Acupuncture and Moxibustion for Breech Presentation
Acupuncture and Moxibustion for Breech Presentation
By Judith L. Balk, MD, MPH, FACOG Assistant Research Professor, University of Pittsburgh, Pittsburgh, PA. Dr. Balk reports no consultant, stockholder, speaker's bureau, research, or other financial relationships with companies having ties to this field of study.
Source: Neri G, et al. Acupuncture plus moxibustion to resolve breech presentation: A randomized controlled study. J Matern Fetal Neonatal Med 2004;15:247-252.
Abstract: In many Western countries, breech presentation is an indication for elective cesarean section. To correct fetal presentation, the stimulation of the acupoint BL67 by moxibustion, acupuncture, or both has been proposed. Since no studies previously had 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 be assigned to the observation group. Bilateral acupuncture plus moxibustion was applied at the BL56 acupuncture point (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). The researchers conclude that acupuncture plus moxibustion is more effective than observation in revolving fetuses in breech position. Such a method appears to be a valid option for women willing to experience a natural birth.
Comments
Breech presentation occurs in 3-4% of term pregnancies, and planned breech cesarean deliveries account for roughly 10-15% of all cesarean deliveries at term. In the past, options for management of a breech presentation found in pregnancy included a planned vaginal delivery, a planned cesarean delivery, or an attempt at external cephalic version to move the fetus from the breech to the vertex presentation. A large international, multicenter, randomized clinical trial compared a policy of planned cesarean birth with planned vaginal birth.1 The investigators found decreased perinatal mortality, neonatal mortality, and serious neonatal morbidity in the planned cesarean group compared with the planned vaginal birth group. There were no differences in maternal mortality or morbidity between the two groups. Because of this large, rigorous study, the American College of Obstetrics and Gynecology recommends that obstetricians continue their efforts to reduce breech presentation through the application of external cephalic version whenever possible. ACOG also recommends that patients with a persistent breech presentation at term in a singleton gestation should undergo a planned cesarean delivery.2
External cephalic version is a procedure in which external pressure is placed on the mother's abdomen to turn the fetus in either a forward or backward somersault to achieve a vertex presentation. Success rates range from 35% to 86%, with an average success rate of 58%. The main benefit is an improved chance of a vaginal delivery if version is successful. Serious adverse events are not common, but transient fetal heart rate changes during attempted versions are common. These heart rate changes usually stabilize when the procedure has ended. Serious complications include a low risk of placental abruption and preterm labor. Because of the potential for serious complications, as well as maternal discomfort, complementary approaches such as acupuncture and moxibustion have been proposed.
The 1998 JAMA issue on complementary medicine included a Chinese study on moxibustion for breech version;3 this article was discussed in academic centers throughout the country and increased public awareness of the technique. The investigators found that the treatment increased fetal activity during the treatment and cephalic presentation at delivery. An earlier study also was a randomized, controlled trial.4 This study compared three groups (moxibustion, electroacupuncture, no intervention) and found that fewer women in the moxibustion group had a non-cephalic presentation compared with the control group. Recently, Cardini et al attempted to confirm the 1998 Chinese study by conducting a virtually identical study in Italy.5 Another goal of this replication study was to assess the ability to transfer a traditional Chinese treatment outside of the original ethnic, social, and cultural context. This study was not completed because of a large amount of treatment interruptions and poor compliance, with the authors concluding that the results supported neither the effectiveness nor ineffectiveness of moxibustion in correcting fetal breech position.5
Neri et al conducted a randomized controlled study comparing acupuncture plus moxibustion vs. observation.6 The study was conducted at two centers in Italy, the University of Modena-Reggio Emilia, and the University of Turin. Pregnant women at 33-35 weeks gestation were enrolled and received either active treatment up to twice per week for up to two weeks. Primary outcome variable was fetal presentation at delivery. The investigators enrolled 240 subjects, but 14 cases dropped out of the study, including six from the observation group and eight from the treatment group. Reasons for dropout in the observation group included threatened preterm labor (2) and because they refused to be assigned to the observation group (4). In the active group, dropouts were due to uterine contractions noted by their obstetrician (5), onset of mild hypertension (2), and reluctance to comply (1). Thus, there were 114 in the observation group and 112 in the active group. At delivery, the proportion of cephalic presentation was higher in the treatment group (53.6%) than in the observation group (36.7%), and the proportion of cesarean deliveries indicated for breech was significantly lower in the treatment group (52.3%) than in the observation group (66.7%). No fetal or maternal adverse events were noted after acupuncture.
The strengths of this study include a randomized approach, whereby confounders should be distributed equally to either arm of the study. Also, the control group is appropriate. No patients were offered external cephalic version, as the authors note that in Italy, external version is not well accepted by either obstetricians or the patients. Method of randomization is computer-generated, and allocation was concealed until after randomization. It is not stated if the assessors were blinded to treatment group, but the outcome is an objective finding and thus blinding would not be important. Power calculations are clearly stated, as is the statistical plan.
The weaknesses of the study are fairly minimal. The 14 patients who dropped out of the study were not included in the analysis; thus the analysis was not intention-to-treat. It is likely that the authors did not have access to these subjects' delivery records. Subjects greater than 35 weeks gestational age were excluded due to possible induction of labor using the same acupoint, but if this point can induce labor, it seems that it could also induce preterm labor and would be contraindicated preterm. Also, the article notes that the acupuncture needles were inserted to a depth of 10-30 mm. Given that this acupuncture point is 2 mm from the corner of the toenail on the lateral little toe, a needle insertion depth of 10-30 mm would be unlikely. Fetal and maternal adverse events were assessed immediately after acupuncture, but no data were presented indicating adverse event differences existed at the time of delivery.
In conclusion, this study demonstrated that acupuncture plus moxibustion given at 33-35 weeks gestation in breech presentations increased the incidence of cephalic presentations at term and decreased the risk for cesarean deliveries. This is an adequately powered study with a rigorous design, and its findings contribute to the research base for acupuncture and moxibustion for breech presentation at term.
References
1. Hannah ME, et al. Planned caesarean section versus planned vaginal birth for breech presentation at term: A randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet 2000;356:1375-1383.
2. ACOG committee opinion: number 265, December 2001. Mode of term single breech delivery. Obstet Gynecol 2001;98:1189-1190
3. Cardini F, Weixin H. Moxibustion for correction of breech presentation: A randomized controlled trial. JAMA 1998:280:1580-1584.
4. Li Q, Wang L. Clinical observation on correcting malposition of fetus by electro-acupuncture. J Tradit Chin Med 1996;16:260-262.
5. Cardini F, et al. A randomised controlled trial of moxibustion for breech presentation. BJOG 2005:112:743-747.
6. Neri I, et al. Acupuncture plus moxibustion to resolve breech presentation: A randomized controlled study. J Matern Fetal Neonatal Med 2004;15:247-252.
Balk JL. Acupuncture and moxibustion for breech presentation. Altern Ther Women's Health 2005;7(11):86-87.Subscribe Now for Access
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