Breech presentation puts both mother and baby at a higher risk of morbidity and mortality. In Western countries, a large proportion of breech babies are delivered by elective caesarean section, which itself presents significant dangers. It is therefore preferable to turn the baby to a cephalic position prior to delivery. Chinese Medicine traditionally treats breech presentation by stimulating acupoint Zhiyin BL-67. This paper reviews the literature on the treatment of breech presentation with acupuncture and moxibustion at Zhiyin BL-67, focusing on the efficacy of these treatments and the viability of offering them in the private and public health sectors. It concludes that there is evidence to support treatment of breech presentation by stimulating Zhiyin BL-67 with both needling and moxibustion, and that moxibustion in particular is a safe and cost-effective method of treating breech presentation. However, more robust research using greater sample sizes is still needed in this area.
By: Andrea Aiello Steinlechner
As pregnancy progresses, lack of space within the woman’s abdomen makes it more difficult for the baby to move. In primiparous pregnancies the foetus normally settles in the pelvis between weeks 34 and 36. In subsequent pregnancies, such engagement of the baby can happen much later, even after labour has been established (Pairman et al., 2006). Non‑cephalic presentations are also possible, as in breech presentation where the baby positions itself in an upright sitting position. Predisposing factors for breech include foetal or uterine abnormality and multiple pregnancies. Other factors remain speculative (Chalmers et al., 1989). Around three to four per cent of nulliparous singleton pregnancies present breech position at full term (NCT, 2010).
The risks of breech delivery have been recognised for hundreds of years. Hippocrates (460 to 370 BCE) wrote of the dangers to the mother and child of vaginal breech delivery (Spencer, 1901). A study by Spencer (1901) between 1890 and 1894 at Guys Hospital in London (UK) found that one in four breech babies were stillborn. This study showed that up to 45 per cent of all non‑cephalic babies were stillborn and an additional five per cent died on their first day of life. The same statistics showed that only 2.4 per cent of cephalic‑positioned babies died during labour, and one per cent died the day after birth. Spencer found that perinatal deaths were frequently caused by the umbilical cord being prolapsed or compressed, leading to asphyxia. The mechanical impact of labour on the baby was also significant, leading to rupture of the baby’s internal organs and haemorrhage ‑ most commonly of the liver and lungs (crushed lungs lead to pneumothorax or newborn pneumonia). The testes in such cases were particularly vulnerable, which may explain why almost two out of three stillborn babies were boys. Some babies survived such births, but subsequently experienced life‑long disabilities. Maternal mortality also nearly doubled to one per cent with breech birth. More recent studies (Hannah et al.,2000; Sanchez‑Ramos et al., 2001) indicate that even with advances in modern medicine there remains a statistically significant risk of perinatal mortality, neonatal mortality and serious neonatal morbidity after vaginal delivery of breech babies compared to delivery by elective caesarean section.
A study of the cost of planned caesarean section versus planned vaginal birth for delivery of breech babies concluded that caesarean delivery is less costly, due to babies being born with this method requiring less neonatal care (Palencia et al., 2006). Another trial examining breech delivery found no statistical difference in maternal complications, with no greater cost in caring for mother, but suggested that caesarean section is safer for the baby than planned vaginal birth, and is thus recommended when pregnancy presents as breech at term (Richardson et al., 2007). External cephalic version (ECV), where the baby is manually turned into the correct position for birth, can be attempted to provide for a safer vaginal delivery. ECV is one of the most common procedures performed in the West to resolve breech presentation, with a success rate of between 35 and 57 per cent in nulliparous women (NICE, 2008). However, this procedure presents a high risk to both mother and baby, and must be performed by a trained gynaecologist in a hospital theatre on or after 37 weeks gestation, as an emergency caesarean section may be required in case of rupture of the membranes (Chapman, 2003).
