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Turning the Breech using moxibustion
The paper intends to inform the reader of a study that is underway on using
Moxibustion (a treatment used by acupuncturists) to turn a fetus presenting by the
breech. It will outline what is available to women presently through the NHS and
alternatively through acupuncturists’ services. It will also review the study’s
implementation process and the literature.
Moxibustion is a dried herb that is packed tightly into a compacted roll that looks very
much like a large cigar. Moxibustion is used routinely as part of traditional Chinese
medicine and the herb Artemisia Princeps (vulgaris) grows freely in the UK. It is
commonly known as ‘Mugwort’. The moxibustion (moxa) stick is burnt at the lateral
side of the little toe over the acupuncture point known as ‘bladder 67’.
Moxibustion has been used in China in hospitals, and by individuals in the home, for
a variety of complaints, as well as for turning the breech. It has a good safety record –
minor burns caused because the individual had placed the lit end on their skin by
accident is the only damage recorded. The method of treatment has been shown also
to be extremely cheap, non-invasive and without complication (Budd, 2000).
The only work that is available on turning the breech using moxibustion, in the UK,
was commenced by Sarah Budd, a midwife acupuncturist. The present study was
developed to further her work.
The studies from China have demonstrated a high success rate from 90.3% (Wei Wen,
1979) spontaneous version with the use of moxa to 75.4% (Cardini & Weixin, 1998),
who also noted that treatment was more effective in multiparous women. These
results suggest that the treatment, which is non-invasive, could provide a real
alternative for women seeking vaginal births.
The treatment is a simple process to perform. Bladder 67 is heated twice a day with
the use of moxa. The moxa stick is held over the point bilaterally for 15-20 minutes.
The treatment will continue until the fetus turns, when it will be abandoned. Any one
can do this including the woman herself – if she can reach her little toe. The optimum
time for the procedure to be performed would be close to the time when the uterus
contains its maximum liquor volume and before the breech starts to descend into the
pelvis. Most of the studies suggest that the optimal time is 34 weeks gestation
(Cardini & Weixin, 1998; Ewics & Olah, 2002; Co-operative research group, 1984).
The treatment with moxibustion has been shown to increase fetal activity at around 7
minutes after the commencement of the procedure until just after the treatment ends
(Budd, 2000; Maciocia, 1998). In addition to this there is an increase in placental
oestrogens and prostaglandin levels which causes an increase in uterine contractility
and therefore moxa is also used to aid the labour process (Maciocia, 1998). The
changes in physiology appear to support pregnancy by increasing peristalsis,
shortening blood clotting time, encouraging alkalosis, increasing phagocytosis and
white blood cells – polynuclear cells (neutrophils, oesinophils and basophils) are
strongly affected (Obaidey, 1998).
The practice of birthing all breech presentation babies via caesarean arose from the
Hannah et al (2000) study which showed better outcomes for the baby. The
commentary in ‘The Lancet’ (21.10.2000: 1368-9) that ran alongside the Hannah et al
(2000) paper noted that the risk of morbidity for women associated with surgical
delivery is high.
Spontaneous version to a cephalic presentation will occur in 57% of cases at 32
weeks gestation as opposed to 25% after 36 weeks gestation (Westgren et al, 1985).
Laros et al’s (1995) study of External Cephalic Version (ECV) after the 36th
completed week of gestation showed a 51% success rate. The Royal College of
Obstetricians & Gynaecologists (1993) state that ECV is more successful when
performed at term or in early labour. It has been suggested that ECV performed at
term, will reduce the caesarean delivery rate for breech presentations by 14% and
vaginal breech births would be reduced (at that time) by 34% (Hoffmeyer, 1991). The
evidence available to date does not allow the risks of performing ECV at term to be
predicted with certainty.
Ethics approval was received through the university and not the hospitals – this
immediately excluded any practitioners in the NHS who needed separate local ethics
approval. The logistics meant filling in ethics applications for every hospital that an
NHS practitioner was employed. Therefore the practitioners who are freely available
to the study tend to be in the private sector. These included acupuncturists who hold
other professional qualifications such as osteopaths, chiropractors and
All acupuncturists on the British Acupuncture Council’s register (N = 1929) were sent
letters asking for voluntary participation in the study. 85 negative responses were
received and 371 positive responses, some interested to have more information about
the study and others willing to give of their time in order to provide the data. 15
letters were sent to the wrong address and were returned to me.
Practitioners have been sent a reply paid envelope with:
The study protocol
A consent form, for their client to sign once the study has been explained by the
practitioner. It was clearly pointed out that the client had the right to withdraw at any
A client information sheet, which explained the study and why it was being conducted
An instruction sheet for the client on how to carry out the procedure at home
A diary booklet where each treatment with any effects are recorded by the client
A client questionnaire which includes the birth outcome
A practitioner questionnaire which includes details of the treatment
Each sheet of paper was coded, so that it could not be traced to a particular woman
and contact was to be made only by the acupuncturist and not the researcher. The
acupuncturists were then asked to return all the completed forms in the reply paid
envelope for data analysis at either 6 months or when 10 women had completed their
treatments – whichever came sooner.
The data is expected to show how many babies spontaneously convert from a breech
to a cephalic presentation following the use of moxibustion. It will also assess any
complications or side-effects on the use of moxibustion. There is no set time limit for
completion of the study as a sample of 500 women were chosen as the target, despite
not working with a power analysis. The packs for completion were mailed out in
January, 04 and as yet 24 packs have been returned completed.
I cannot draw any conclusions from the data as yet. Already though I am concerned
that women see Acupuncturists late in pregnancy, when there is less liquor available
for spontaneous version. So it is easy for me to speculate that if they had been treated
sooner the outcome may have been positive. What is amazing are the women’s
comments. A common theme appears to be that they were happy doing something to
enable spontaneous version. Women also needed to employ partners to apply the
moxibustion as they could not reach their little toes. The side-effects are mainly
positive – where they feel relaxed and positive as the baby moves.
I was surprised and at times overwhelmed by the amount of time that the study has
required in amongst my full time teaching post. However, I feel that the study is
important and may give women the possibility of a vaginal birth. Because I have no
time limit set on achieving results, it would seem that it is going to be a long process
in collecting this data possibly over many years. The results will be published as an
interim and final paper.
Budd, S. 2000 Moxibustion for breech presentation Comp Therapies in Nursing &
Midwifery 6 176-179
Cardini, F. & Weixin, H. 1998 Moxibustion for correction of breech presentation: a
randomised controlled trial. Journal of the American Medical Association 280 1580-4
Cheng, Dan-An et al 1996 Acupuncture & Moxibustion Formulas & Treatments.
China Books & Periodicals. Blue Poppy Press.
The Cochrane Pregnancy & Childbirth Group 2003 The trials register Cochrane
Co-operative Research group on Moxibustion version 1984 Clinical observation on
the effects on version by moxibustion Abstracts from the 2nd national symposium on
Acupuncture Anaesthesia. All China society of Acupuncture and moxibustion.
Beijing pp 150
Cui Yongqiang 1993 Chinese Acupuncture and Moxibustion China Publishing &
Ewics, A. & Olah, K.2002 Moxibustion in breech version – a descriptive review
Acupunct Med 20 26-9
Hannah, M. et al 2000 Planned Caesarean section versus planned vaginal birth for
breech presentation at term: a randomised multicentre trial The Lancet 356 1375-83
Hofmeyr, G.J. 1991 External Cephalic Version at term Br J Obstet Gynaecol 98:1 1-3
Laros, R.K. Flanagan, T.A. Kilpatrick, S.J. 1995 Management of term breech
presentation Am J Obs & Gyn 172:6 1916-1925 June
Maciocia, G. 1998 Obstetrics & Gynaecology in Chinese Medicine Churchill
Neri, I. Fazzio, M. Menghini, S Volpe, A Facchinetti, F. 2002 Non-stress changes
during acupuncture plus moxibustion on Bl 67 point in breech presentation J Soc
Gynecol Investig 9 158-62
Obaidey, E. 1998 Introduction to moxibustion Pacific Journal of Oriental Medicine
The Royal College of Obstetricians & Gynaecologists 1993 The management of
breech presentation http://www.rcog.org.uk/guidelines.asp?pageID
Westgren, M. Edvall, H. Nordstrom, E. Svalenius, E. Spontaneous cephalic version of
breech presentation in the last trimester Brit J Obstet & Gynaecol 92 19-22