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Acupuncture for breech version: Principles, technique, mode of action and utility – A literature review
Abstract
Objective. Version to correct breech presentation at term remains important, because feet-first vaginal delivery of a baby is associated with a higher risk of fetal morbidity and mortality. Method. The technique consists of puncture at point B67. This technique is thought to work by increasing the probability of the fetus turning by increasing active fetal movements. Results. Five randomised studies evaluating the value of acupuncture in cases of siege presentation indicate that this method tended to be effective. However, no placebo-controlled study has been carried out. Conclusion. Acupuncture should be attempted in cases of breech presentation.
Background:
Several studies have investigated the efficacy of moxibustion with or without acupuncture for fetal version, but the results are discordant. Meta-analyses pointed out the need for robust, methodologically sound, randomized controlled trials.
Objective:
The objective of this study was to assess the effectiveness of acupuncture with fire needling on acupoint BL67 for version of breech presentation.
Study design:
This was a randomized, sham-controlled, single-blinded trial, which took place in Strasbourg teaching maternity hospital, France. A total of 259 patients between 32 and 34 weeks of gestation have been randomized and analyzed. Patients were randomized to either acupuncture with fire needling or sham group, and were analyzed in their initial allocation group. Statistical analysis was conducted using Bayesian methods, in univariate analysis and in multivariate analysis after adjustment on parity.
Results:
The primary outcome was the rate of cephalic presentations at ultrasound examination performed between 35 and 36 weeks of gestation. A total of 49 (37.7%) fetuses were in cephalic presentation in the acupuncture group, versus 37 (28.7%) in the sham group: RR 1.34 [0.93-1.89], Pr RR>1=94.3%. After adjustment on parity, the acupuncture did not increase the rate of fetal cephalic version: OR 1.47 [0.84-2.42], Pr OR>1=90.3%.
Conclusions:
Our study suggests that acupuncture with fire needling on acupoint BL67 does not promote fetal cephalic version. Further studies might investigate effectiveness of other protocols of acupuncture. Randomization should be stratified for nulliparous and parous patients.
Since the publication of the Term Breech Trial in 2000, planned cesarean has become the preferred mode of birth for women whose fetus is in a breech presentation. Over the past 20 years, however, subsequent evidence has not shown conclusively that cesarean birth is safer than vaginal birth for a fetus in a breech presentation when certain criteria are met. Many obstetric organizations support the option of planned vaginal birth for women with a breech presentation under strict prelabor selection criteria and intrapartum management guidelines. The growing trend toward cesarean unfortunately has left midwives and other intrapartum care providers in training with dwindling opportunities to competently master skills for vaginal breech birth. Although simulation training offers opportunities to practice infrequently encountered skills such as vaginal breech birth, it is unknown if this alternative will provide sufficient experience for future generations of clinicians. As a result, women with a breech presentation at term who desire a trial of labor often have limited choices. This article reviews the controversies surrounding the ideal mode of birth created by the Term Breech Trial. Criteria for vaginal breech birth are summarized and the role of simulation explored. Implications for midwifery practice when a breech presentation is diagnosed are also included.
Pallister-Killian syndrome (PKS), which is characterized by mental retardation, seizures, pigmentary skin lesions and dysmorphic facial features, is a rare chromosomal anomaly with the mosaic presence of an extra tissue-specific isochromosome 12p (mosaic tetrasomy 12p). Advanced maternal age is believed to be a risk factor for PKS. Ultrasound is a useful tool in the prenatal detection of characteristic findings associated with PKS. This article provides an overview of the prenatal sonographic features of PKS, including congenital diaphragmatic hernia, polyhydramnios, abnormal extremities, increased nuchal translucency or nuchal edema, cardiovascular anomalies, central nervous system anomalies, an abnormal facial profile, and other rare anomalies. Appropriate tissue samples and laboratory analytic techniques should be selected for an accurate prenatal diagnosis because of the instability of isochromosome 12p and the potentially incorrect interpretation as tetrasomy 21q on the traditional G-banded technique. Fryns syndrome, which has phenotypic overlap with PKS, is also discussed. Increasing awareness and knowledge of various anomalies of PKS on prenatal ultrasound would be helpful for the early detection of PKS. Definite diagnosis of fetuses with PKS could help clinical physicians in the decisionmaking process during the prenatal or postnatal periods.
