Acupuncture plus moxibustion to resolve breech presentation: a randomized controlled study.

OBJECTIVE: In many Western countries breech presentation is an indication for elective Cesarean section. In order to correct fetal presentation, the stimulation of the acupoint BL67 by moxibustion, acupuncture or both has been proposed. Since no studies had previously 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. METHODS: 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 to be assigned to the observation group. Bilateral acupuncture plus moxibustion was applied at the BL67 acupoint (Zhiyin). The primary outcome of the study was fetal presentation at delivery. RESULTS: 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). CONCLUSIONS: Acupuncture plus moxibustion is more effective than observation in revolving fetuses in breech presentation. Such a method appears to be a valid option for women willing to experience a natural birth.     

Acupuncture plus moxibustion to resolve breech presentation: a randomized controlled study

Objective: In many Western countries breech presentation is an indication for elective Cesarean section. In order to correct fetal presentation, the stimulation of the acupoint BL67 by moxibustion, acupuncture or both has been proposed. Since no studies had previously 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.

Methods: 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 to be assigned to the observation group. Bilateral acupuncture plus moxibustion was applied at the BL67 acupoint (Zhiyin). The primary outcome of the study was fetal presentation at delivery.

Results: 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).

Conclusions: Acupuncture plus moxibustion is more effective than observation in revolving fetuses in breech presentation. Such a method appears to be a valid option for women willing to experience a natural birth.     

Spontaneous cephalic version of breech presentation in the last trimester

Summary. A prospective longitudinal investigation of spontaneous cephalic version from breech presentation in the last trimester is reported. All pregnancies were assessed with ultrasound in the 32nd week of gestation, and were thereafter checked weekly. Of the 310 singleton breech presentations identified at 32 weeks, spontaneous cephalic version occurred in 177 (57%) while breech presentation persisted in 133 patients (43%). Of 140 patients with a breech presentation at delivery 95% were already presenting by the breech in the 32nd week. Spontaneous cephalic version was less likely in pregnancies with extended fetal legs, low birth-weight, short umbilical cord and primiparity.     

Spontaneous cephalic version of breech presentation in the last trimester

A prospective longitudinal investigation of spontaneous cephalic version from breech presentation in the last trimester is reported. All pregnancies were assessed with ultrasound in the 32nd week of gestation, and were thereafter checked weekly. Of the 310 singleton breech presentations identified at 32 weeks, spontaneous cephalic version occurred in 177 (57%) while breech presentation persisted in 133 patients (43%). Of 140 patients with a breech presentation at delivery 95% were already presenting by the breech in the 32nd week. Spontaneous cephalic version was less likely in pregnancies with extended fetal legs, low birth-weight, short umbilical cord and primiparity.     

The Variability of Fetal Lie, Presentation and Position During "Normal" Pregnancy

Summary: The fetal lie, presentation, and position was recorded serially from the 16th week of gestation until delivery in 100 pregnant women.
The incidence of these characteristics varied with gestation and parity, with stabilization of fetal lie occurring at the 22nd week in nulliparous patients, and at the 30th week in parous patients; the frequency of longitudinal lie rose from 63% at 16 weeks of gestation to 99% at 32 weeks of gestation.
Only 1 persistent breech presentation and 1 persistent transverse lie occurred in the 100 patients. The predominant position in the cephalic presentations was left occipital with a significantly higher incidence in the nullipara.
Considerable variability of lie, presentation, and position occurred in serial examinations, and late spontaneous version from breech to vertex occurred in 4 multiparous patients.     

Knee-Chest Postural Management for Breech at Term: A Randomized Controlled Trial

Background: In 3 to 4 percent of all term births, the fetus presents as a breech. The objectives of this trial were to assess if assuming the knee-chest position reduced the frequency of breech presentation at delivery, increased the success of the subsequent external cephalic version, or both, and to determine if this management plan reduced the need for cesarean delivery. Methods: A randomized clinical trial recruited 100 women from two hospitals in Adelaide, South Australia, with a singleton breech presentation and a gestational age equal to or more than 36 weeks. Women in the treatment group were advised to assume the knee-chest position for 15 minutes three times a day for one week. Women in the control group did not perform postural management. All participants were reviewed one week later, and women whose baby remained as a breech presentation were offered an external cephalic version. Results: Postural management did not increase the success of the external cephalic version, reduce the frequency of breech presentation at delivery, or reduce the need for cesarean delivery in women with a breech presentation at term. Conclusions: Findings from this trial included in a meta-analysis of postural management for breech presentation at term suggested that this is not an effective form of care to be offered routinely to women with a breech presentation at term.     

