Statement on Anesthesia Management and Support for External Cephalic Version

Developed by: Committee on Obstetric Anesthesia
Original Approval: October 15, 2025

Rationale & Benefits: The American College of Obstetricians and Gynecologists (ACOG) recommends external cephalic version (ECV) for breech presentation at or after 37 weeks’ gestation in the absence of a contraindication to vaginal birth (VB) to decrease the rate of cesarean delivery (CD).¹ ECV may be performed with or without anesthesia care and local practices and/or policies vary. Breech presentation occurs in 3-4% of term pregnancies. Neuraxial anesthesia increases the success rates of ECV (RR 1.37 95% CI 1.19-1.58) and VB (RR 1.23, 95% CI 1.03-1.47).² Thus Anesthesia services are frequently requested to support and facilitate ECV procedures. This statement provides guidance for anesthesia care of ECV.

Procedure Location: ECV should be provided in a setting where expedited access to perform an emergency CD, a known complication, is available. The specific location of ECV should be individualized for each patient and institution. When providing a neuraxial technique, anesthetic doses, compared to analgesic doses, should be cared for by an anesthesia professional in accordance with the ASA/SOAP Practice Guidelines for Obstetric Anesthesia.³

NPO Status: Emergency surgical and anesthesia intervention is an uncommon complication of ECV occurring in 0.2-0.7%⁴ and the frequency does not differ with or without neuraxial anesthesia.^5,6 Therefore, NPO status should be ensured per ASA Guidelines and Statements, the same as for elective cesarean delivery.^3,7-9

Preoperative Anesthesia Assessment and Situational Awareness: Notification of an anesthesia professional prior to an ECV procedure with or without anesthesia services can help ensure prompt access to anesthesia services in the event of an emergency. Evaluation and informed consent for anesthesia services should be considered prior to ECV. Staffing and response times for emergency CD vary between units and include needing OR staff, anesthesia professionals, and obstetric teams. Communication in advance of ECV may help reduce response times and improve coordination of services. A multidisciplinary huddle prior to ECV can identify key team members as well as allow for discussion of medication needs, planned attempts, and management strategies in the setting of emergent maternal or fetal distress and disposition in the event of an unsuccessful procedure.

Anesthetic Management: Neuraxial (epidural, spinal, or CSE) techniques increase success rates of ECV and reduce CD rates with similar neonatal risks. Neuraxial anesthesia for ECV is associated with significantly higher odds of ECV success as well as maternal hypotension compared with controls, without significant differences in emergent CD or non-reassuring fetal heart tracing.¹⁰ Therefore, maternal hypotension should be aggressively prevented and managed with intravenous fluids and/or vasopressors as needed by bolus or infusion. The optimal dosing of local anesthetic and neuraxial opioid adjuvants has not been determined. A 2017 randomized controlled trial found a 51.5% success rate of ECV with no difference among intrathecal bupivacaine doses (2.5, 5.0, 7.5 or 10 mg and 15mcg of IT fentanyl) with no difference in CD rate.¹¹ The 7.5 and 10 mg groups had a longer time to discharge and a higher incidence of hypotension.¹¹ Dosing and technique should be individualized based on specific patient, provider, and institutional factors. Providing neuraxial analgesia/anesthesia for ECV when requested should be supported by local institutions and practices. 

Cost Analysis: ECV is a cost-effective intervention.^12,13 Neuraxial blockade prevented 17 CDs for every 100 ECVs attempted, although did not produce significant cost savings for hospital or insurance payors.¹⁴ The financial impact of this reduced CD rate on society, patients, quality life years, and future pregnancies was not considered and should be appreciated.

Hospitals, payors and health care systems should support ECV and anesthesia services for ECV.¹⁵

Standardized Care and Clinical Pathways: Standardized clinical pathways may aid institutional workflow and multidisciplinary communication, although clinical practice and pathways may vary based on patient, provider, and institutional factors. Post-procedural patient disposition will depend on gestational age, version success, and anesthetic technique. Standardized institutional post-recovery criteria should be met prior to discharge.

The ASA Committee on Obstetric Anesthesia has a more complete discussion of these recommendations as a committee resource.

