(270) A Cost-Effectiveness Analysis of Neuraxial Anesthesia and Number of Attempts for External Cephalic Version

ECV is a key tool in management of presentation and reducing cesarean deliveries. There is debate regarding the optimal use of neuraxial anesthesia for ECV procedures, and whether it is beneficial to offer a second ECV attempt for patients with persistently breech fetuses. Studies have found ECVs with neuraxial anesthesia to be the cost-effective strategy, however this is the first study to directly compare both the use of neuraxial anesthesia and the number of attempts.

Study Design:

A cost-effectiveness model was built using TreeAge 2023 software to compare outcomes and costs of one or two attempts of ECV with or without use of neuraxial anesthesia. We used a theoretical cohort of 100,000 nulliparous women with non-vertex presenting singletons. The model accounted for costs and quality adjusted life years (QALYs) for the mother and the neonate. Outcomes included unsuccessful ECV, cesarean delivery, maternal death, neonatal death, and major neurodevelopmental disability. Probabilities were derived from the literature, and a cost-effectiveness threshold was set at $100,000/QALY.

Results:

In our theoretical cohort of 100,000 pregnant women, we found that two attempts, the first without neuraxial anesthesia, and the second with neuraxial anesthesia to be the most cost-effective strategy with an ICER of $27,874. Two attempts with both under neuraxial anesthesia was the most effective option with 3000 fewer cesarean deliveries, 5 fewer cases of neonatal death and 1 fewer case of major neurodevelopmental disability. However, in our cohort, two attempts under neuraxial anesthesia was 24 million dollars more expensive. With sensitivity analysis, two attempts with neuraxial becomes the dominant strategy if the rate of successful ECV with neuraxial anesthesia were greater than 0.62.

Conclusion:

Two attempts for ECVs with and without neuraxial anesthesia is optimal when compared to one attempt. The most cost-effective option is to perform the first ECV without neuraxial anesthesia and the second attempt with neuraxial anesthesia at the time of possible cesarean delivery.