CHAPTER 6
Complementary Therapies
for Breech Presentation
Breech presentation can be a worrying diagnosis for the expectant mother, given the limited options for conventional obstetric care. Many women want to avoid Caesarean section or external cephalic version, and few are given the option of a vaginal breech birth. Moxibustion, a traditional Chinese medicine technique, has become a popular, inexpensive and empowering alternative for these women and is now fairly well known in the west, although its availability on the NHS is negligible.
This chapter addresses moxibustion treatment in detail, with an exploration of the mechanism of action and research into the effectiveness and safety of the technique. A brief discussion on other complementary therapies for women with breech presentation is also included.
This chapter includes:
• introduction
• moxibustion
• other alternative options for women with breech presentation
• conclusion.
The incidence of breech presentation at term is around 3 to 4 per cent (Mitchell and Allen 2008) and may be associated with stillbirth and adverse perinatal outcomes including oligohydramnios, fetal growth restriction, gestational diabetes and congenital anomalies (Macharey et al. 2017). Standard obstetric practice is to offer women external cephalic version (ECV) or Caesarean section to minimise the risks to mother and baby (RCOG 2017). Vaginal breech birth is not currently offered as a standard option in the majority of UK maternity units, except in the case of a late admission or an undiagnosed breech presentation, because of the perceived risks such as fetal asphyxia and neonatal trauma. ECV and Caesarean section are, however, also associated with significant risks (Hunter 2014). Questions have been raised about the ability of obstetricians to perform Caesareans safely (Glezerman 2011), although the phenomenal operative delivery rates in many countries suggest that they are exceptionally experienced in the surgical procedures involved. This may, of course, be one of the reasons why vaginal breech birth is not viewed favourably by obstetricians, as their skills have developed in operative delivery, but this also means that midwives have also largely become de-skilled.
Guittier et al. (2011) found that women undergo a complex decision-making process on being informed that they have a breech presentation. They need time to discuss their concerns in a supportive environment in order to maintain control over the experience (Warriner, Bryan and Brown 2014). The limited conventional options available have led women to seek alternative ways to attempt to turn a breech-presenting fetus to cephalic in an effort to facilitate normal birth.
Moxibustion is by far the most well-known complementary therapy for breech presentation, with almost two thirds of women now prepared to try it, rather than submitting to ECV and/or Caesarean section (Guittier et al. 2012). Practitioners of other therapies such as hypnotherapy, reflexology and homeopathy may also be consulted by women with an abnormal presentation. Some therapies can also be used to assist in achieving the optimal position for the fetus when the presentation is cephalic.
Moxibustion
Moxibustion is a technique used in traditional Chinese medicine, the mechanism of action of which can be difficult to understand for those trained in conventional anatomy and physiology. Traditional Chinese medicine is based on the concept of holism, with the notion of a branching tree-like structure of internal subcuticular energy lines, called meridians, which convey the body’s life force and link one part of the body to another (see Chapter 2, Acupuncture). Moxibustion is a technique used to stimulate heat and energy along these meridians where the internal energy is deficient. In China, moxibustion is used in the treatment of over 300 medical conditions (Deng and Shen 2013) and in maternity care has long been used as an alternative to, or alongside, ECV. In western medical research, there is increasing interest in the potential of moxa therapy to treat various conditions including irritable bowel syndrome (Bao et al. 2016), osteoarthritis (Choi et al. 2017) and dysmenorrhoea (Yang et al. 2017). Moxibustion is also often used in combination with acupuncture, to increase the heat stimulation to the acupoints.
In Chinese medicine theory, fetal malpresentations such as breech and malpositions such as occipito-posterior are thought to arise from a deficiency in the energy (qi) passing through the Kidney meridian, which is in close proximity to the uterus. The Kidney meridian is said to have a role in nourishing the fetus; disharmony in Kidney qi can lead to deficiency or stagnation of the qi in the uterus. Kidney meridian deficiency also affects uterine and fetal muscle tone, so the fetus is unable to maintain a cephalic presentation or possibly even a longitudinal lie. The Bladder meridian, which is closely linked with the Kidney meridian, is instrumental in reproduction, and Bladder qi also influences uterine function. This means that Kidney meridian qi deficiency can be corrected by working on the Bladder meridian, and this is relevant to the practice of moxibustion to convert a breech presentation to cephalic.
The bilateral Bladder meridians (sometimes called the Urinary Bladder meridians) start in the inner corner of the two eye sockets (these points being called the left- and right-sided Bladder 1 acupoints). They then pass up and over the head, down the back either side of the spine, around the kidneys, through the bladder and continue down the legs, around the lower edges of the outer ankle bones, along the outer edges of the feet and end in the outer corners of the little toes (see Figure 6.1). This final acupoint, Bladder 67 (also called “Zhiyin”), is the point at which the Bladder and Kidney meridians connect; thus treatment at this point helps to correct both Bladder and Kidney meridian energy.