Acupuncture has a growing clientele during pregnancy, delivery and the puerperium for an ever increasing list of indications. Objective evidence for its benefit is necessary to establish its roles in current practice.
For many of the current uses, randomized studies when conducted using at least one control group have not established any clear advantages from treatment. Those areas which rely upon subjective assessment of symptoms are particularly difficult to investigate without rigorous blinding strategies, separating those who provide the acupuncture from those assessing outcome. Studies investigating the possible therapeutic benefit of acupuncture for managing intrapartum care require outcomes for nulliparae and multiparae to be analysed separately.
Acupuncture therapy may offer some advantage over conventional treatment in the management of hyperemesis gravidarum and postcaesarean section pain and these areas warrant further study. Rigorous randomized studies, particularly those using objective measures, have failed to identify any obvious benefits from acupuncture for many of the other conditions studied.
Traditional Chinese medicine uses moxibustion (burning herbs to stimulate acupuncture points) of acupoint BL 67 (Zhiyin, located beside the outer corner of the fifth toenail), to promote version of fetuses in breech presentation. Its effect may be through increasing fetal activity. However, no randomized controlled trial has evaluated the efficacy of this therapy.
To evaluate the efficacy and safety of moxibustion on acupoint BL 67 to increase fetal activity and correct breech presentation.
Randomized, controlled, open clinical trial.
Outpatient departments of the Women's Hospital of Jiangxi Province, Nanchang, and Jiujiang Women's and Children's Hospital in the People's Republic of China.
Primigravidas in the 33rd week of gestation with normal pregnancy and an ultrasound diagnosis of breech presentation.
The 130 subjects randomized to the intervention group received stimulation of acupoint BL 67 by moxa (Japanese term for Artemisia vulgaris) rolls for 7 days, with treatment for an additional 7 days if the fetus persisted in the breech presentation. The 130 subjects randomized to the control group received routine care but no interventions for breech presentation. Subjects with persistent breech presentation after 2 weeks of treatment could undergo external cephalic version anytime between 35 weeks' gestation and delivery.
Fetal movements counted by the mother during 1 hour each day for 1 week; number of cephalic presentations during the 35th week and at delivery.
The intervention group experienced a mean of 48.45 fetal movements vs 35.35 in the control group (P<.001; 95% confidence interval [CI] for difference, 10.56-15.60). During the 35th week of gestation, 98 (75.4%) of 130 fetuses in the intervention group were cephalic vs 62 (47.7%) of 130 fetuses in the control group (P<.001; relative risk [RR], 1.58; 95% CI, 1.29-1.94). Despite the fact that 24 subjects in the control group and 1 subject in the intervention group underwent external cephalic version, 98 (75.4%) of the 130 fetuses in the intervention group were cephalic at birth vs 81 (62.3%) of the 130 fetuses in the control group (P = .02; RR, 1.21; 95% CI, 1.02-1.43).
Among primigravidas with breech presentation during the 33rd week of gestation, moxibustion for 1 to 2 weeks increased fetal activity during the treatment period and cephalic presentation after the treatment period and at delivery.
The aim of this study was to assess the value of acupuncture (AP) in the conversion of fetal breech presentation into vertex presentation.
A randomized prospective controlled clinical study included 67 pregnant women with fetal breech presentation: 34 women with singleton pregnancies treated with manual AP (urinary bladder 67, Zhiyin) and a control group which included 33 women with singleton pregnancies without AP treatment. The AP treatment lasted 30 min a day, and was conducted during and after 34 weeks of pregnancy with simultaneous cardiotocography.
The success rate of the AP correction of fetal breech presentation is 76.4% (26 women), and spontaneous conversion without AP in vertex presentation is observed in 15 women (45.4%; p<0.001).
