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Acupuncture & Moxibustion for Breech Presentation

Acupuncture & Moxibustion for Breech PresentationBY SUSAN WALLMEYER, L.AC. & SARAH TEWHEY, L.AC.

EVIDENCE SUMMARY:

ACUPUNCTURE & MOXIBUSTION FOR BREECH PRESENTATION

Strength of evidence

INTRODUCTION

Breech (feet first) presentation of the foetus in the last month of pregnancy occurs in 3-4% of all pregnancies.1 In the United States, 90% of all breech babies are born via cesarean section,2 a major surgical procedure that carries risk but also impacts maternal outcomes, postpartum recovery, and adds to costs in the healthcare system.3 Access to a variety of corrective options that may increase the chance of a baby turning from breech to cephalic (head down) will benefit both the healthcare system and people giving birth.

Acupuncture and Moxibustion for Breech Presentation PDF

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Moxibustion treatment for breech presentation generally involves lighting a rolled cigar-like moxa stick of dried Chinese mugwort, also known as Ai Ye, or Artemisia argyi, and using the heat from it to warm and stimulate a point located on the outer edge of the 5th toe known as Zhi Yin or Urinary Bladder 67 (UB67). The moxa stick is held close to the point to warm it once or twice daily for 15-30 minutes, for 5-14 consecutive days. Optimal timing for moxibustion and acupuncture treatment for breech has not yet been definitively determined by research, but it is generally accepted within the acupuncture community that treatment is most effective at 33-35 weeks gestation.4 Providing this intervention as an option to parents may help to reduce rates of breech presentation at term,5,6 thereby lowering rates of cesarean section and improving maternal outcomes, leading to improved satisfaction with birth experience.

CURRENT STANDARD OF CARE

The most commonly performed treatment for correction of a breech baby’s position is an External Cephalic Version (ECV). During this procedure, a healthcare provider in a hospital setting uses their hands on the outside of the abdomen, attempting to manually turn the baby. It is 50-60% effective and is typically used at 36-37 weeks gestation.2 ECV carries risks such as premature labour and can be a painful, emotionally stressful process.2 For these reasons, ECV is not offered by all prenatal care providers and is not an intervention all those with a breech presentation will choose to undergo.

SUMMARY OF RESEARCH

A 2023 Cochrane Systematic Review by Coyle et al.5 looked at 13 trials (2181 participants) that assessed the use of moxibustion, acupuncture, postural techniques, and usual care for breech presentation in uncomplicated pregnancies. Of those 13 trials, 7 studies (1152 participants) compared moxibustion treatment plus usual care to usual care alone and found moderate certainty evidence that moxibustion before 37 weeks of pregnancy probably reduces the chance of breech presentation at birth and the need for oxytocin use during birth. Despite these findings, the overall rate of cesarean section was not decreased by using moxibustion to change foetal presentation. The authors noted that although a cesarean section can occur for many reasons unrelated to a baby’s position, none of the studies reported on the reasons for cesarean section in either group.

While contemporary East Asian Medicine practised in the West tends to emphasize moxibustion for turning breech babies, a survey of practitioners reported that 50% combine it with acupuncture as the standard of care in their practice.4 At this time, only a small amount of research looks at the effect of this combination. A 2021 Systematic Review by Liao et al.6 of 16 studies (2555 participants) found that each “acupuncture-type intervention” (whether moxibustion at UB67 alone, acupuncture alone or moxibustion at UB67 plus acupuncture) led to an increased rate of cephalic presentation at birth when compared to usual care. However, the 2023 Cochrane Review authors concluded that there is not enough data to determine if the “combination treatments” (moxibustion plus acupuncture) led to an increase in head down babies at birth over moxibustion alone.5 More research is needed to determine the effects of this clinically relevant style of treatment.

Vas et al.7 conducted a large (406 participants) and well-designed study to determine if the UB67 acupuncture point location was specifically helpful with turning breech babies. They compared three groups; those who had moxibustion at UB67, those who had moxibustion at an “inactive” point, and those who received usual care (no moxibustion). Fifty-eight percent of participants in the UB67 moxibustion group had babies who turned head down. The groups performing moxibustion on an inactive point or who had usual care had lower rates of cephalic version (43% and 45% respectively). This result shows a statistically significant difference between the groups. Although more studies are needed, this study suggests there may be something unique about the UB67 acupuncture point that is specifically useful in this context. The rates of cesarean section were not significantly different between the two groups in this study and the reasons for cesarean birth were not provided.