Traditional Chinese medicine
TCM considers the Kidney to be the root of pre‑heaven qi and the basis of prenatal life. Kidney essence comes from the parents and is established at conception, and Kidney qi is the foundation of the yin and yang of all the other organs. Kidney yin governs birth, growth and reproduction, whilst Kidney yang provides the driving force behind all physiological activities (Wu, 2002; Kaptchuk, 2000). Kidney qi thus plays a fundamental role in pregnancy. Kidney yin is more prominent in the early developmental stages of the foetus, while Kidney yang becomes more important during the later stages and through labour (Betts, 2006). With this explanation in mind it becomes clear why failure of the foetus to move into a correct position before birth tends to relate to Kidney yang deficiency and stagnation (Betts, 2006), and that in such cases the appropriate treatment principle is to tonify and promote movement of Kidney yang.
In practice there are several methods of tonifying or stimulating Kidney yang. In the case of breech presentation, Zhiyin BL‑67 ‑ located at the lateral border of the nail of the little toe ‑ is usually selected as an empirical point for treatment (Deadman et al., 2007; O’Connor et al., 1981; Cheng, 1999; Cheung, 2009). According to TCM theory, the Kidney relates to the water element and is paired with the Bladder ‑ the Kidney corresponds to yin, while the Bladder corresponds to yang. Zhiyin (‘Reaching Yin’) BL‑67 is the last point on the Bladder channel, where yang is at its greatest and the energy of the channel is shifting to the yin of the Kidney, and thus ‘reaching yin’ (O’Connor et al., 1981). Zhiyin BL‑67 is a metal point ‑ the ‘mother ’ point on the channel ‑ and thus has a tonifying action, whilst as a jing‑well point it can clear stagnation from the channel (Deadman et al., 2007).
Moxibustion is the practice of burning moxa (mugwort or Artemisia Vulgaris) on or near the body (Manaka et al., 1995). Moxibustion is easy to apply and mothers are usually taught to self‑treat this point at home (Cheng, 1999). In China and Japan breech presentation is routinely treated by daily stimulation of the point Zhiyin BL‑67 using a moxa stick (Deadman et al., 2007; Cheng, 1999; Kanakura et al., 2001; Zhao, 2002). Zhiyin BL‑67 is a sensitive point and is thus usually treated with moxa rather than needling. Although needling combined with moxibustion may hypothetically be more powerful than moxibustion alone, needling is more invasive and thus less user‑friendly and cost‑effective, as it is not appropriate for home‑treatment. Moxa is yang in comparison with needling and has the ability of penetrating the channel, promoting nourishment and circulation of qi and blood and moving stasis (Abbate, 2002). This is said to promote the movement of mother ’s qi and blood, which in turn encourages foetal movement (Neri et al., 2004; Vas et al., 2008).
The Cochrane Library, MEDLINE, MIDIRS and PubMed were searched for articles on breech presentation using the following individual keywords: breech presentation, ECV, treatment for breech presentation, Zhiyin BL‑67, moxibustion, moxibustion for breech and acupuncture for breech. Only English‑language randomised controlled trials (RCTs) and controlled clinical trials (CCTs) comparing moxibustion or acupuncture with a control group were included, and papers were limited to those studying singleton breech pregnancies confirmed by ultrasound published after 1998 (all of which offered ECV after the two weeks of the trial ended). TCM texts and bibliographies of relevant books and journal articles were also searched manually.
A recent systematic review found that treatment with acupuncture or moxibustion is effective in correcting breech (Van den Berg et al., 2008), although some of the studies were of inferior quality. Another systematic review found that although the available studies lack homogeneity, moxibustion is effective in the treatment of breech presentation (Vas et al., 2009). Likewise, a Beijing‑based systematic review that analysed RCTs as well as CCTs reported positive outcomes for the use of moxibustion to treat breech (Li et al., 2009). In contrast, a Cochrane review found insufficient evidence to recommend the use of moxibustion for the treatment of breech, due to a lack of well‑designed large‑scale studies (Coyle et al., 2005). Taken together these findings suggest that further large‑scale, quality studies are necessary to definitively state whether moxibustion is an effective treatment for breech presentation.
