The lost skill of the vaginal breech birth
Fans of the series ‘ Call the Midwife’ may recall an episode in which Chummy, a newly qualified midwife, is challenged to deliver a breech (‘bottom first’) baby on her own. Interestingly, the series reveals that the use of breech vaginal delivery was routinely performed in the 1950s. Yet fast forward to the present and you could argue this is now becoming a lost skill.
Breech is present in around 3-4% of pre-term pregnancies. It is expected that by week 34 to 36 most babies will settle head down (vertex or cephalic) within the maternal pelvis.
Breech is associated with some risk factors such as placenta previa, amniotic fluid volume and uterus shape among others. The advice currently given by the Royal College of Obstetricians (RCOG)(1), due to be revised in 2016, is that a planned Cesarean section is safer for breech babies than a vaginal birth. Yet although vaginal breech delivery may involve some threats to the baby, providing there are no risk factors present, and if handled by a suitably experienced doctor or midwife, the baby can safely be delivered vaginally. After all if Chummy could do it in the 1950s surely today we can manage any risks associated with a vaginal breech birth.
This remains a contentious point and sparks debate amongst obstetricians and midwifes (2, 3, 4).
The fact is, though, that vaginal deliveries of breech births are practiced relatively rarely: the vast majority of breech babies in developed countries are being born by Caeserian-section.
Current medical management
For low risk pregnancies an External Cephalic Version (ECV) manoeuvre can be rotinely offered. This involves the manipulation of the foetus through the maternal abdomen to a cephalic presentation.
The success rate of an ECV varies according to several factors such as parity, uterine tone and engagement of the breech, but overall a 50% success rate can be achieved (5). However, a considerable proportion of women refuse ECV because of the fear of pain, thus increasing the likelihood for Cesarean sections (6, 7).
The moxibustion alternative
There are, however, a number of alternative methods to conventional management of breech. These include approaches based on Chinese medicine and acupuncture. Chinese medicine uses a particular technique to help babies turn to cephalic, when there are no contraindications, by stimulating the acupoint Zhiyin Bladder 67, which is located at the tip of the fifth toe. This can be done both through the insertion of needles and by the technique of Moxibustion. Moxibustion is the practice of burning the herb Mugwort, which is often referred to as Moxa.
Moxa can be applied either directly or indirectly onto the skin. The direct method uses loose dried leaves that are rolled into tiny grains and lit with an incense at the acupuncture point before being extinguished before they get too hot. The indirect method involves burning a charcoaled moxa cigar over, but not touching, the acupoint.
Acupuncturists teach women and their partners to apply indirect Moxa at home for 10 consecutive days for at least 20 minutes a day (8,9,10). Ideally Moxa treatment will commence at around weeks 34 to 35 of pregnancy, although in my clinical experience babies can turn to vertex towards later weeks as well. Most women report their babies start increasing their normal movements as soon as the Moxa is applied.
The postural effect
When there is no clear anatomical or physiological disfunction present, some health professionals, including biomedical, complementary and acupuncturists, argue that maternal pelvic imbalances play a crucial part in how babies position into the pelvis. For the most comprehensive resource on this topic see the information at spinningbabies.com.
This insight is potentially relevant for informing the treatment of breech.
In modern times we often tend to use our bodies in ways that favour postural positions that underuse certain muscles groups, thus creating weaknesses or inhibited tone (hypotonia). On the other hand we overuse other muscle groups, resulting in chronic short and tight (hypertonic) muscle contractions. These imbalances are often the result of long-term postural habits. These can arise from sitting at a desk for too long, and just consider how many pregnant women work until the last two weeks of their pregnancy. Other causes can be our tendency to sit slouched on the sofa or reclined on chairs.
In the case of second pregnancies, these problems can be further exacerbated by other factors such as mothers carrying their infants on one hip (11). On the other hand, the increased weight of the abdomen, combined with hormonal changes typical of pregnancy (12), can affect soft tissue such as ligaments and may lead to joint instability and pelvic misalignment.
The effect of pelvic shifts, and postural fatigue of the skeletal muscles, may lead to uterine muscle tension and contraction (13) making it increasingly difficult for the baby to achieve an optimal position for birth.
The term “optimal fetal positioning” (OFP) (14) refers to maternal positions that can be used specifically throughout the third trimester of pregnancy in order to improve the likelihood of the fetus being in an optimal position. This would be either left occipital anterior, where the baby’s occiput (or the back of its head) is in the front of the mothers pelvis, or occiput transverse, where the baby’s head is in the middle of the mother’s front and her back.