We believe that AP correction of fetal malpresentation is a relatively simple, efficacious and inexpensive method associated with a lower percentage of operatively completed deliveries, which definitely reflects in improved parameters of vital and perinatal statistics.
Background:
External cephalic version (ECV) of the breech fetus at term (after 37 weeks) has been shown to be effective in reducing the number of breech presentations and caesarean sections, but the rates of success are relatively low. This review examines studies initiating ECV prior to term (before 37 weeks' gestation).
Objectives:
To assess the effectiveness of a policy of beginning ECV before term (before 37 weeks' gestation) for breech presentation on fetal presentation at birth, method of delivery, and the rate of preterm birth, perinatal morbidity, stillbirth or neonatal mortality.
Search methods:
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2015) and reference lists of retrieved studies.
Selection criteria:
Randomised controlled trials (RCTs) of ECV attempted before term (37 weeks' gestation) or commenced before term, compared with a control group of women (in breech presentation) in which either no ECV attempted or ECV was attempted at term. Cluster-randomised trials were eligible for inclusion but none were identified. Quasi-RCTs or studies using a cross-over design were not eligible for inclusion.
Data collection and analysis:
Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked for accuracy. Studies were assessed for risk of bias and for important outcomes the overall quality of the evidence was assessed using the GRADE approach.
Main results:
Five studies are included (2187 women). It was not possible for the intervention to be blinded, and it is not clear what impact lack of blinding would have on the outcomes reported. For other 'Risk of bias' domains studies were either at low or unclear risk of bias.One study reported on ECV that was undertaken and completed before 37 weeks' gestation compared with no ECV. No difference was found in the rate of non-cephalic presentation at birth (risk ratio (RR) 1.04, 95% confidence interval (CI) 0.64 to 1.69; participants = 102). One study reported on a policy of ECV that was initiated before term (33 weeks) and up until 40 weeks' gestation and which could be repeated up until delivery compared with no ECV. This study showed a decrease in the rate of non-cephalic presentation at birth (RR 0.59, 95% CI 0.45 to 0.77; participants = 179).Three studies reported on ECV started at between 34 to 35 weeks' gestation compared with beginning at 37 to 38 weeks' gestation. Pooled results suggested that early ECV reduced the risk of non-cephalic presentation at birth (RR 0.81, 95% CI 0.74 to 0.90; participants = 1906; studies = three; I² = 0%, evidence graded high quality), failure to achieve vaginal cephalic birth (RR 0.90, 95% CI 0.83 to 0.97; participants = 1888; studies = three; I² = 0%, evidence graded high quality), and vaginal breech delivery (RR 0.44, 95% CI 0.25 to 0.78; participants = 1888; studies = three; I² = 0%, evidence graded high quality). The difference between groups for risk of caesarean was not statistically significant (RR 0.92, 95% CI 0.85 to 1.00; participants = 1888; studies = three; I² = 0%, evidence graded high quality). There was evidence that risk of preterm labour was increased with early ECV compared with ECV after 37 weeks (6.6% in the ECV group and 4.3% for controls) (RR 1.51, 95% CI 1.03 to 2.21; participants = 1888; studies = three; I² = 0%, evidence graded high quality). There was no clear difference between groups for low infant Apgar score at five minutes or perinatal death (stillbirth plus neonatal mortality up to seven days) (evidence graded as low quality for both outcomes).
Authors' conclusions:
Compared with no ECV attempt, ECV commenced before term reduces non-cephalic presentation at birth. Compared with ECV at term, beginning ECV at between 34 to 35 weeks may have some benefit in terms of decreasing the rate of non-cephalic presentation, and risk of vaginal breech birth. However, early ECV may increase risk of late preterm birth, and it is important that any future research reports infant morbidity outcomes. Results of the review suggest that there is a need for careful discussion with women about the timing of the ECV procedure so that they can make informed decisions.
