Debra Betts - Acupuncture and Acupressure for Pregancy and Childbirth

Breech: Evidence base phamplet (689.0 KB)

Acupuncture and Moxibustion for Breech. Summary sheet.pdf (301.3 KB)

Acupuncture and Moxibustion for Breech Presentation:  Summary sheet

 

Background

While the incidence of breech presentation is common before 28 weeks – this decreases as  a pregnancy progresses; with 7-15% of babies remaining breech at 32 weeks and 3-4% at birth.1

Usual care to turn a breech baby to a cephalic presentation may involve the use of an external rotation (ECV), a procedure that requires close medical monitoring.   While this has been shown to be more successful than no treatment, the success rate remains relatively low.2  However there is some evidence, although limited, that moxibustion alone or moxibustion in combination with acupuncture may assist babies turn cephalic.3 It is also known that there is an interest from women in seeking interventions such as moxibustion in order to achieve cephalic version.4

Moxibustion is often recommended in acupuncture texts as a treatment for breech presentation. This is usually in the form of the herb compressed into a cigar like moxa stick. The precise mechanism by which Moxibustion may effect a baby’s position remains unknown but moxa has been shown to emit long-wavelength infrared radiation5 and it has been suggested that stimulation of the point BL 67 stimulates the production of maternal hormones (placental oestrogens and prostaglandin), encouraging the lining of the uterus to contract which in turn may stimulates fetal activity.6

In the studies to date no differences have been reported in the risk of risk of premature rupture of membranes  or other pregnancy complications between groups for those receiving moxibustion and those of  the control groups or those receiving usual  care.3

To date there is no research available for women with twin pregnancies where the presenting twin is breech.

The Evidence Base for moxibustion and moxibustion with Acupuncture

A Cochrane review found limited evidence to support the use of moxibustion for correcting breech presentation (Table 1).  However within these studies the length of time that the moxibustion was used and the frequency of treatment delivered varied considerably.  It may be that these ‘dosage’ differences impacted on the findings. Only two trials examined the use of moxibustion as recommended in acupuncture texts (7,8).This involves using moxibustion for 15 minutes bilaterally.  Trials that do not reflect the therapeutic dose delivered in clinical practice may well limit the confidence of research findings.

A finding from the research that has important considerations for clinical practice was that for women in western countries there were two trials where women failed to fully comply with the research protocols (9.10). Practitioners may need to consider how to support women compleate treatment if the concept of moxa is unfamiliar. Written information sheets and follow up may be required.  

Table 1. Trials in Cochrane review

Citation

Control

Intervention

Treatment details

Findings

Cardini

1998

N =260

Usual care

Moxa only

15 mins each toe   

Daily up to 14 days

Moxa       (+)

Cardini

2005

N=123

Usual care

Moxa only

15 mins each toe  

Daily up to 14 days  

Discontinued  due to noncompliance

Chen

2004

 N = 142

Usual care

Moxa + position 

10 – 15 minutes in total

Once a day for 3 days  

Moxa plus position (+)

Lin

2002 

N= 122

Position exercises

Moxa + position 

15 minutes in total  

Once a day for 2 days  

Moxa plus position (+)

Yang

2006

N=206

Position exercises

Moxa + position

15 – 20 mins in total  

Twice a day up to one week

Moxa plus position (+)

Guittier

2009 

N=212

Usual care

 Moxa 

10 minutes each toe 

Once up to 14 days

18 % turned  Moxa

16% usual care

Neri

2004 

N=226

Observation (no ECV)

Moxa  + acupuncture

20 mins in total  

Twice a week up to 2 weeks 

Moxa + aupuncture    (+)

Neri

2007

N= 41

Moxa/ Acupuncture/ Moxa  + acupuncture

20 mins each toe  

Twice a week up to 2 weeks 

80% for moxibustion

28% for acupuncture

57% for acup + Moxa

(+) Statically significant.    N= number of women

 Although the studies using moxibustion plus positioning demonstrated positive befits it is worth noting that two of these studies ( Lin 2002; Yang 2006)  accepted women under 34 weeks gestation and as more babies are expected to tune spontaneously before 34 weeks these results may not be transferable.  

 Further studies to this review include a comparison of Moxa on BL 67 to Moxa on Sham point and an inactive laser on BL 67. This study found that the moxa treatment was statically significant to the sham and control.11 While a study that used an inactive laser as a control to a treatment of moxa plus acupuncture did not find any statically significant differences, 12  it should be noted that the use of acupuncture is not recommended in acupuncture texts 7.8 and may not reflect recommended clinical practice. Finally a study examined usual care to the use of moxibustion for a total time of 15- 20 minutes rather than 15 mins to both toes.10.  This does not necessarily reflect recommended clinical practice and may have impacted on their findings that there was no statically significant differences between groups.

Conclusion

When considering the evidence for the use of moxibustion to turn breech babies cephalic it is worth considering dosage. To date very few studies have used the moxibustion as recommended in acupuncture texts. This may impact on the research findings reported.  

References

1. Hickok DE, Gordon DC, Milberg JA, Williams MA, Daling JR. The frequency of breech presentation by gestational age at birth: a large population-based study. Am J Obstet Gynecol 1992;166(3):851-2.

2. Hutton EK., Hofmeyr GJ, Dowswell T. External cephalic version for breech presentation before term.  Cochrane Database Syst Rev 2105: doi: 10.1002/14651858.CD000084.pub3.

3. Coyle ME, Smith CA, Peat B.Cephalic version by moxibustion for breech presentation. Cochrane Database Syst Rev 2012: doi: 10.1002/14651858.CD003928.pub3.

4. Smith, CA, 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 2014;22:75—80

5. Pach D, Brinkhaus B, Willich SN. Moxa sticks: thermal properties and possible implications for clinical trials. Complementary Therapies in Medicine 2009;17:243-6.

6. Cooperative Research Group of Moxibustion Version of Jangxi Province. Further studies on the clinical effects and mechanism of version by moxibustion. Abstracts of the Second National Symposium on Acupuncture, Moxibustion, and Acupuncture Anesthesia; 1984 Aug 7-10; Beijing, China. 1984:150-1.

7 Betts D. The Essential Guide to Acupuncture in Pregnancy & Childbirth. Hove: Journal of Chinese Medicine Publications 2006

8 Deadman P, Al-Khafaji M, Baker K. A Manual of Acupuncture. London: Journal of Chinese Medicine Publications 2001

9. Cardini F, Lombardo P, Regalia AL, Regaldo G, Zanini A, Negri MG, et al. A randomised controlled trial of moxibustion for breech presentation. BJOG: an international journal of obstetrics and gynaecology 2005;112:743-7

10. Bue L, Lauszus F. Moxibustion did not have an effect in a randomised clinical trial for version of breech position.Dan Med J, 2016;63(2):A5199.

11. Vas J, Aranda-Regules JM, Modesto M, Ramos-Monserrat M, Barón M, Aguilar I, Benítez-Parejo N et al. Using moxibustion in primary healthcare to correct non-vertex presentation: a multicentre randomised controlled trial. Acupunct Med. 2013 Mar;31(1):31-8. doi: 10.1136/acupmed-2012-010261

12 Coulon C, Poleszczuk M, Paty-Montaigne MH, Gascard C, Gay C, Houfflin-Debarge V et al. Version of breech fetuses by moxibustion with acupuncture: a randomized controlled trial. Obstet Gynecol. 2014 Jul;124(1):32-9. doi: 10.1097/AOG.0000000000000303