Thank you for your letter and your interest. We are aware of the existence of previous meta-analyses about this topic, but the fact that there were a few and we had limited editorial space restricted our opportunity to review them in detail, except for the Cochrane, which we mentioned in our article. We did not state that such meta-analyses do not exist but “To our knowledge, no prior meta-analysis on this issue is as large, up to date or comprehensive.” Moreover, we are very aware of the anesthesia literature (3 of our references were indeed from anesthesia journals), and one of our co-authors is an anesthesiologist.

The first meta-analysis on maternal anesthesia as intervention to facilitate external cephalic version (ECV) was published in 2004, with 4 randomized controlled trials (RCTs) included. A second meta-analysis was published in 2010 with 7 RCTs included. Another meta-analysis published in 2011 included 6 RCTs, excluding abstracts. Drs Sultan and Carvalho’s (authors of this letter) meta-analysis included 6 RCTs. Our meta-analysis includes 9 RCTs.

We recognize the excellent work in the meta-analysis by Lavoie and Guay, and we agree that optimizing muscle relaxation in addition to maternal comfort increases the success rate of ECV. We chose not to include a subgroup analysis of anesthetic dose vs analgesic dose because this was a very heterogeneous group with varying medication types and doses. We believe these different neuraxial techniques have inherent differences in the quality of muscle relaxation, with a spinal technique possibly producing more relaxation of the anterior abdominal wall than that produced by epidural despite the same sensory level. The levels documented in the studies included in our meta-analysis were based on assessing sensory level only and excluded simple motor testing. We believe this represents an opportunity in the future to compare muscle relaxation in spinal versus epidural to differentiate the effectiveness of these neuraxial techniques in facilitating ECV.

We thank Drs. Sultan and Carvalho, as they also point to the safety of ECV under neuraxial anesthesia, citing their randomized and nonrandomized data. In our meta-analysis of RCTs only, we reported on several more safety outcomes than Sultan and Carvalho, including emergency cesarean delivery, transient fetal bradycardia, nonreassuring fetal testing (excluding transient bradycardia) after ECV, and abruption placentae, which were all similar between ECV with or without neuraxial analgesia, whereas a significantly lower incidence of maternal discomfort and a lower pain score were found with neuraxial analgesia.

In summary, we want to thank the authors for this letter because it gives us the opportunity to clarify some aspects of our meta-analysis and to highlight again the safety and efficacy of neuraxial analgesia in improving ECV success.