Bei der heute routinemäßig durchgeführten Ultraschalluntersuchung in der Schwangerschaft wird sich für den Untersucher und die Patientin häufig die Diagnose einer Beckenendlage ergeben. Aus 4066 Einzelbestimmungen wurde eine Kurve ermittelt, die die relativen Anteile von Beckenendlagen, Kopflagen und Querlagen im Verlauf der Schwangerschaft angibt. Dabei zeigen sich deutliche, z. T. statistisch signifikante Unterschiede zwischen Erstund Mehrgebärenden in bezug auf die einzelnen Lagen. Die Auswertung mehrerer Ultraschallbefunde an ein und derselben Patientin erlaubt Aussagen über die Wahrscheinlichkèit der zu einem bestimmten Zeitpunkt der Schwangerschaft noch zu erwartenden Drehung von der Beckenendlage in die Kopflage. Hierbei zeigen sich deutliche Unterschiede zwischen Erst- und Mehrschwangeren: So beträgt die Chance einer Erstschwangeren mit Beckenendlage ihres Kindes in der 29. Woche, daß sich das Kind noch spontan in die Kopflage drehen kann, 32,1%, während es bei der Mehrschwangeren 70,2% Wahrscheinlichkeit für eine spontane Drehung sind. In der 33. Woche ist die Wahrscheinlichkeit bei der Erstgravida 15,5% gegenüber 57,5% bei der Mehrgravida. Ab der 37. Woche ist weder bei Erst-, noch bei Mehrschwangeren mit einer spontanen Drehung in die Kopflage zu rechnen. Ein Kind in Kopflage hingegen dreht sich in der 29. Woche bei einer Erstpara mit 0,6% Wahrscheinlichkeit in eine BEL; bei einer Mehrpara ist die Chance mit 2,3% deutlich höher. Jenseits der 33. Woche ist bei beiden Gruppen mit einer Drehung in die BEL nicht mehr zu rechnen.
In je einer Tabelle werden - getrennt für Erst- und Mehrschwangere - die Wahrscheinlichkeiten der Drehung bei BEL und Kopflagen für die 13.-41. Schwangerschaftswoche angegeben, so daß der untersuchende Arzt die Patientin exakt über die Wahrscheinlichkeit einer noch zu erwartenden Drehung in die »richtige« Lage (und umgekehrt) informieren kann: Tab. 3. Die häufigste (und somit wohl physiologische) Drehung ist die in die Kopflage, die bis zur 37. Schwangerschaftswoche abgeschlossen ist. Danach ist mit spontanen Drehungen nicht mehr zu rechnen.
ABSTRACTA technological exchange visit with the People's Republic of China is described. The authors and a group of childbirth educators observed the cultural aspects of childbirth, obstetric practices, and family planning programs. They studied the organization of the health care system, including the use of midwives and “barefoot” doctors. Traditional Chinese medicine practices such as acupuncture and moxibustion were observed. The need for cultural sensitivity in transporting American practices to other nations was a significant learning experience for the group, as was the reciprocal value of the educational exchange.
The application of acupuncture, moxibustion, acupressure, and shiatsu to antepartal and intrapartal care are discussed. Information on therapeutic interventions as described in textbooks is presented and compared with specific treatments evaluated in research studies. Specific clinical indications addressed include nausea during pregnancy, repositioning of the fetus in breech position, stimulation of contractions and true labor, and pain relief in labor. Qualifications for practitioners and recommendations for certified nurse-midwives caring for clients seeking referral for these services are discussed.
Moxibustion at the Zhiyin acupuncture point (67 B) is an ancient method of obtaining the version of abnormal presentation of the fetus during the last three months of pregnancy. The authors reviewed the Chinese references on this subject and stressed the importance of parity and gestational age in testing the efficacy of this therapy. Preliminary results are described and compared with those reported in Chinese articles. Success rates in version by moxibustion versus spontaneous version are also compared.