Studies comparing moxibustion or acupuncture treatment to observation alone have found positive statistical significance and conclude by recommending the use of these treatments to correct breech presentation (Cardini et al., 1998; Kanakura et al., 2001; Habek et al., 2003; Neri et al., 2004). The Italian obstetrician and acupuncturist, Dr. Francesco Cardini, published a pioneering and highly influential trial. His European non‑governmental non‑profit organisation‑ funded RCT took place in China (Cardini et al., 1998) and saw a 75 per cent (moxibustion at Zhiyin BL‑67) versus 48 per cent (observation) positive outcome. Unfortunately an attempt to replicate the same study in Italy failed to complete due to lack of compliance (Cardini et al., 2005). Conversely, a Turin‑based RCT had only one drop‑out due to poor compliance (Neri et al., 2004) and saw 54 per cent (treatment ‑ moxa and acupuncture on BL‑67) versus 38 per cent (control ‑ observation) positive outcome. Equally, a small scale Croatian‑based RCT reported good compliance and a 76 per cent treatment versus 45 per cent control positive outcome (Habek et al., 2003). Possibly the largest trial to date ‑ a Japanese CCT (Kanakura et al.,2001) that started treatment at week 28 ‑ presented the highest number of cephalic versions in both the treatment and control groups, with a higher number observed in the treatment group. Amore recently‑published RCT (Guittier et al., 2009), which recruited women at 38 weeks gestation failed to demonstrate the efficacy of the use of moxibustion to treat breech presentation, a result which disagrees with all previously‑published studies. However, this study reported a controversial 47 per cent compliance failure, and included these subjects in the non‑blinded statistical analysis. In addition, this was the only study to have recruited multiparas, who were mostly allocated to the control group. After two weeks of the trial, 18 per cent of the treatment group versus 16 per cent of the control group presented cephalic. The authors concluded that despite its lack of effectiveness, women favoured moxibustion over being left to ‘wait and see’. Table 1 summarises the findings of the most recent trials on breech presentation treatment with moxibustion and needling.
Non‑invasive options for treating breech presentation are limited. Women are typically told to ‘wait and see’, and if the baby does not turn elective caesarean section is recommended. ECV is often offered as an alternative, although it comes with serious risks, and its success is contingent on increasingly scarce skilled personnel (Chapman, 2003; Coco et al.,1998). Moxibustion on the other hand is easy to apply, non‑invasive and generally regarded as safe for mother and baby (Guittier et al., 2008). In the UK, current National Institute for Health and Clinical Excellence (NICE) guidelines merely acknowledge the use of moxibustion to treat breech presentation, and the procedure is not available in most hospitals (NICE, 2008).
This review has found that there is good evidence to suggest that both acupuncture and moxa‑stick stimulation at Zhiyin BL‑67 are effective treatments for breech presentation. Regrettably, no studies comparing moxibustion with needling were found. Whilst acupuncture may constitute an effective treatment, Zhiyin BL‑67 is a very sensitive point and needling requires frequent visits to a qualified acupuncturist which makes it less practical and cost‑effective. A study on the cost‑effectiveness of moxibustion found that compared to standard care it is both clinically effective and cost‑effective (Van Den Berg et al., 2006). A link between moxibustion and a decrease of incidence of caesarean section was noted in a clinical audit undertaken by Calderdale and Huddersfield NHS Trust (Steen et al., 2008).
The literature is, however, inconsistent with regards to moxibustion treatment protocols. For instance, Cardini et al. (1998) suggests that half an hour of treatment once daily with traditional fresh moxa is an effective treatment, whilst Guittier et al. (2009) chose to treat patients for 20 minutes with smokeless moxa. The research also shows variability with regard to when treatment should commence. While some trials started treatment at 28 weeks gestation (Kanakura et al., 2001), Guittier et al. (2009) did not commence treatment until 38 weeks. Most authors agree that 34 weeks is the optimum week to commence treatment (Cardini et al., 1998; Budd, 2000; Betts, 2006). In addition there are no set guidelines outlining contraindications to treatment of breech presentation with these methods. Some trials exclude placenta previa and congenital uterine malformation (Cardini et al., 1998) while Budd (2000) extrapolates ECV exclusion guidelines as contraindications to moxa treatment.