Factors affecting the success of moxibustion in the management of a breech presentation as a preliminary treatment to external cephalic version

Objectives

to explore the effects of moxibustion treatment, to examine the predictors of its use in causing a breech presentation to spontaneously turn to a cephalic presentation which will result in a vaginal birth (the paper will refer to this as ‘successful’) and offer external cephalic version (ECV) subsequently after moxibustion treatment when the fetus remains in a breech presentation.

Design

a prospective study over a two-year time period from February 2004 until January 2006.

Participants

76 pregnant women from various acupuncture practices in the UK, with a third trimester breech presentation.

Interventions

the acupuncturist taught the women how to apply moxibustion (sticks of compressed dried herbs—Artemisia vulgaris) treatment at home by stimulating the acupoint on the outer edge at the base of the little toe nail for seven days twice a day (morning and afternoon). If the breech presentation persisted after treatment, ECV was carried out towards the end of the pregnancy. The obstetricians offered this during the routine antenatal hospital visits.

Findings

the results show that following treatment with moxibustion, 31 (40.8%) of the breech presentations spontaneously turned to cephalic presentations, and a further 33 (43.4%) breech presentations were turned by ECV. Women who involved other people in the administration of moxibustion were twice as likely to be successful. Multiparous women were also 16% more likely than primiparous women to succeed in achieving a spontaneous version with the use of moxibustion. Fewer side effects reported when using moxibustion were the strongest predictor of successful spontaneous cephalic version with an odds ratio of 12% (p=0.02).

Key conclusions

moxibustion creates a better chance of vaginal birth for expectant mothers. Of the women who were successful in turning their babies using moxibustion, 88% went on to have a normal birth and 12% had a caesarean section. Moxibustion treatment also significantly increases version from a breech presentation to a cephalic presentation where there are fewer side effects reported, if the woman is multiparous and has support during the administration of moxibustion treatment.

Implications for practice

moxibustion treatment should be offered to all women with a breech presentation because it is non-invasive and can be self-administered by the woman. It is therefore a simple, cost-effective technique that requires no medical intervention.     

Conservative management in breech deliveries leads to similar results compared with cephalic deliveries.

OBJECTIVE: To compare the difference in neonatal mortality and morbidity between breech and cephalic presentations at term. METHODS: This was a retrospective matched cohort study in two centers between July 1998 and April 2000, including all breech deliveries between 37(+0) and 41(+6) weeks, except cases with multiple gestations and antepartum intrauterine deaths. All breech presentations were matched with two cephalic presentations. Onset of labor and route of delivery were recorded, and neonatal data were categorized into variables belonging to serious morbidity or moderate morbidity. RESULTS: One thousand one hundred and nineteen deliveries were included. Three hundred and seventy-three babies were in breech position and 746 in cephalic position. The gestational age and birth weight of the babies in the breech group were lower than in the cephalic group (p < 0.001). Congenital abnormalities occurred more often in the breech group (p < 0.005). An elective cesarean section was performed in 23.3% of breech presentations versus 3.5% of cephalic presentations (p < 0.001). Emergency cesarean sections were done in 29.2% of breech presentations versus 8.8% of cephalic presentations (p < 0.001). Children born in breech presentation had lower Apgar scores after 1 minute (p < 0.0001), but 5-minute Apgar scores were the same in both groups (p = 0.22). Children born in breech presentation received significantly more resuscitation than children born in cephalic presentation (p < 0.001). In both groups no perinatal mortality occurred. No differences were observed in percentages of children with serious or moderate neonatal morbidity between the breech and cephalic lies. CONCLUSIONS: Although the numbers are small, this study shows that the conservative (vaginal) approach in selected fetuses in breech position can be safely pursued with neonatal results similar to fetuses in cephalic presentation.     