Applying fresh ginger paste at Zhihying acupoint before retiring, we treated 133 pregnant women (28 to 38 weeks' gestation) with breech position. There were 118 primigravidas. 238 untreated pregnant women (28 to 32 weeks' gestation) with breech position made up the control group. 113 out of the treated pregnant women had normal fetal position after treatment with 77.4% of correction rate. 48 out of the 113 pregnant women whose fetal position corrected by treatment only received once therapy, accounting for 42.5% of cured cases. Spontaneous correction of fetal position happened in 123 pregnant women of the control group with 51.6% of correction rate. There was a significant difference in the correction rate between study and control groups. (P less than 0.01), suggesting that this therapy is easy, economical, safe, and suitable to popularization at the basic level.
The authors corrected the abnormal fetal position in 413 cases of pregnant women by the auricular plaster therapy (APT) with a success rate of 83.3%--remarkably higher than treatment by knee-chest positioning. Further analysis showed that APT was also superior to the knee-chest positioning for primiparae, breech fetal position, and pregnancies over 33 weeks. The authors also noted the clinical signs of successful cases and failures.
A prospective longitudinal investigation of spontaneous cephalic version from breech presentation in the last trimester is reported. All pregnancies were assessed with ultrasound in the 32nd week of gestation, and were thereafter checked weekly. Of the 310 singleton breech presentations identified at 32 weeks, spontaneous cephalic version occurred in 177 (57%) while breech presentation persisted in 133 patients (43%). Of 140 patients with a breech presentation at delivery 95% were already presenting by the breech in the 32nd week. Spontaneous cephalic version was less likely in pregnancies with extended fetal legs, low birth-weight, short umbilical cord and primiparity.
Variable rates of external cephalic version (ECV) success in late pregnancy and of spontaneous version have been reported for different population groups. An ECV attempt by one operator in 80 patients beyond 36 weeks gestation was successful less frequently in white nulliparous patients and in those with lateral or cornual placental situation. A similar influence of ethnic and other variables was found on the spontaneous version rate in 108 patients in whom no ECV was attempted. Despite population differences in ECV success rates, the ratio of successful ECV to spontaneous version in reported randomized control trials is consistent at about 3:1.
PIP
The authors describe a technological exchange visit with the People's Republic of China sponsored by the China Association for Science and Technology. A group of childbirth educators observed the cultural aspects of childbirth, obstetric practices, and family planning programs. 5 cities were visited in which the visitors discussed US childbirth practices and received information regarding Chinese practices. The status of women was crucial to the Chinese attitude towards childbirth. There are measures to protect women in the work place during pregnancy and lactation, an improvement over past years. China's primary health care system is divided into 4 levels: 1) part-time health workers, 2) cooperative medical stations staffed by "barefoot doctors," 3) commune health centers, and 4) the county hospital. Urban dwellers can make use of factory health services and local hospitals. Midwives are responsible for low risk prenatal care and 90-95% of all births are to primigravidas, since the 1 child family campaign began in 1979. Labor and delivery procedures are described and seem to be similar to US practices 10-20 years ago although progress has been made in decreasing maternal and infant morbidity and mortality. Postpartum practices include breastfeeding for 1 year, restricting activity, and eating certain foods for 1 month after birth. Acupuncture is used to replace anesthesia in 99% of cesarean sections and sometimes during labor to relieve pain. Moxibustion therapy, the burning of leaves of the mugwart plant in a wrapped tube to warm a specific site on the skin is used for turning breech presenting babies. The Chinese family planning program has been successful in dropping the birth rate by 50% between 1970-78 due to the commitment of government leaders, a successful incentives program, strong information programs, and widely available contraceptives; it is estimated that by 2035 25% of the population will be over 65 years. 20-50% of Chinese preschool children are in day care and child health is considered a priority.
Many studies of acupuncture treatment are seriously flawed by methodological problems. Poor design, inadequate measures and statistical analysis, lack of follow-up data and sub-standard treatment are all too common. However, the major problem, which many investigators consider to be still unresolved, is the definition of an appropriate placebo control. The use of inappropriate placebo controls has bedeviled acupuncture research and led to serious misinterpretation of the results of clinical trials. While a number of different solutions have been proposed there is, as yet, no agreed way of assessing the adequacy of control conditions or of deciding which placebo to use in a particular trial. We propose that assessing the credibility of treatments and control conditions may provide a way forward to a more rigorous, consensus approach.
