manœuvre externe Expérience à la maternité Port-Royal à partir de 237 versions. [External cephalic version: experience about 237 versions at Port-Royal maternity]. In. Franch. J Gynecol Obstet Biol Reprod. 2004;33:297-303.
    1. Hutton EK, Hannah ME, Ross SJ, et al. The Early External Cephalic Version (ECV) 2 Trial: an international multicentre randomised controlled trial of timing of ECV for breech pregnancies. BJOG. 2011;118:564-577.
    1. Rosman AN, Guijt A, Vlemmix F, Rijnders M, Mol BWJ, Kok M. Contraindications for external cephalic version in breech position at term: a systematic review. Acta Obstet Gynecol Scand. 2013;92:137-142.
    1. Burgos J, Cobos P, Osuna C, et al. Nitrous oxide for analgesia in external cephalic version at term: prospective comparative study. J Perinat Med. 2013;41:719-723.
    1. Burgos J, Melchor JC, Pijoán JI, Cobos P, Fernández-Llebrez L, Martínez-Astorquiza T. A prospective study of the factors associated with the success rate of external cephalic version for breech presentation at term. Int J Gynaecol Obstet. 2011;112:48-51.
    1. Kok M, Cnossen J, Gravendeel L, van der Post J, Opmeer B, Mol BW. Clinical factors to predict the outcome of external cephalic version: a metaanalysis. Am J Obstet Gynecol. 2008;199:630.e1-630.e7;discussion e1-e5.
    1. Coppola C, Mottet N, Mariet AS, et al. Impact de la version par manœuvre externe sur le pronostic obstétrical dans une équipe à fort taux de réussite de l’accouchement vaginal du siège. [Impact of the external cephalic version on the obstetrical prognosis in a team with a high success rate of vaginal delivery in breech presentation]. In French. J Gynecol Obstet Biol Reprod. 2016;45:859-865.
    1. Ebner F, Friedl TWP, Leinert E, et al. Predictors for a successful external cephalic version: a single centre experience. Arch Gynecol Obstet. 2016;293:749-755.
    1. Macarthur AJ, Gagnon S, Tureanu LM, Downey KN. Anesthesia facilitation of external cephalic version: a meta-analysis. Am J Obstet Gynecol. 2004;191:1219-1224.
    1. Fok WY, Chan LW, Leung TY, Lau TK. Maternal experience of pain during external cephalic version at term. Acta Obstet Gynecol Scand. 2005;84:748-751.
    1. Weiniger CF, Ginosar Y, Elchalal U, Sela HY, Weissman C, Ezra Y. Randomized controlled trial of external cephalic version in term multiparae with or without spinal analgesia. Br J Anaesth. 2010;104:613-618.
    1. Vlemmix F, Kuitert M, Bais J, et al. Patient’s willingness to opt for external cephalic version. J Psychosom Obstet Gynaecol. 2013;34:15-21.
    1. Rosen MA. Nitrous oxide for relief of labor pain: a systematic review. Am J Obstet Gynecol. 2002;186:S110-S126.
    1. Collins MR, Starr SA, Bishop JT, Baysinger CL. Nitrous oxide for labor analgesia: expanding analgesic options for women in the United States. Rev Obstet Gynecol. 2012;5:e126-e131.
    1. Richardson MG, Lopez BM, Baysinger CL. Should nitrous oxide be used for laboring patients? Anesthesiol Clin. 2017;35:125-143.
    1. Melo P, Georgiou EX, Hedditch A, Ellaway P, Impey L. External cephalic version at term: a cohort study of 18 years’ experience. BJOG. 2019;126:493-499.
    1. Wastlund D, Moraitis AA, Dacey A, Sovio U, Wilson ECF, Smith GCS. Screening for breech presentation using universal late-pregnancy ultrasonography: a prospective cohort study and cost effectiveness analysis. PLoS Medicine Med. 2019;16:e1002778.
    1. Wilcox CB, Nassar N, Roberts CL. Effectiveness of nifedipine tocolysis to facilitate external cephalic version: a systematic review. BJOG. 2011;118:423-428.
    1. Velzel J, Vlemmix F, Opmeer BC, et al. Atosiban versus fenoterol as a uterine relaxant for external cephalic version: randomised controlled trial. BMJ. 2017;356:i6773.
    1. Cluver C, Gyte GML, Sinclair M, Dowswell T, Hofmeyr GJ. Interventions for helping to turn term breech babies to head first presentation when using external cephalic version. Cochrane Database Syst Rev. 2015;(2):CD000184.
    1. Lansac J, Crenn-Hebert C, Rivière O, Vendittelli F. How singleton breech babies at term are born in France: a survey of data from the AUDIPOG network. Eur J Obstet Gynecol Reprod Biol. 2015;188:79-82.
    1. Paul C. The baby is for turning: external cephalic version. BJOG. 2017;124:773.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe