MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

If you are pregnant, a ‘breech presentation’ is not good news. It occurs when the fetus presents ‘bottom-down’ in the uterus. There are three types:

  • Breech with extended legs (frank) – 85% of cases
  • Breech with fully flexed legs (complete)
  • Footling (incomplete) with one or both thighs extended

The significance of breech presentation is its association with higher perinatal mortality and morbidity when compared to cephalic presentations. This is due both to pre-existing congenital malformation, increased incidence of breech in premature deliveries and increased risk of intrapartum trauma or asphyxia. Caesarean section has been adopted as the ‘normal’ mode of delivery for term breech presentations in Europe and the USA, as the consensus is that this reduces the risk of birth-related complications.

But Caesarian section is also not a desirable procedure. Something far less invasive would be much more preferable, of course. This is where the TCM-practitioners come in. They claim they have the solution: moxibustion, i.e. the stimulation of acupuncture points by heat. But does it really work? Can it turn the fetus into the correct position?

This new study aimed to assess the efficacy of moxibustion (heating of the acupuncture needle with an igniting charcoal moxa stick) with acupuncture for version of breech presentations to reduce their rate at 37 weeks of gestation and at delivery. It was a randomized, placebo-controlled, single-blind trial including 328 pregnant women recruited in a university hospital center between 33 4/7 and 35 4/7 weeks of gestation. Moxibustion with acupuncture or inactivated laser (placebo) treatment was applied to point BL 67 for 6 sessions. The principal endpoint was the percentage of fetuses in breech presentation at 37 2/7 weeks of gestation.

The results show that the percentage of fetuses in breech presentation at 37 2/7 weeks of gestation was not significantly different in both groups (72.0 in the moxibustion with acupuncture group compared with 63.4% in the placebo group).

The authors concluded that treatment by moxibustion with acupuncture was not effective in correcting breech presentation in the third trimester of pregnancy.

You might well ask why on earth anyone expected that stimulating an acupuncture point would turn a fetus in the mother’s uterus into the optimal position that carries the least risk during the process of giving birth. This is what proponents of this technique say about this approach:

During a TCM consultation to turn a breech baby the practitioner will take a comprehensive case history, make a diagnosis and apply the appropriate acupuncture treatment.  They will assess if moxibustion might be helpful. Practitioners will then instruct women on how to locate the appropriate acupuncture points and demonstrate how to safely apply moxa at home. The acupuncture point UB 67 is the primary point selected for use because it is the most dynamic point to activate the uterus.  Its forte is in turning malpositioned babies.  It is located on the outer, lower edge of both little toenails. According to TCM theory, moxa has a tonifying and warming effect which promotes movement and activity.  The nature of heat is also rising.  This warming and raising effect is utilised to encourage the baby to become more active and lift its bottom up in order to gain adequate momentum to summersault into the head down position. This technique can also be used to reposition transverse presentation, a situation where the baby’s has its shoulder or back pointing down, or is lying sideways across the abdomen.

Not convinced? I can’t say I blame you!

Clearly, we need to know what the totality of the most reliable evidence shows; and what better than a Cochrane review to inform us about it? Here is what it tells us:

Moxibustion was not found to reduce the number of non-cephalic presentations at birth compared with no treatment (P = 0.45). Moxibustion resulted in decreased use of oxytocin before or during labour for women who had vaginal deliveries compared with no treatment (risk ratio (RR) 0.28, 95% confidence interval (CI) 0.13 to 0.60). Moxibustion was found to result in fewer non-cephalic presentations at birth compared with acupuncture (RR 0.25, 95% CI 0.09 to 0.72). When combined with acupuncture, moxibustion resulted in fewer non-cephalic presentations at birth (RR 0.73, 95% CI 0.57 to 0.94), and fewer births by caesarean section (RR 0.79, 95% CI 0.64 to 0.98) compared with no treatment. When combined with a postural technique, moxibustion was found to result in fewer non-cephalic presentations at birth compared with the postural technique alone (RR 0.26, 95% CI 0.12 to 0.56).

In other words, there is indeed some encouraging albeit not convincing evidence! How can this be? There is no plausible explanation why this treatment should work!

But there is a highly plausible explanation why the results of many of the relevant trials are false-positive thus rendering a meta-analysis false-positive as well. I have repeatedly pointed out on this blog that practically all Chinese TCM-studies report (false) positive results; and many of the studies included in this review were done in China. The Cochrane review provides a strong hint about the lack of rigor in its ‘plain language summary’:

The included trials were of moderate methodological quality, sample sizes in some of the studies were small, how the treatment was applied differed and reporting was limited. While the results were combined they should be interpreted with caution due to the differences in the included studies. More evidence is needed concerning the benefits and safety of moxibustion.

So, would I recommend moxibustion for breech conversion? I don’t think so!

One Response to Acupuncture/moxibustion for version of breech fetuses? Probably not!

  • Most breech positions spontaneously turn into correct, cephalad position before the last weeks of pregnancy. I believe the incidence of breech presentation is in the vicinity of 3-4% even if many fetuses lie with their head up before 24 gestational weeks.
    Therefore any mumbo-jumbo supposed to facilitate such a happy outcome will frequently have a false positive result and elucidate a misdirected elation and excitement in both quack and customer.
     

    

Following a link from David Gorski’s latest post on SBM I stumbled over a discussion thread starting with a question from an Arizonian naturopath about “techniques to help turn a breech baby”. 
”I have a patient whose daughter is pregnant and the baby is in breech. Her Ob/Gyn will try a technique to flip and if that doesn’t happen wants to do a c-section, which is not a good idea for this patient (or any) as the daughter has had problems with recurrent MRSA. The mom asked me for advice on helping the flip the baby. “
The naturopath obviously prefers homeopathy but is unsurprisingly ready to believe any nonsense:
    ”Are there any go to herbs, homeopathics (I have not taken any constitutional case and just asking a general question as we know for bruising injury there is arnica, etc), nutrients, etc, or naturopathic techniques to help turn a breech baby? Of course, in med school we were shown some French doc who simply gently reached into the squatting woman and pulled out the breech baby by its legs. One, two, three, healthy baby was born. “

This discussion thread ( http://pastebin.com/zCYSQpCi ) is one of very many that have been surreptitiously lifted from a secret discussion forum for naturopaths on Yahoo. As most of this material, this short discussion is eerily revealing of the ignorance, irrationality and dangerous “Expectancy Based Medicine” approach of naturopaths to serious health problems. This spine-chilling material has been posted by an incognito whistleblower calling himself “naturowhat” and can be found here. 
Gorski’s article cited above contains and refers to material that confirms the veracity of the documents.
In the discussion thread I am referring to, a couple of the suggestions from fellow naturopaths for correcting a breech presentation, recommend acupuncture stimulation of the UB67 point, which is said to be on the “bladder meridian” and located on the outside of the fifth toe close to the nail.
Further exploration revealed no less than a Cochrane review of the use of moxibustion for stimulation of said pinky-toe-point. The document is updated in 2012 to include a total of eight trials (involving 1346 women) . The conclusion is a word salad, basically saying they found no conclusive evidence:
“There is some evidence to suggest that moxibustion may reduce the number of non-cephalic presentations at birth, either alone or in combination with acupuncture or postural techniques. When used in combination with acupuncture, moxibustion may result in fewer births by caesarean section. Moxibustion may also be useful in decreasing women’s use of oxytocin (compared with no treat- ment). There is some evidence that moxibustion combined with postural techniques (knee-chest therapy, and LBSL) may reduce the number of non-cephalic presentations at birth. Further evidence is needed to confirm (or refute) benefit for correcting breech presentation. Practitioners should ensure appropriate ventilation is available when performing moxibustion, to reduce the respiratory adverse events reported with the procedure. “
They then go on with the usual disclaimer “There is a need for robust, methodologically sound, randomised controlled trials of adequate statistical power to evaluate this intervention…” and so on, which means they found the quality of studies wanting.

    Unsurprisingly, the internet is full of pages describing this “surprisingly effective, safe, non-invasive treatment” and the review and/or individual papers directly or indirectly referenced as proof of its utility.

    What struck me most in the parts of the full Cochrane review I have had time to read was a paragraph in the introduction:
    ”How the intervention might work
    The effect of moxibustion is proposed to be associated with the chemical and thermal stimulation from the burning of moxa. The procedure is thought to stimulate the production of placental oestrogens and prostaglandin, encouraging fetal activity through contraction of the lining of the uterus (West 2003). “

    
I am not an obstetrician and my personal one (my wife) is at the moment about 36000 feet above the Atlantic. But I dear say my basic, knowledge of anatomy tells me the ‘lining’ of the uterus contains no significant contractile tissue elements and a general prerequisite for correction of any malpresentation of the fetus would be to relax the uterus, not contract.
    I fear the authors of this confusing Cochrane document may not be fully aware of basic facts?

    Further scrutiny of their analysis and the papers involved will have to wait.

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