Breech Presentation
Posted on August 16, 2016
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Research
While clinical practice does not always reflect the methods used in research and questions remain over the use of methods such as a placebo in acupuncture, or the use of prescribed points rather than an individual diagnosis, western medical research does offer opportunities to discuss and promote acupuncture to medical professionals and the community. This is especially relevant in the area of obstetrics were safety and evidenced based practice are primary concerns.
Interventions on BL 67 for women with a breech foetus at 33 weeks gestation.
van den Berg I, Kaandorp G, Bosch J, Duvekot J, Arends L, Hununk M. Cost-effectiveness of breech version by acupuncture-type interventions on BL 67, including moxibustion, for women with a breech foetus at 33 weeks gestation: a modelling approach. Complementary Therapies in Medicine 2010;18, 67—77.
A modelling approach to evaluate the effectiveness and costs of using acupuncture-type interventions on BL67 (Zhiyin) compared to expectant management for women presenting with a baby in a breech position at 33 weeks gestation.
Summary
A modelling approach was used to predict the number of caesarean sections that could be prevented using moxibustion and or acupuncture on BL 67 at 33 gestational weeks. There were two strategies for women presenting with breech presentation at 33 weeks gestation:
- Expectant management – a wait and see approach with external cephalic version (ECV) offered if required
- Acupuncture-type interventions on BL67
Ten thousand women were accounted for in this model. Also included were the medical costs of two ultrasounds for every woman, ECV treatment if required and costs for pre- and postnatal care until eight days post delivery.
The acupuncture treatment included extra costings for two visits with an acupuncturist and the moxibustion sticks supplied for home treatment.
Both strategies of this modelling included an option for women to receive an ECV at 36 gestational weeks and for all births to occur in hospital. Women refusing the option of acupuncture-type interventions on BL67 or non compliance with using the moxa treatment at home were also accounted for.
Treatment Methods
The probability that women would accept treatment and that babies would remain in a persistent breech presentation were retrieved from a systematic review and meta-analysis of six randomized controlled trials (RCTs) reporting on the effectiveness of acupuncture-type interventions on BL 67 versus expectant management. These trials comprised of three RCT’s using moxibustion. The remaining three used acupuncture, electro- acupuncture and a mixture of moxibustion and acupuncture.
Conclusion
Two data analysis were preformed for the women receiving acupuncture type intervention: one with and one without ECV. Both resulted in a decreased breech presentation at term.
To prevent one caesarean section, seven women with breech presentation at 33 weeks gestation would need to be treated with acupuncture-type interventions on BL 67. Sensitivity analysis showed that if 16% or more of the women offered moxibustion treatment complied, it was more effective and less costly than expectant management. The cost difference per woman with a baby in breech position at 33 weeks gestation using the moxa around 33 weeks versus no additional treatment was € 451 (95% CI € 109, € 775; p = 0.005) eight days post delivery.
The authors concluded that offering acupuncture type interventions at BL 67 to women with a breech foetus at 33 weeks gestation reduced the number of breech presentations at term, the number of caesarean sections required, and was cost effective when compared to expectant management.
Clinical Perspective
The lead researcher of this study has published a previous systematic review on the safety and effectiveness of using acupuncture type interventions on BL 67 for women presenting with breech presentation. This recent research approach is timely, enabling acupuncturists to now engage in discussions with medical, midwifery and hospital clinic management staff about of the cost effectiveness of implementing acupuncture type interventions for breech presentation. Being able to enter into such discussions may well be an important factor for acupuncturists to facilitate the integration of acupuncture services within main stream medical care.
http://www.ncbi.nlm.nih.gov/pubmed/20430289
Moxibustion use for Breech Presentation
Cardini et al in 1998 [7] had the following randomised controlled trial published in the Journal of American Association (JAMA)
Summary
The objective was to evaluate the efficacy and safety of moxibustion on Zhiyin BL-67 to correct breech presentation. 130 women having their first baby (primigravidas) at 33 gestation received moxibustion to Zhiyin Bl 67 while 130 women, also primigravidas, received no intervention.
The moxibustion was administered for 7 days .Women were then assessed and a further 7 days of moxibustion treatment given if the position had not changed.
Outcomes were measured in terms of fetal movements, as counted by the mother for one hour each day for one week and the number of cephalic presentations both at 35 weeks gestation and at delivery
At 35 weeks gestation 75.4% in the intervention group were cephalic (47.7% in the control).
Women in both groups then had the option of undergoing external cephalic version (ECV). One woman took this option from the intervention group and 24 from the control group
At delivery the presentation of 75.4% of the intervention group were cephalic compared to 62.3% in the control group.
The presentation did not change in any of the groups after 35 weeks except in those undergoing ECV. In terms of fetal movement the moxibustion group experienced a greater number of movements (a mean of 48.45 compared to the control group with a mean of 35.35).
Conclusion
That in prigravidas at 33 weeks gestation with breech presentation moxibustion treatment for 1 to 2 weeks at Zhiyin BL-67 increased fetal activity during the treatment period and cephalic presentation at 35 weeks and at delivery.
Treatment method
The women and their partner (or a person to help with the treatment) were given a treatment and taught how to use the moxibustion in a hospital appointment within 24 hours of the scan confirming the breech position. They then applied the treatment to Zhiyin BL-67 daily at home. Moxa sticks were used with the women sitting or in a semisupine position and the partner delivering the treatment.
Clinical Perspective
As part of this study an attempt was made to assess if there was a difference in delivering moxibustion sessions once or twice a day.
87 women used moxibustion for a total of 30 minutes (15 minutes to each point) while 43 women used moxibustion in the same way but received treatment twice a day.
At the end of the first week 79% of the cephalic versions were obtained in the women using moxibustion twice a day compared to 55.2 % in the daily treatments. But by the end of the second week 15 additional cephalic versions were obtained in the group having moxibustion treatment once a day.
This meant that at 35 weeks the results were termed as a nonsignificant difference (72.4% in the once a day moxibustion group compared to 81% for the women having moxibustion treatment twice a day).
From a safety perspective it was reassuring that no adverse events (such as intrauterine death or placental detachment) were noted in the treatment group. It was also interesting that while the number of premature rupture of membranes was similar in both groups the number of premature births was lower in the intervention group and that the use of oxytocin, before or during labour, was also reduced in the moxibustion group (8.6% compared to 31.3%).