To determine whether planned vaginal or elective cesarean delivery is better for singleton term breech infants.
Articles that included singleton term pregnancies with breech presentation published in English between 1966 and September 1992 were searched through the Index Medicus, Oxford Database of Perinatal Trials, and MEDLINE.
We reviewed 24 studies that presented results according to the intended mode of delivery in terms of the following adverse outcomes: perinatal mortality, low 5-minute Apgar score, traumatic neonatal morbidity, overall short-term neonatal morbidity, long-term infant morbidity, and maternal morbidity and mortality.
The effect of planned vaginal delivery, compared with planned cesarean delivery, for each adverse outcome was determined by calculating a typical odds ratio. Perinatal mortality was higher for the planned vaginal delivery groups than for the elective cesarean groups, with a typical odds ratio of 3.86 (95% confidence interval [CI] 2.22-6.69). Neonatal morbidity due to trauma was also higher for the planned vaginal delivery groups, with a typical odds ratio of 3.96 (95% CI 2.76-5.67).
The results suggest that planned vaginal delivery may be associated with higher perinatal mortality and morbidity rates than planned cesarean delivery. Because of selection bias in the majority of studies, differences in outcomes may be due to factors other than the planned method of delivery. An appropriately sized, randomized controlled trial is needed to answer this question definitively.
Forty-eight cases of malposition of fetus were treated by electro-acupuncture, using Zhiyin (UB 67) points. 39 cases were corrected with a rate of 81.3%, the average session of treatment being 1.41. Two control groups were set up: moxibustion and blank control group. Statistical analysis shows that efficacy of electro-acupuncture is markedly superior to that of the blank. Sessions of electro-acupuncture were less than that of moxibustion and the difference was statistically significant, though there is no significant difference of efficacy between the two groups.
For 3-4% of pregnancies, the fetus will be in the breech presentation at term. For most of these women, the approach to delivery is controversial. We did a randomised trial to compare a policy of planned caesarean section with a policy of planned vaginal birth for selected breech-presentation pregnancies.
At 121 centres in 26 countries, 2088 women with a singleton fetus in a frank or complete breech presentation were randomly assigned planned caesarean section or planned vaginal birth. Women having a vaginal breech delivery had an experienced clinician at the birth. Mothers and infants were followed-up to 6 weeks post partum. The primary outcomes were perinatal mortality, neonatal mortality, or serious neonatal morbidity; and maternal mortality or serious maternal morbidity. Analysis was by intention to treat.
Data were received for 2083 women. Of the 1041 women assigned planned caesarean section, 941 (90.4%) were delivered by caesarean section. Of the 1042 women assigned planned vaginal birth, 591 (56.7%) delivered vaginally. Perinatal mortality, neonatal mortality, or serious neonatal morbidity was significantly lower for the planned caesarean section group than for the planned vaginal birth group (17 of 1039 [1.6%] vs 52 of 1039 [5.0%]; relative risk 0.33 [95% CI 0.19-0.56]; p<0.0001). There were no differences between groups in terms of maternal mortality or serious maternal morbidity (41 of 1041 [3.9%] vs 33 of 1042 [3.2%]; 1.24 [0.79-1.95]; p=0.35).
Planned caesarean section is better than planned vaginal birth for the term fetus in the breech presentation; serious maternal complications are similar between the groups.
Breech presentation was successfully corrected by stimulating acupuncture points with moxibustion or low-frequency electrical current. Only patients with breech pregnancies at the 28th week or later were entered into the study. With moxibustion treatment, the control group had a spontaneous correction rate of 165/224 (73.66%), and the treatment group had a correction rate of 123/133 (92.48%) (P<0.0001, x2 test). With low-frequency percutaneous electrical stimulation, the correction rate was 20/941 (83.87%) in the control group and 171/191 (89.52%) in the treatment group (P=0.094, x2 test). The controls in the moxibustion study did no exercises and received no external manipulation to correct breech presentation whereas those in the electrical stimulation study experienced both. Acupuncture stimulation, especially with moxibustion, is expected to serve as a safe and effective modality in the management of breech presentation in a clinical setting.