The smell of burning moxa can be strong, and smokeless moxa with its less intense odour is more popular in the West due to health concerns (Cardini et al., 2005; Guittier et al., 2009; Betts, 2006). Although there is no evidence suggesting that fresh moxa might be harmful to mother and baby, there is concern that smokeless moxa may produce carbon monoxide (Peck, 1993). The National Toxicology Program (NTP), an American organisation concerned with toxicology and public health, has reported the presence of alpha‑thujone – a psychedelic chemical compound found in cooking herbs as well as absinthe – in moxa (NTP, 2009). These findings highlight the need for further study and evaluation of the toxicity of moxa. Evidence suggests that mothers in the West favour and are more likely to comply with treatment using smokeless moxa (Cardini et al., 2005), although practitioners believe that fresh moxa is safer, more effective and cheaper (Peck, 1993). TCM practitioners are in daily contact with moxa and little complaint is reported with regards to side effects of moxibustion (Budd, 2000). A recent study on the side‑effects and acceptability of moxibustion in the treatment of breech presentation detected no effects on foetal or maternal well‑being (Guittier et al., 2008). Treating breech presentation with moxibustion generally lasts no longer than two weeks for a maximum of 30 minutes at day.
Further research is clearly required to ascertain the optimum gestational week for commencing moxibustion treatment and the most effective treatment protocol (including the relative effectiveness of fresh/smokeless moxa and the daily and total duration of treatment). It is therefore recommended that a study should compare fresh moxa (Group 1) with smokeless moxa (Group 2) treatment at Zhiyin BL‑67 and a no treatment control group (Group 3). A fourth group comparing these treatments to acupuncture needling should also be considered. Any future RCTs should follow CONSORT (Moher at al.,2001) as well as STRICTA (MacPherson et al., 2001) guidelines. The research team should include a trained TCM acupuncturist, an experienced researcher and an obstetrician or midwife. Statistical analysis should be blinded. It is recommended that future RCTs should look at cephalic version ratio, effectiveness of ECV after moxibustion treatment and the number of caesarean sections in all groups. It is imperative that contraindications to moxibustion treatment should be established through communication between Western doctors and TCM practitioners. Stimulation at Zhiyin BL‑67 has been indicated to induce labour (Betts, 2006) which may constitute an undesirable side‑effect of treatment. Toxicology, acceptance to moxibustion, Apgar score and number of caesareans should also be further investigated. It is also recommended that a study is performed to investigate the health risks posed by inhaling moxa smoke or smokeless moxa fumes.
In addition to medical concerns, it is important and moxibustion should be offered routinely for the treatment of breech presentation. to consider the significance of the emotional issues surrounding the treatment of breech presentation. Budd (2000) reports that most patients benefit from knowing that they are doing something to change their situation. A small‑scale qualitative study involving eight patients (Mitchell et al., 2008) found that before treatment women were worried and fearful about breech presentation and were finding difficult to decide whether to undergo ECV. Generally, they found it easy to accept moxibustion because they perceived it as ‘non‑invasive’ and ‘natural’. Post‑treatment they reported increased foetal movement, which reinforced their belief that moxibustion was having a beneficial effect. All the women expressed positive feelings and described the experience as ‘relaxing’, ‘pleasant’, ‘safe’ and ‘enjoyable'. Guittier et al. (2009) found that patients felt relaxed after treatment, and subsequently confirmed that they would recommend moxibustion to others and try it again themselves. Overall these findings suggest that Western women are keen to try moxibustion in an attempt to resolve breech presentation. It is therefore recommended that both mother and baby’s well‑being should also be considered in future RCTs.