In 2017, the Royal College of Obstetricians and Gynecologists (RCOG) included moxibustion and acupuncture in their Green-top Guidelines for External Cephalic Version and Reducing the Incidence of Term Breech Presentation.8 This document represents the first inclusion of moxibustion and acupuncture treatment in a clinical guideline by a major professional organization within the field of Obstetrics. The RCOG guidelines8 recommend that pregnant people may wish to consider the use of moxibustion at 33-35 weeks gestation. The recommendation also emphasizes the importance of choosing a trained practitioner for individuals seeking out this type of treatment.8

 

According to the 2023 Cochrane Review,5 one hypothesized mechanism of action is that treatment at the acupuncture point UB67 may stimulate maternal hormones (placental oestrogens and prostaglandin). This hormonal change may prompt the lining of the uterus to gently contract, resulting in increased foetal activity. A 1998 study by Cardini and Weixin9 measured foetal activity in a group receiving moxibustion treatment and a group receiving usual care. Foetal movements were counted by the pregnant participants for one hour each day for a week. An average of 48.45 movements per hour were reported in the moxibustion group versus 35.35 movements in the group receiving usual care. This result represents a statistically significant difference and indicates that an increase in foetal movement may play a role in the mechanism of UB67 to correct breech presentation. Since the exact mechanism by which moxibustion and/or acupuncture acts to correct breech position is unknown, more well-designed research is needed.

SAFETY

Using acupuncture and moxibustion to attempt to correct foetal position in uncomplicated pregnancies carries low risk. Serious adverse events, though not adequately reported in trials, appear to be rare.5,6

The 2023 Cochrane Review5 reported the most common adverse events as the potential for burns, increased foetal movements, uterine contractions, nausea, and headaches. In many cases, adverse events were not reported by group allocation and causality was not well established, making definitive conclusions about safety difficult to determine. Moreover, current research on the safety and effectiveness of moxibustion for breech presentation has included uncomplicated pregnancies only. Therefore, providers performing these treatments must be well versed in potential risks and contraindications.

Moxibustion should be used in a well-ventilated room or outdoors due to the potential for respiratory irritation from the smoke it can produce. Additionally, the person performing the moxibustion should be attentive in order to avoid contact with skin and prevent burns.

The Maternal Acupuncture Mentoring and Peer Support (MAMPS)12 advisory group provides a safety sheet for acupuncturists on their website that outlines a framework for safe practice by practitioners who are performing treatments for breech presentation.13

 

CONCLUSION

Since treatment with acupuncture and moxibustion can be attempted several weeks prior to an ECV, it has potential to be an effective, safe, and well tolerated first-line option for breech presentation.

The authors wish to thank Debra Betts, PhD, LAc and Zena Kocher, LAc for their invaluable feedback in preparing this summary.

References:

1. Hofmeyr, G. J., Kulier, R. & West, H. M. External cephalic version for breech presentation at term. Cochrane Database of Systematic Reviews 2019, (2015).

3. Obstetric Care Consensus No. 1: Safe Prevention of the Primary Cesarean Delivery. Obstetrics & Gynecology 123, 693–711 (2014).

4. Smith, C. A. & Betts, D. The practice of acupuncture and moxibustion to promote cephalic version for women with a breech presentation: Implications for clinical practice and research.
Complementary Therapies in Medicine 22, 75–80 (2014).

5. Coyle, M. E., Smith, C. A. & Peat, B. Cephalic version by moxibustion for breech presentation. Cochrane Database of Systematic Reviews (2023). doi:10.1002/14651858.CD003928. pub4

6. Liao, J.-A., Shao, S.-C., Chang, C.-T., Chai, P. Y.-C., Owang, K.-L., Huang, T.-H., Yang, C.-H., Lee, T.-J. & Chen, Y.-C. Correction of Breech Presentation with Moxibustion and Acupuncture: A Systematic Review and Meta-Analysis. Healthcare 9, 619 (2021).

7. Vas, J., Aranda-Regules, J. M., Modesto, M., Ramos-Monserrat, M., Barón, M., Aguilar, I., Benítez-Parejo, N., Ramírez-Carmona, C. & Rivas-Ruiz, F. Using Moxibustion in Primary Healthcare to Correct Non-Vertex Presentation: A Multicentre Randomised Controlled Trial. Acupunct Med 31, 31–38 (2013).

8. External Cephalic Version and Reducing the Incidence of Term Breech Presentation: Green-top Guideline No. 20a. BJOG: Int J Obstet Gy 124, e178–e192 (2017).

9. Cardini, F. & Weixin, H. Moxibustion for Correction of Breech Presentation: A Randomized Controlled Trial. JAMA 280, 1580 (1998).

10. Cardini, F., Lombardo, P., Regalia, A. L., Regaldo, G., Zanini, A., Negri, M. G., Panepuccia, L. & Todros, T. A randomised controlled trial of moxibustion for breech presentation. BJOG: Int J O&G 112, 743–747 (2005).

11. Neri, I., Airola, G., Contu, G., Allais, G., Facchinetti, F. & Benedetto, C. Acupuncture plus moxibustion to resolve breech presentation: a randomized controlled study. The Journal of Maternal-Fetal & Neonatal Medicine 15, 247–252 (2004).

12. MAMPS. Maternity Acupuncture Mentoring & Peer Support. Maternity Acupuncture Mentoring & Peer Support at https://www.mamps.org

13. MAMPS. MAMPS – Resources. Maternity Acupuncture Mentoring & Peer Support at https://www.mamps.org/resources