The management of breech presentation at term remains controversial. It appears logical that maternal and perinatal outcomes would be improved if breech presentation could be avoided. External cephalic version is considered a safe procedure if cases are selected appropriately and anaesthesia avoided. Moxibustion is a traditional Chinese method of treatment, which utilizes the heat generated by burning herbal preparations containing the plant Artemisia vulgaris to stimulate the acupuncture points. It is used for breech version with a reported success rate of 84.6% after 34 weeks gestation. Moxibustion technique is cheap, safe, simple, self-administered, non-invasive, painless and generally well tolerated. Although many studies give encouraging results regarding the use of moxibustion in inducing cephalic version of breech presentation, a definitive conclusion cannot be made as most involve small sample sizes and are not randomised. Moxibustion could be an extra option offered to women with breech presentation along with vaginal delivery, caesarean section and external cephalic version. This article discusses the possible role of moxibustion in correction of breech presentation in the hope that, some interest will be stimulated in what is a very interesting area for future research.
We assessed fetal heart variability and activity using a computerized non-stress test (NST) during acupuncture plus moxibustion on the BL67 point. For comparison, the same changes were assessed during placebo acupuncture (minimal acupuncture) in the same subjects.
Twelve pregnant women in the 33rd week of gestation, carrying singletons in the breech presentation were enrolled in the study. In a single-blind design, each woman received a first session of minimal acupuncture followed 1-2 days later by true acupuncture. During the sessions, women were monitored using computerized non-stress testing starting 20 minutes before the stimuli and continuing for 20 minutes after treatment.
During true acupuncture a significant reduction in fetal baseline heart rate, and more accelerations and movement were observed. During minimal acupuncture, there were no significant changes in these variables. No signs of fetal distress or changes in short- or long-term variability were noted, and there were no uterine contractions.
In our study population, acute application of acupuncture plus moxibustion did not cause fetal distress as assessed by either fetal heart rate decelerations or changes in either short- or long-term variability. Considering that the modifications in fetal movement and heart rate occurred in true but not during minimal acupuncture, we could consider that such changes are related to the effect of the acupuncture stimulation. The mechanisms leading to the cephalic version remain to be clearly established.
Fetal breech presentation at term is more and more treated by a planned cesarean section. Considering the increased maternal morbidity and mortality in relation to abdominal delivery versus vaginal birth, natural and innocuous methods have been proposed for the promotion of a spontaneous fetal cephalic version during the last two Months of pregnancy. In order to stimulate fetal motility many techniques have been described, either advising postural methods (passive bridge, Indian version, knee-chest position) or using acupuncture (stimulation of the fifth toe and auricular points). Other techniques like chiropractic manipulations or hypnosis have also been tried. Unfortunately, most publications are retrospective and methodologically inaccurate, but it seems that their results may be favorably compared with that of the external cephalic version, a much more complex procedure, which is potentially dangerous and certainly time consuming and expensive. The only randomized controlled trial with a proven efficacy concerns moxibustion (burning herbs to stimulate the acupoint BL 67 or Zhiyin, located beside the outer corner of the fifth toenail).
In many Western countries breech presentation is an indication for elective Cesarean section. In order to correct fetal presentation, the stimulation of the acupoint BL67 by moxibustion, acupuncture or both has been proposed. Since no studies had previously been carried out on Western populations, pregnant Italian women at 33-35 weeks gestational age carrying a fetus in breech presentation were enrolled in a randomized, controlled trial involving an active BL67 point stimulation and an observation group.
A total of 240 women at 33-35 weeks of gestation carrying a fetus in breech presentation were randomized to receive active treatment (acupuncture plus moxibustion) or to be assigned to the observation group. Bilateral acupuncture plus moxibustion was applied at the BL67 acupoint (Zhiyin). The primary outcome of the study was fetal presentation at delivery.