Despite inconsistencies in the treatment approaches studied, there is evidence that acupuncture and moxibustion are effective treatments for breech presentation. Moxibustion is cheap, safe, pain free, and easy to administer as home‑based self‑treatment. However, there are no published standardised protocols for the treatment of breech presentation with moxibustion or acupuncture. If moxibustion is to be offered widely, more robust research using greater sample sizes is needed in order to ascertain best practice, optimal treatment time and the most effective and safe treatment protocol. Analysis of toxicology and possible side‑effects of fresh and smokeless moxa is also advised. In sum, this research supports the hypothesis that acupuncture and moxibustion treatment of breech presentation is a safe and effective option for both mother and baby and therefore recommends that acupuncture and moxibustion should be offered routinely for the treatment of breech presentation.
Abbate, S. (2002). “An overview of the therapeutic application of moxibustion”, Journal of Chinese Medicine, 69, 5‑12.
Betts D. (2006). The essential guide to acupuncture in pregnancy and childbirth. Journal of Chinese Medicine: Hove.
Budd, S. (2000). “Moxibustion for breech presentation”,Complementarytherapies in nursing & midwifery, 6, 176‑179.
Cardini, F. & Huang, W. (1998). “Moxibustion for correction of breech pesentation: a randomized controlled trial”, The journal of the American medical association, 280(18), 1580‑1584.
Cardini, F., Lombardo, P., Regalia, A. L., Regaldo, G., Zanini, A., Negri, M. G., et al. (2005). “Arandomised controlled trial of moxibustion for breech presentation”, Journal of obstetrics and gynaecology,112, 743‑747.
Chalmers I., Enkin M., Keirse M. (1989).Effective care in pregnancy and childbirth. Oxford University Press: Oxford.
Chapman V. (2003). The midwife’s labour and birth handbook. Blackwell Publishing: Oxford.
Cheng X. (1999). Chinese acupuncture and moxibustion. Foreign Languages Press: Beijing.
Cheung, N. (2009).“Chinese midwifery: the history and modernity”, Midwifery,25(3), 228‑41.
Coco, A. & Silverman, S. (1998). “External cephalic version”, The American academy of family physician , 59(5),1122.
Coyle, M., Smith, C. & Peat, B. (2005). “Cephalic version by moxibustion for breech presentation”, Cochrane database of systematic reviews, (2), CD003928.
Deadman P, Al‑Khafaji, M., & Baker K., (1998). A manual of acupuncture. Journal of Chinese medicine: Hove.
Guittier, M., Jauch Klein, T., Dong, H. et al. (2008). “Side‑effects of moxibustion for cephalic version of breech presentation”, Journalofalternativeandcomplementary medicine , 14(10), 1231‑1233.
Guittier, M., Pichon, M., Dong, H. et al. (2009). “Moxibustion for breech version: a randomized controlled trial”, Journal of obstetrics & gynecology , 114 (5),1034‑1040.
Habek, D., Cerkez, J. & Jagust, M. (2003). “Acupuncture conversion of fetal breech presentation”, Fetal diagnosis and therapy, 18, 418‑421.
Hannah, M., Hannah, W., Hewson, S. et al. (2000). “Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial”, Lancet , 356 (9239),1375‑1383.
Kanakura, Y., Kometani, K., Nagata, T. et al. (2001). “Moxibustion treatment of Breech presentation”, American journal of Chinese medicine, 29(1), 37‑45.
Kaptchuk T. (2000). Chinese medicine: the web that has no weaver. Rider: London.
Li, X., Hu, J., Wang, X. et al. (2009). “Moxibustion and other acupuncture point stimulation methods to treat breech presentation: a systematic review of clinical trials”, Chinese medicine,4(4), 1‑8.
Liburd,A. (1999). “The use of complementary therapies in midwifery in the UK”, Journal for nurse‑midwifery , 44(3),325‑329.
MacPherson, H., White, A., Cummings, M . et al. (2001). “Standards for reporting intervention in controlled trials of acupuncture: the STRICTA recommendations”, Complimentary therapies in medicine, 9, 246‑249.
Manaka Y., Itaya K. & Birch S. (1995). Chasing the Dragon’s tail. Paradigm Publications: Massachusetts.
