Neuraxial Anesthesia for External Cephalic Version and the Risk of Emergent Cesarean Delivery: A Retrospective Cohort Study

OBJECTIVE: External cephalic version (ECV) is performed to reduce cesarean delivery rates by rotating a breech fetus to cephalic presentation. Neuraxial anesthesia has been proposed to improve success by reducing maternal pain and increasing uterine relaxation. However, its impact on emergency cesarean delivery following ECV remains unclear, as prior studies have not isolated emergent cases from overall cesarean rates. Therefore, we aimed to evaluate whether neuraxial anesthesia (NA) increases emergency cesarean delivery risk and impacts ECV success and delivery mode. METHODS: This retrospective cohort study analyzed 299 ECV procedures from 2013 to 2022 at a single institution. Patients received either NA (spinal, epidural, or combined spinal-epidural) or no NA. The primary outcome was emergency cesarean for fetal heart rate abnormalities. Secondary outcomes included version success and delivery mode. Logistic regression models and entropy balancing adjusted for confounding. RESULTS: NA was used in 96 (33.4%) procedures. Emergency cesarean delivery occurred in 21 cases, with 18 (85.7%) after NA. NA was associated with a significantly increased risk of emergency cesarean (adjusted odds ratio 11.6; 95% CI 3.25-41.1, P < 0.001). ECV success rates were similar (35.4% vs. 29.3%, P = 0.451), as were vaginal delivery rates following successful ECV (83.9% vs. 82.6%). CONCLUSIONS: NA during ECV was strongly associated with increased emergency cesarean delivery risk without improving external cephalic version success. Routine use should be reconsidered in favour of a more selective approach.