The benefit of external cephalic version with tocolysis as a routine procedure in late pregnancy.

The effectiveness of external cephalic version with tocolysis when routinely used in the 37th week of gestation is reported. The procedure had earlier been ruled out in our department, was found effective in a prospective study, and afterwards settled as a routine. Among 1038 women with single breech presentation, 882 could be offered an attempt of external cephalic version during the period 1982-1988. Attempt of version was carried out in 316 women resulting in a vertex presentation at delivery in 100. The success rate on average was 35%. The estimated reduction of breech deliveries was 100/1038 = 9.6%. As the mean caesarean section rate in women with breech presentation was 81% during the period studied, the estimated reduction in the number of caesarean sections during those seven years was 81. Thus the total caesarean section rate (11.3%) was estimated to be reduced by 0.4%. No immediate serious complications were associated with the procedure. Two cases of intra-uterine fetal death occurred 2 and 5 weeks, respectively, after successful, uncomplicated version to vertex presentation. No obvious connection with the external cephalic version could be demonstrated. The effectiveness of version as a routine procedure is less than expected from reports of prospective trials of external cephalic version carried out by a few investigators, but the results may realistically illustrate what is achieved in the long term.     

Does Advice to Assume the Knee-Chest Position Reduce the Incidence of Breech Presentation at Delivery? A Randomized Clinical Trial

ABSTRACT: A randomized clinical trial of 76 women with a persistent singleton breech presentation at 37 weeks’ or more gestation tested the value of advising women to assume the knee-chest position for 15 minutes three times a day in reducing the incidence of breech presentation at delivery. In the 39 women advised to perform the procedure, 16 (41.0%) fetuses underwent rotation and remained cephalic at delivery compared to 12 (32.4%) of the 37 women in the control group in whom spontaneous version to cephalic occurred. The procedure warrants further evaluation in other obstetric populations, at or in the thirty-seventh week of gestation, and in a larger study group.     

Maternal and fetal factors in breech presentation

The authors used ultrasound examination in an attempt to identify fetal and environmental differences between breech and vertex presentations. During a period of 13 months, 228 pregnancies with the fetus in breech position were found by routine ultrasound screening in the 33rd gestational week. Before delivery, 132 fetuses (58%) turned to vertex presentation and 96 (42%) remained in breech presentation. Fetal growth, posture, position, placental site, and amniotic fluid volume in the 33rd, 35th, and 38th gestational weeks were studied. In contrast to earlier proposed theories, no difference between the two groups (breech and vertex) was found regarding the frequency of extended fetal legs and cornual-fundal placental implantation. However, the neonates born in breech presentation had a shorter gestational age by ten days at delivery, and preterm delivery was more common. At birth, the breech neonates weighed 4.9% less than their vertex controls in relation to gestational age. In the breech group, there was an increased frequency of oligohydramnios, contracted pelvis, and uterine and fetal malformations. These conditions occurred only in 15% of the breech pregnancies; in the remaining 85%, no single cause of the breech presentation could be identified.     

Outcomes of external cephalic version and breech presentation at term, an audit of deliveries at a Sydney tertiary obstetric hospital, 1997-2004

BACKGROUND: Probabilistic information on outcomes of breech presentation is important for clinical decision-making. We aim to quantify adverse maternal and fetal outcomes of breech presentation at term. METHODS: We conducted an audit of 1,070 women with a term, singleton breech presentation who were classified as eligible or ineligible for external cephalic version or diagnosed in labor at a tertiary obstetric hospital in Australia, 1997-2004. Maternal, delivery and perinatal outcomes were assessed and frequency of events quantified. RESULTS: Five hundred and sixty (52%) women were eligible and 170 (16%) were ineligible for external cephalic version, 211 (20%) women were diagnosed in labor and 134 (12%) were unclassifiable. Seventy-one percent of eligible women had an external cephalic version, with a 39% success rate. Adverse outcomes of breech presentation at term were rare: immediate delivery for prelabor rupture of membranes (1.3%), nuchal cord (9.3%), cord prolapse (0.4%), and fetal death (0.3%); and did not differ by clinical classification. Women who had an external cephalic version had a reduced risk of onset-of-labor within 24 h (RR 0.25; 95%CI 0.08, 0.82) compared with women eligible for but who did not have an external cephalic version. Women diagnosed with breech in labor had the highest rates of emergency cesarean section (64%), cord prolapse (1.4%) and poorest infant outcomes. CONCLUSIONS: Adverse maternal and fetal outcomes of breech presentation at term are rare and there was no increased risk of complications after external cephalic version. Findings provide important data to quantify the frequency of adverse outcomes that will help facilitate informed decision-making and ensure optimal management of breech presentation.     