References:

1. 1. External Cephalic Version: ACOG Practice Bulletin, Number 221. Obstet Gynecol. 2020;135(5):e203-e212. doi:10.1097/AOG.0000000000003837
2. Limming Lei, PhD ; Zhiyong Fang, PhD ; Chenyang Xu PhD, et al. Effect of anesthesia on the success rate of external cephalic version: GRADE- assessed systematic review and meta-analysis of randomized controlled trials. Syst Rev. 2024 Jul 30;13(1):202. doi: 10.1186/s13643-024-02616-y. 
3. Practice Guidelines for Obstetric Anesthesia: An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology. Anesthesiology 2016;124(2):270-300. Doi: 10.1097/ALN.000000000000935.
4. Gwang Jun Kim, PhD. Reviving external cephalic version: a review of its efficacy, safety, and technical aspects. Obstet Gynecol Sci 2019;62(6):371-381. 
5. Pervez Sultan, MD, MBChB, FRCA; Brendan Carvahlo, MBChB, FRCA. Neuraxial blockade for external cephalic version: a systematic review. Int J Obstet Anesth 2011;20:299-306. Doi: 10.1016/j.ijoa.2011.07.001
6. Elena Rita Magro-Malosso, MD; Gabriele Saccone, MD; Mariarosaria Di Tommaso, MD, PhD; Michele Mele, MD; Vincenzo Berghella, MD. Neuraxial analgesia to increase the success rate of external cephalic version: a systematic review and meta-analysis of randomized controlled trials. Am J Obstet Gynecol. 2016;215(3):276–86.
7. Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures: An Updated Report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. Anesthesiology 2017;126(3):376-393. Doi: 10.1097/ALN.0000000000001452.
8. Girish P. Joshi, MD, MB, BS, FCAI, FASA; Basem B. Abdelmalak, MD, FASA; Wade A. Weigel, MD, FASA; et al. Practice Guidelines for Preoperative Fasting: Carbohydrate-containing Clear Liquids with or without Protein, Chewing Gum, and Pediatric Fasting Duration - A Modular Update of the 2017 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting. Anesthesiology 2023;138(2):132-151.
9. ASA Statement on Oral Intake During Labor.  https://www.asahq.org/standards-and-practice-parameters/statement-on-oral-intake-during-labor 
10. Qingzhong Hao, MD; Yirui Hu, BS, MS, PhD; Li Zhang, MD, PhD; John William Ross, MD; Sarah Robishaw, PhD; Christine A. Noble, MD; et al. A systematic review and meta-analysis of clinical trials of neuraxial, intravenous, and inhalational anesthesia for external cephalic version. Anes Analg. 2020;131(6):1800-11.
11. Laurie A. Chalifoux, MD, FASA; Jeanette R. Bauchat, MD, MS; Nicole Higgins, MD, FASA; Paloma Toledo, MD, MPH, FASA; Feyce M. Peralta, MD, MS, FASA; Jason R. Farrer, MD; Susan E. Gerber, MD, MPH; Robert J. McCarthy, PhD, PharmD; John T. Sullivan, MD, MBA. Effect of intrathecal bupivacaine dose on the success of external cephalic version for breech presentation. Anesthesiology 2017;127(4):625-632
12. Jonathan M.Tan, MD, MBI, MPH, FASA; Alex Macario, MD, MBA; Brendan Carvalho, MD, FASA; et al. Cost-effectiveness of external cephalic version for term breech presentation. BMC Pregnancy Childbirth 2010;10:3.
13. David S. Gifford, MD, MPH;  Emmett Keeler, PhD; Katherine L. Kahn, MD. Reductions in cost and cesarean rate by routine use of external cephalic version: A decision analysis. Obstet Gynecol 1995;85:930-936. 
14. Kelly Yamasato, MD; Bliss Kaneshiro, MD, MPH; Jennifer Salcedo, MD, MPH, MPP, FAGOC. Neuraxial blockade for external cephalic version: Cost analysis. J Obstet Gynaecol Res;2015:41(7):1023-1031.
15. ASA Statement on Economic Credentialing and Contracting, 2024, https://www.asahq.org/standards-and-practice-parameters/statement-on-economic-credentialing-and-contracting