We read the recent meta-analysis by Magro-Malosso et al with interest and agree with their findings confirming improved success rates of external cephalic version (ECV) with neuraxial blockade. We were surprised, however, that the authors stated that no such previous meta-analysis exists, since efficacy of neuraxial block for ECV was first described in 2010. A previous meta-analysis and systematic review both have reported improved ECV success rates with the use of neuraxial blockade. We find it concerning that published literature in anesthesia journals have not been disseminated within the obstetric domain and that this omission was not detected during the peer-review process. We are nevertheless hopeful that this publication will lead to greater obstetrical awareness and use of this technique, which can improve ECV success, and importantly potentially avoid a cesarean delivery for women with breech presentation.

We agree with the authors that the optimal neuraxial technique and dose required to maximize ECV success have yet to be elucidated; however, they fail to cite a key subgroup analysis from a previous meta-analysis clearly demonstrating that anesthetic rather than analgesic dosing strategies are needed to optimize success rates. Muscle relaxation from anesthesia is therefore likely to be required, and analgesia alone probably is inadequate to facilitate ECV.

Concerns have been raised regarding the potential for morbidity secondary to the use of greater force by the obstetrician in the presence of less maternal pain and abdominal muscle contraction under anesthesia. The authors do address the safety aspect of performing ECV under neuraxial block; however, they do not refer to systematic review safety data previously extrapolated from a larger cohort of patients (n = 850) including both randomized and nonrandomized controlled studies. The incidence of placental abruption was found previously to be 0.22% (95% confidence interval [95% CI], 0.07–0.66%) with neuraxial block compared with 0.48% (95% CI. 0.16–1.44%) in control groups, and requirement for emergency cesarean delivery for nonreassuring heart rate was 0.44% (95% CI, 0.15–1.32) with neuraxial block compared to 0.48% (95% CI, 0.16–1.44) in control groups.

In summary, we thank Magro-Malosso et al for highlighting the role of neuraxial blockade in improving the success rates of ECV. The omission of key publications in their meta-analysis highlights inadequate dissemination of anesthesia findings within the obstetric specialty. We hope interspecialty transfer of such information will occur in the future. Importantly, providers using neuraxial anesthesia to facilitate ECV should use anesthetic doses to optimize the success of ECV.