Fourteen cases dropped out. The final analysis was thus made on 226 cases, 114 randomized to observation and 112 to acupuncture plus moxibustion. At delivery, the proportion of cephalic version was lower in the observation group (36.7%) than in the active-treatment group (53.6 %) (p = 0.01). Hence, the proportion of Cesarean sections indicated for breech presentation was significantly lower in the treatment group than in the observation group (52.3% vs. 66.7%, p = 0.03).
Acupuncture plus moxibustion is more effective than observation in revolving fetuses in breech presentation. Such a method appears to be a valid option for women willing to experience a natural birth.
Limited evidence suggests that moxibustion may be useful for turning babies from breech presentation (bottom first) to cephalic presentation (head first) for labour. Breech presentation of babies is common in the mid trimester of pregnancy, and while many babies will turn themselves before the onset of labour, some do not. A baby coming bottom first can have more difficulty being born, and a caesarean section is often suggested. Moxibustion, a type of Chinese medicine which involves burning a herb close to the skin, may be helpful in turning a breech baby when applied to the little toe. The review found that moxibustion may help to correct breech presentation, but studies were small. More evidence is needed concerning the benefits and safety of moxibustion.
To evaluate the efficacy of moxibustion for the correction of fetal breech presentation in a non-Chinese population.
Single-blind randomised controlled trial (RCT).
Six obstetric departments in Italy.
Healthy non-Chinese nulliparous pregnant women at 32-33 weeks + 3 days of gestational age with the fetus in breech presentation.
Random assignment to treatment or observation. Treatment consisted of moxibustion (stimulation with heat from a stick of Artemisia vulgaris) at the BL 67 acupuncture point (Zhiyin) for one or two weeks. Two weeks after recruitment, each participant was subjected to an ultrasonic examination of the fetal presentation.
Number of participants with cephalic presentation in the 35th week.
The study was interrupted when 123 participants had been recruited (46% of the planned sample). Intermediate data monitoring revealed a high number of treatment interruptions. At this point no difference was found in cephalic presentation in the 35th week (treatment group: 22/65, 34%; control group: 21/58, 36%; RR 0.95; 99% CI 0.59-1.5).
The results underline the methodological problems evaluating of a traditional treatment transferred from a different cultural context. They do not support either the effectiveness or the ineffectiveness of moxibustion in correcting fetal breech presentation.
To describe the changes in the rate of caesarean deliveries before labour among women with term breech presentations in France and to identify the factors associated with this change over two periods: 1972-1995/1998 and 1995/1998-2003.
The study population consisted of 1479 women with a foetus in a breech presentation at term and without any previous caesarean delivery, from the population of births in the 1972, 1995, 1998 and 2003 national perinatal surveys (N=53136). Data from the 1995 and 1998 surveys were pooled.
The principal endpoint was caesarean delivery before labour. Associations between the factors studied and caesarean before labour were estimated by odds ratios, both crude and adjusted with a logistic regression model.
Between 1972 and 2003, the rate of caesareans before labour for women with term breech presentations rose sharply (from 14.5% in 1972 to 42.6% in 1995/1998 and to 74.5% in 2003). Between 1972 and 1995/1998, this increase was especially marked among the nulliparous women (16.7% versus 52.9%). From 1995/1998 to 2003, the increase was greatest for multiparas: in 2003 this rate among women with children was close to that for women who had never given birth (64.5% and 79.5%, respectively). After adjustment, the factors associated with a high rate of caesarean before labour were nulliparity, birth between 38 and 40 weeks' gestation, birth weight > or =3800g, delivery in the private sector and year of delivery. The rate of caesareans before labour was significantly higher in 2003 (ORa=19.04 [12.06-30.06]) and in 1995-1998 (ORa=4.30 [2.87-6.47]) than in 1972.
The increase in the rate of caesarean deliveries before labour in women with term breech presentations was associated principally with changes in obstetrical practices.
La pratique de l'acupuncture en obstétrique
- Rempp C,
- Bigler A.
- Rempp C,
- Bigler A.
Obstétrique 2ème édition
- Pierre F,
- Bertrand J.
- Pierre F,
- Bertrand J.