Breech presentation is the term used when the fetus’ buttocks or lower extremities are positioned to enter the pelvis first. Since the fetus is always moving and turning, this is not a concern until week 36 or later.
Introduction
In the last weeks of pregnancy, a fetus usually moves so that their head is positioned to come out of the vagina first during birth. When this is not the case, the fetus is presented in a breech position. A breech presentation occurs when the fetus’s buttocks, feet, or both are in place to come out first during birth. According to ACOG (American College of Obstetricians and Gynecologists), breech presentation occurs in 3 to 4% of full-term births. As the gestational age begins to increase, it becomes more and more difficult for the fetus to turn. If the fetus has not turned by week 37, most hospitals will schedule a cesarean section.
Background
The expertise required to deliver breech babies vaginally is quickly disappearing in western countries. As a result, after 37 weeks of gestation women with breech fetuses are scheduled for a cesarean section for week 39 or 40. This new tendency to opt for a cesarean section when the fetus is breech, is the outcome of a study known as the Term Breech Trial (TBT). The trial was conducted in 121 centers in 26 countries and included 2,088 women at term with fetuses in breech presentation who were randomized for delivery by either planned cesarean section or vaginal breech delivery. Unfortunately, the trial was stopped early because interim analysis apparently indicated that planned cesarean section was superior to vaginal breech delivery. The results of the TBT study were published in the year 2000 and the medical community enthusiastically embraced the conclusions of the trial. Many experts believe that the main reason for hospitals and obstetricians to accept the results of this study is that cesarean section requires fewer skills and the obstetrician feels more legally protected.
Not everybody agrees with the TBT study
The TBT study received a considerable amount of disagreement from the obstetric community, including a paper published by the Expert Review of Obstetrics & Gynecology where they concluded that:
“ There is no convincing evidence that caesarean section is better for breech babies than assisted vaginal delivery when conducted in appropriate settings, with experienced obstetricians and strict prevailing protocol”
Other critics of the TBT study mentioned that: “In actual fact, there is no convincing evidence that neonatal morbidity is higher for vaginally delivered breech babies than for those delivered abdominally. Ironically, the two most severe cases of fetal morbidity, namely skull fracture and spinal cord injury, occurred in abdominally delivered babies.”
What most experts agree on is that planned vaginal breech delivery is becoming an uncommon event, creating fewer opportunities for obstetric residents to master the skills of vaginal birth of breech presentations, and allowing for more unnecessary cesarean sections.
Types of breech presentations
Although its role in the prognosis for delivery remains controversial, the type of breech is sometimes taken into account in the decision about mode of delivery. The three most common breech presentations are frank or extended breech — where the fetus’ legs are straight up in front of their body, with their feet up near their face, complete or flexed breech — where the fetus is in a sitting position with their legs crossed in front of their body and their feet near their bottom, and footling breech — where one or both of the fetus’ feet are hanging below their bottom, so the foot or feet are coming out first. In 2020 the journal of Gynecology Obstetrics and Human Reproduction published a study titled: “Type of breech presentation and prognosis for delivery” where they compared 495 cases of vaginal breech deliveries. They concluded that:
“ Among women eligible for vaginal delivery, the type of breech presentation (complete or frank) has little influence on delivery maternal and neonatal morbidity. The type of breech need not be taken into account in deciding the route of delivery”
Breech presentation and TCM
From a Traditional Chinese Medicine (TCM) point of view, a breech presentation results when there is insufficient Kidney Yang energy from the mother. The mother’s Yin energy from the Kidneys is what the fetus requires to be nourished and grow in a healthy manner. Once the Yin energy reaches its peak, it transforms into Yang. It is this Yang energy that helps the fetus to turn into a cephalic presentation.
By increasing the Yang energy of the Yang meridian paired with the Kidney meridian, the Urinary Bladder meridian, the fetus can receive the Yang energy that it needs to turn. This is mainly achieved by applying heat to the last point of the Urinary Bladder meridian, UB-67. Moxibustion, a traditional Chinese medicine therapy consisting in burning a dried herb known as artemisia vulgaris (mugwort), is used to heat up the meridian and increase the Yang energy. During the treatment, a lit stick of compacted or rolled mugwort is brought close to the point UB-67 to create a strong sensation.
The journal of Evidence-based Complementary and Alternative Medicine in 2013 published a study with the aim to assess the effectiveness and safety of moxibustion for the correction of breech presentation. The study concluded that:
“ The results of our systematic review and meta-analysis showed a positive effect of moxibustion on the correction of non-vertex presentation. In addition, moxibustion might reduce the need for oxytocin”
A randomized controlled trial published by JAMA in 1998, titled “Moxibustion for Correction of Breech Presentation”, was the first randomized controlled trial to evaluate the efficacy and safety of moxibustion on acupoint UB-67 to increase fetal activity and correct breech presentation. The trial included 260 subjects; 130 were randomized to the intervention group where they received stimulation of acupoint UB-67 by moxa, and 130 were randomized to the control group where they received routine care but no interventions for breech presentation. The results of the trial showed that during the 35th week of gestation, 98 (75.4%) of 130 fetuses in the intervention group were cephalic versus 62 (47.7%) of 130 fetuses in the control group. The study concluded by saying that:
“ ..moxibustion for 1 to 2 weeks increased fetal activity during the treatment period and cephalic presentation after the treatment period and at delivery.”
Conclusion
Planned vaginal breech delivery is becoming an uncommon event - not because of its safety but, because of the lack of knowledge and experience of practitioners. As this skill disappears we are seeing more and more cesarean section. One effective and safe way to turn a breech fetus is acupuncture and moxibustion.
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