These positions and movements are mainly forward leaning and vertical and can be encouraged by postures that use gravity to create more space at the pelvic brim and outlet.
To this end supine (or lying face up ) and semi-reclined positions are discouraged as they prompt the baby to adopt a less optimal position.
New evidence supports these pre-natal recommendations, and some research indicates that pelvic diameter, in both pregnant and non-pregnant women, changes when women adopt different positions,. Furthermore the research suggests that the depth and width of the pelvis increases fairly dramatically in kneeling squat positions compared to supine positions (15).
In my clinic, as well as treating pelvic imbalances with acupuncture and Moxa to women with breech babies, I show some very simple postural exercises, that can be incorporated easily into women’s daily activities, and discuss some straightforward but effective lifestyle changes.
Discrepancies in the evidence
The RCOG (2) guidelines retain scepticism over the evidential basis of claims for the effectiveness of postural management and moxibustion over the officially sanctioned technique of ECV. However, a Cochrane Library review in 2012 found “some evidence to suggest that moxibustion may be useful for turning babies from breech presentation to cephalic when used with either acupuncture or postural techniques of knee to chest or lifting buttocks while lying on the side” (16).
Conclusion
By the time women turn for help for their breech babies at an acupuncture clinic, they have already either tried ECV unsuccessfully, or opted out of it and are wanting to explore a less invasive technique.
With time to turn the baby running out fast, their range of options concerning birthing choice are increasingly limited.
There are no guarantees that a late-term baby will turn from a breech position. However, the combination of an effective non invasive technique, such as moxibustion, in addition to postural changes, are alternatives worth considering for women who wish to contemplate expanding their birthing options.
Note: this information is for general advice only. Please consult your doctor or midwife, before attempting to use moxibustion treatment to turn a baby to ensure that no contraindications apply.
References
- Royal College of Obstetricians, Breech presentation, Management. Published 1/12/2006.
- Walker, S. Breech birth: an unusual normal. The practicing midwife, Vol.15, n3, March 2012, pp 18-21
- Glezerman M. ‘Five years to the Term Breech trial: the rise and fall of randomized controlled trials’. Am Jo of Obs and Gyn, (2006)194(1): 20-25.
- Fahy K. ‘Is breech birth really unsafe? Treatment validity in the Term Breech Trial’. Essentially MIDIRS, (2011) 2(10): 17-21.
- Royal College of Obstetricians, External Cephalic Version and reducing the incidence of Breech presentation. Published 1/12/2006.
- Truijens SE, van der Zalm M, Pop VJ, Kuppens SM. Determinants of pain perception after external cephalic version in pregnant women.Midwifery. 2014 Mar;30(3):e102-7. doi: 10.1016/j.midw.2013.11.005. Epub 2013 Nov 23.
- Walker, S.To ECV or not to ECV? The current evidence base concerning external cephalic version. The Practising Midwife, 2014. 17(9), pp. 30-33
- Kamakura, Kometani, Nagata. Moxibustion treatment of Breech presentation AJCM (2001)
- Smith CA,Betts. D. The practice of acupuncture and moxibustion to promote cephalic version for women with a breech presentation: implications for clinical practice and research.Complement Ther Med. 2014 Feb;22(1):75-80. doi: 10.1016/j.ctim.2013.12.005. Epub 2013 Dec 12.
- For further research, tips and information see this excellent website by a midwife acupuncturist:https://acupuncture.rhizome.net.nz/acupuncture/research/moxabustion-breech/
- Matsumoto K, Euler D. Kiiko Matsumotos’ clinical strategies. In the spirit of Master Nagano. Vol 1,Kiiko Matsumotos International, MA USA. 2010.
- Yates, S. Pregnancy and childbirth. A holistic approach to massage and bodywork. Churchill Livingstone, Elsevier, 2010.
- Simkin P, Ancheta R. The labor progress handbook. Early interventions to prevent and treat dystocia. Wiley- Blackwell, 2011.
- Reitter A, Daviss B-A, Bisits A, et al. Does pregnancy and/or shifting positions create more room in a woman’s pelvis? Am J Obstet Gynecol 2014;211:662.e1-9.
- Coyle ME, Smith CA, Peat B. Cephalic version by moxibustion for breech presentation. Cochrane Database of Systematic Reviews 2012, Issue 5. Art. No.: CD003928. DOI: 10.1002/14651858.CD003928.pub3.