The Zhiyin point is said to have a specific function in promoting downwards movement of the fetal head; it is considered one of the points contraindicated for use in earlier pregnancy, as it may trigger miscarriage or preterm labour. The Bladder 67 point also has an impact at the other end of the meridian and can be used to treat headache, migraine, eye pain, epistaxis and sinus congestion (in non-pregnant clients). Indeed, it is interesting to note that many women with a breech presentation suffer from sinus congestion in pregnancy. In maternity care, the acupoint is used to correct a malpresentation or malposition; needling of the point can aid a difficult or protracted labour and deal with a retained placenta (following appropriate training).
Moxibustion is performed using moxa, specially prepared sticks containing a compressed, dried herb, mugwort (Artemesia vulgaris). The sticks are used as a heat source applied to the Bladder 67 acupoints on the dorsal surface at the outer edges of the cuticles on the little (fifth) toes (see Figure 6.1). Locating the point can, however, be complicated by the shape of the individual’s toenails, and can also be quite deep within the tissues. Inserting a sharp fingernail should elicit a sensation of tenderness on the correct point. It is for this reason that acupressure (applying finger or thumb pressure to the point) is generally ineffective in stimulating sufficient energy to cause conversion of the breech to cephalic presentation.
The aim of the treatment is to stimulate the deficient energy in the Bladder and Kidney meridians, increasing muscle tone and thus converting the breech to a cephalic presentation by harmonising the qi. In conventional physiological terms, the heat generated via moxibustion stimulates the adrenocortical system (adrenaline and noradrenaline), leading to changes in placental oestrogen and prostaglandin output, thereby increasing myometrial sensitivity and contractility. Moxa heat may also stimulate adenosine triphosphate (energy) (Hu et al. 2015), particularly in the fetus, so there is usually a slight, but normal, rise in the fetal heart rate during the treatment. A combination of extra “give” in the uterus from the hormonal changes and increased fetal activity may lead the fetus to turn itself to a cephalic presentation.
Figure 6.1 Location of the Bladder 67 acupoint for moxibustion
Suitability for moxibustion
As with any clinical treatment, there are some women in whom moxibustion is contraindicated. Acupuncturists assess women in terms of their qi deficiency and stagnation and do not consider the normal physio-pathological issues which are part of mainstream clinical practice. However, where midwives, doctors, doulas or antenatal educators are advising women about self-administration of moxibustion, caution should be employed to ensure that there are no clinical contraindications. This is particularly important when clinicians incorporate a complementary strategy which is new to the management of breech presentation, particularly a technique which has a relatively poor evidence base (or one for which most research papers are in Chinese). Also, when the woman is carrying out the treatment at home, there are no facilities for emergency treatment in the event of complications, so extra safety considerations are paramount.
In simple terms, contraindications to moxibustion are essentially the same as those for ECV. In addition, any woman with current or previous essential or gestational hypertension should not receive the treatment, because the moxa heat may raise the blood pressure, although systematic reviews by Kim et al. (2010) and Yang et al. (2014) suggest that moxibustion is sometimes used to reduce blood pressure (in non-pregnant patients and applied to different acupoints). In addition, anyone with respiratory compromise such as asthma should avoid moxibustion as the smoke generated during burning of the moxa sticks contains numerous constituents that are inhaled by the client and anyone else present and may, in susceptible people, cause respiratory problems or allergic reactions (Li and Liu 2008). For these women, acupuncture would be a safer option.
Women due to have an elective Caesarean section for another medical or obstetric indication should refrain from using moxibustion as it may complicate the condition. Indeed, any major medical or obstetric complication is a contraindication to using moxibustion. Confirmed or suspected cephalopelvic disproportion may mean vaginal birth may not be feasible, and it would therefore be inappropriate to subject the fetus to the stress of moxibustion for no reason. It should not be performed by or for women with poorly controlled diabetes or if there is a risk of a large baby, although non-insulin-controlled diabetes mellitus is not, in itself, a reason to avoid moxibustion. Current vaginal bleeding, major placental abruption, known placenta praevia or low-lying placenta are logical contraindications in a compromised pregnancy. Pyrexia, with or without infection, is also a reason to decline, as moxa heat may increase the body temperature, although this is disputed by Dharmananda (2004).
If there has been threatened preterm labour in this or a previous pregnancy it may be wise to delay the use of moxibustion until at least 36 weeks gestation to avoid any risk of preterm contractions or membrane rupture (Djakovic et al. 2015), although this may reduce the chances of successful version. In the event of an unstable lie, it is highly likely that any conversion will revert to a breech presentation if moxibustion is performed too early, so delaying the procedure until almost term may prevent this. Moxa heat may exacerbate existing fetal distress and, in the case of intrauterine growth retardation or reduced fetal movements, may stress the fetus unnecessarily. Moxibustion is contraindicated in multiple pregnancy to avoid the risk of fetal or cord entanglement. In the case of abnormal liquor volume, moxibustion would be a precaution if polyhydramnios is present, although the fetal lie may be changeable in any case. The procedure is contraindicated with oligohydramnios as it may cause additional problems, particularly if the reduction in amniotic fluid is due to fetal abnormalities. In the event of intrauterine death, moxibustion is inappropriate as the loss of muscle tone will probably cause the fetus to revert and it is not known how moxibustion may affect clotting factors, which can be compromised after fetal death. See Table 6.1 for a summary of the contraindications to moxibustion.