Effect of external cephalic version in late pregnancy on presentation at delivery: a randomized controlled trial

Summary. The effect of repeated external cephalic version, performed at between 33 and 40 weeks gestation, on presentation at delivery was studied in a randomized controlled trial comprising 180 pregnant women with breech presentation. No tocolysis, analgesia or anaesthesia was used. Approximately 25% of all attempts in the study group of 90 women were successful; repeated external version resulted in cephalic presentation at delivery in 48% of patients. Spontaneous version to cephalic presentation occurred in 23 (26%) of the 90 women in the control group in whom version was not attempted, indicating a therapeutic gain from the procedure of 22%, with a 95% confidence interval of 8 to 35%. No severe complications of external cephalic version were noted. We conclude that external cephalic version reduces the frequency of breech presentation at delivery. This mainly benefits the mother because of the decrease in the number of caesarean sections and their inherent maternal morbidity.     

Effect of external cephalic version in late pregnancy on presentation at delivery: a randomized controlled trial

The effect of repeated external cephalic version, performed at between 33 and 40 weeks gestation, on presentation at delivery was studied in a randomized controlled trial comprising 180 pregnant women with breech presentation. No tocolysis, analgesia or anaesthesia was used. Approximately 25% of all attempts in the study group of 90 women were successful; repeated external version resulted in cephalic presentation at delivery in 48% of patients. Spontaneous version to cephalic presentation occurred in 23 (26%) of the 90 women in the control group in whom version was not attempted, indicating a therapeutic gain from the procedure of 22%, with a 95% confidence interval of 8 to 35%. No severe complications of external cephalic version were noted. We conclude that external cephalic version reduces the frequency of breech presentation at delivery. This mainly benefits the mother because of the decrease in the number of caesarean sections and their inherent maternal morbidity.     

Signal quality of non-invasive fetal electrocardiogram in vaginal breech delivery: a case–controlled study

Objective

Recently, a non-invasive fetal electrocardiogram monitor has been approved for clinical usage in labour and delivery. To determine the fetal signal quality of vaginal breech deliveries in comparison with a case–controlled cephalic group during labour.

Study design

This case–control study was carried out at the Department of Obstetrics and Gynecology of the University Hospital Frankfurt between 1st July 2012 and 30th September 2012. A total of seven breech deliveries were evaluated. A case–controlled cephalic group with same gestational age and parity were selected from a previous trial.

Results

During first stage of labour, vaginal breech and cephalic delivery had no significant different fetal signal success rates (mean 87.8 vs. 85.7 %; p > 0.05). There was a trend of higher fetal signal success rates in the vaginal breech delivery group during second stage of labour (78.4 vs. 55.4 %; p = 0.08).

Conclusion

Similar fetal signal success rates in vaginal breech delivery in comparison to cephalic presentation were demonstrated using the new commercially available non-invasive abdominal fECG device (the Monica AN24^TM).     

Non-stress test changes during acupuncture plus moxibustion on BL67 point in breech presentation

OBJECTIVES: We assessed fetal heart variability and activity using a computerized non-stress test (NST) during acupuncture plus moxibustion on the BL67 point. For comparison, the same changes were assessed during placebo acupuncture (minimal acupuncture) in the same subjects. METHODS: Twelve pregnant women in the 33rd week of gestation, carrying singletons in the breech presentation were enrolled in the study. In a single-blind design, each woman received a first session of minimal acupuncture followed 1-2 days later by true acupuncture. During the sessions, women were monitored using computerized non-stress testing starting 20 minutes before the stimuli and continuing for 20 minutes after treatment. RESULTS: During true acupuncture a significant reduction in fetal baseline heart rate, and more accelerations and movement were observed. During minimal acupuncture, there were no significant changes in these variables. No signs of fetal distress or changes in short- or long-term variability were noted, and there were no uterine contractions. CONCLUSION: In our study population, acute application of acupuncture plus moxibustion did not cause fetal distress as assessed by either fetal heart rate decelerations or changes in either short- or long-term variability. Considering that the modifications in fetal movement and heart rate occurred in true but not during minimal acupuncture, we could consider that such changes are related to the effect of the acupuncture stimulation. The mechanisms leading to the cephalic version remain to be clearly established.     