Mitchell, M. & Allen, K. (2008). “An exploratory s tud y of wom en’ s experiences and key stakeholders views of moxibustion for cephalic version in breech presentation”, Complementary therapies in clinical practice (14),264‑272.
Moher, D., Schulz, K. F. & Altman, D. G. (2001). “The CONSORT statement: revised recommendations for improving the quality of reports of parallel‑group randomised trials”, Lancet , 357(9263),1191‑1194.
National Childcare Trust. (2010). Info centre - breech baby. Available at http://www.nct.org.uk/info‑centre/information/view‑41 [Accessed March 27, 2010]
National Institute for Health and Clinical Excellence. (2008). Antenatal care - Routine care for the healthy pregnant woman. RCOG Press: London.
Natio nal To xic o lo gy P r o gram . (2009). Alpha-thujone. Available at http://ntp.niehs .nih.go v / index.cfm?objectid=03DB8C36‑ E7A1‑9889‑3BDF8436F2A8C51F [Accessed July 22, 2010]
Neri, I.,Airola, G., Contu, G. et al. (2004). “Acupuncture plus moxibustion to resolve breech presentation: a randomized controlled study”, The journal of maternal–fetal and neonatal medicine , 15, 247–252.
O’Connor J. & Bensky D. (1981). Acupuncture a comprehensive text. Eastland Press: Seattle.
Pairman S., Pincombe J. & Thorogood C. (2006). Midwifery: preparation for practice. Elsevier: Marrickville.
Palencia, R., Gafni, A., Hannah, M. et al. (2006). “The costs of planned cesarean versus planned vaginal birth in the term breech trial”, Canadian medical association journal, 174(8), 1109‑1113.
Peck, G. (1993). “Moxa smoke and the acupuncturist”, Journal of Chinese medicine , 41, 10‑11.
Richardson A. & Mmata C. (2007). NHS maternity statistics, England: 2005-06. Department of health: London.
Sanchez ‑ Ramos, L., Mantel, G., Moodley, J. et al. (2001). “For breech presentation at term, planned cesarean section had better neonatal outcome than planned vaginal birth”, Evidence‑based obstetrics & gynecology, 3(1), 5‑7.
Spencer, H. (1901). “The dangers and diagnosis of breech presentation, and its treatment by external version towards the end of pregnancy ”, Brit ish medical journal, 1192‑1196.
Steen, M. & Kingdon, C. (2008). “Breech birth: Reviewing the evidence for external cephalic version and moxibustion”, Evidence based midwifery, 6(4): 126‑129.
Van Den Berg, I., Bosch, J., Jacobs, B. et al. (2008). “Effectiveness of acupuncture‑type interventions versus expectant management to correct breech presentation: a s ys tem ati c r ev iew ”, C o m ple m en ta ry ther apies in medicine, 16, 92‑100.
Van Den Berg, I., Kaandorp, G., Bosch,J., et al. (2006). “The effectiveness and cost‑effectiveness of Breech version acumoxa compared to standard care to correct breech presentation”, Focus on alternative and complementary therapies,11, 5.
Vas, J., Aranda, J. M., Baron, M. et al. (2008). “Correcting non cephalic presentation with moxibustion: study protocol for a multi‑centre randomised controlled trial in general practice”, BioMed central complementary and alternative medicie, 8(22).
Vas, J., Aranda, J., Nishishinya, B. et al. (2009). “Correction of nonvertex presentation with moxibustion: a systematic r eview and metaanalysis”, American journal of obstetrics and gynecology,201(3), 241‑259.
Wu, C. (2002). Basic theory of traditional Chinese medicine. Publishing house of Shanghai university of traditional Chinese medicine: Shanghai.
Zhao, J. (2002). Chinese acupuncture and moxibustion. Publishing house of Shanghai university of traditional Chinese medicine: Shanghai.
Should Acupuncture And Moxibustion Be Recommended For Breech Presentation?
Journal of Chinese Medicine • Number 98 • February 2012