Placental location and its influence on the position of the fetus in the uterus

There are different opinions concerning the influence of the placental localization on the position of the fetus in the uterus. Two options are suggested in breech presentation--placenta praevia and cornual localization as possible causes for breech presentation. The aim of the present prospective study is to establish the influence of placental localization on the fetal position in the uterus. Two groups of pregnant women were examined--the first with cephalic resentation (n = 125) and the second with breech presentation (n = 124). All of the pregnant women examined were nulliparas, with term pregnancy (37-40 weeks). Uterine and fetal abnormalities were excluded. The localization of the placenta was determined by ultrasonography. The cornu-fundal localization of the placenta was found in 4.8% in the pregnant women with cephalic presentation and 62.6% in pregnant women with breach presentation. Placenta praevia or low insertion of the placenta was found in 3.2% of the cases with breech presentation and in none of the cases with cephalic presentation. The authors conclude on the basis of the data in the study that the localization of the placenta influences the fetal position in the uterus.     

Growth in breech presentation. Ultrasound and post-partal assessment of growth in 225 fetuses presenting by the breech in the 33rd gestational week

225 fetuses with ultrasonically determined gestational age were shown by ultrasound to be in breech presentation in the 33rd gestational week. The biparietal diameter (BPD) and the mean of two perpendicular abdominal diameters (AD) were measured ultrasonically in gestational weeks 33, 35, and 38. Based on these measurements, fetal weight was estimated and compared with weight, length, and head circumference at birth and at 18 months of age. 42% of the fetuses were born in breech presentation (breech group) and 58% in vertex presentation (vertex group). The mean birth weight corrected for gestational age was 4.9% lower in the breech group than in the vertex group, which corresponds to the lower intra-uterine values of BPD and AD found in the breech group. The weight differences at birth still persisted at 18 months of age. There were no differences between the groups regarding head circumference or length, either at birth or at 18 months of age.     

An exploratory study of women's experiences and key stakeholders views of moxibustion for cephalic version in breech presentation

A phenomenological research approach was taken to explore women's feelings and experiences of using moxibustion for cephalic version in breech presentation. Eight women with an uncomplicated breech presentation at term were offered moxibustion. Qualitative interviews were carried out before and after the treatment and women completed daily logs of their experiences. Women experienced anxieties about the implications of breech presentation and the options offered to them. All women carried out the treatment successfully and overall experiences were positive. Compliance was excellent and women reported few negative effects. The partner's co-operation was important to ensure that the procedure was carried out effectively and safely. Key stakeholders were also interviewed to determine their views on the requirements of implementing moxibustion into the maternity services. The need for research evidence of effectiveness was a priority. In addition, a number of practical issues are suggested for consideration in the implementation of a service or in future research designs.     

Small fetal size: a risk factor for breech birth at term.

OBJECTIVE: To examine fetal size as a risk factor for breech birth at term. METHODS: Singleton breech or cephalic births of gestational age > or = 37 weeks in New South Wales (NSW), Australia from 1990 to 1996 were analyzed. Birthweight percentile was used as a measure of fetal size at the time of birth. Factors associated with breech birth at term were analyzed using logistic regression. RESULTS: There were 18914 singleton breech and 540164 cephalic births in the study period. The important independent predictors of breech birth at term were advancing maternal age, primiparity, female sex and small size for gestational age. Infants < 10th percentile had an adjusted odds ratio of 1.33 (95% CI 1.28-1.38) for breech birth at term compared with 25th-75th percentile infants. CONCLUSIONS: Breech birth at term was associated with smaller fetal size for gestational age. This was shown directly through an association with birthweight-for-gestational-age percentiles and indirectly through association with female sex, primiparous birth and congenital anomalies.