Consensus-based recommendations for the care of women with a breech presenting fetus.

OBJECTIVE: To establish consensus related to aspects of breech presentation and care. DESIGN: A multinational, three round e-Delphi study. PARTICIPANTS: A panel of 15 midwives, four obstetricians and an academic with knowledge and/or experience of caring for women with a breech presenting fetus. METHODS: An initial survey of 45 open-ended questions. Answers were coded and amalgamated to form 448 statements in the second round and three additional statements in the third round. Panellists were asked to provide their level of agreement for each statement using a 5-point Likert scale. Consensus was deemed met if 70% of panellists responded with strongly agree to somewhat agree, or strongly disagree to somewhat disagree after the second round. FINDINGS: Results led to the development of a consensus-based care pathway for women with a breech presenting fetus and a skills development framework for clinicians. KEY CONCLUSIONS: A cultural shift is beginning to occur through the provision of physiological breech workshops offered by various organisations and may result in greater access to skilled and experienced clinicians for women desiring a vaginal breech birth, ultimately improving the safety of breech birth. IMPLICATIONS FOR PRACTICES: The care pathway and skills development framework can be used by services wishing to make changes to their current practices related to breech presentation and increase the level of skill in their workforce.

Cephalic version by moxibustion for breech presentation.

BACKGROUND: Breech presentation at term can cause complications during birth and increase the chance of caesarean section. Moxibustion (a type of Chinese medicine which involves burning a herb close to the skin) at the acupuncture point Bladder 67 (BL67) (Chinese name Zhiyin), located at the tip of the fifth toe, has been proposed as a way of changing breech presentation to cephalic presentation. This is an update of a review first published in 2005 and last published in 2012. OBJECTIVES: To examine the effectiveness and safety of moxibustion on changing the presentation of an unborn baby in the breech position, the need for external cephalic version (ECV), mode of birth, and perinatal morbidity and mortality. SEARCH METHODS: For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register (which includes trials from CENTRAL, MEDLINE, Embase, CINAHL, and conference proceedings), ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) (4 November 2021). We also searched MEDLINE, CINAHL, AMED, Embase and MIDIRS (inception to 3 November 2021), and the reference lists of retrieved studies. SELECTION CRITERIA: The inclusion criteria were published and unpublished randomised or quasi-randomised controlled trials comparing moxibustion either alone or in combination with other techniques (e.g. acupuncture or postural techniques) with a control group (no moxibustion) or other methods (e.g. acupuncture, postural techniques) in women with a singleton breech presentation. DATA COLLECTION AND ANALYSIS: Two review authors independently determined trial eligibility, assessed trial quality, and extracted data. Outcome measures were baby's presentation at birth, need for ECV, mode of birth, perinatal morbidity and mortality, maternal complications and maternal satisfaction, and adverse events. We assessed the certainty of the evidence using the GRADE approach.   MAIN RESULTS: This updated review includes 13 studies (2181 women), of which six trials are new. Most studies used adequate methods for random sequence generation and allocation concealment. Blinding of participants and personnel is challenging with a manual therapy intervention; however, the use of objective outcomes meant that the lack of blinding was unlikely to affect the results. Most studies reported little or no loss to follow-up, and few trial protocols were available. One study that was terminated early was judged as high risk for other sources of bias. Meta-analysis showed that compared to usual care alone, the combination of moxibustion plus usual care probably reduces the chance of non-cephalic presentation at birth (7 trials, 1152 women; risk ratio (RR) 0.87, 95% confidence interval (CI) 0.78 to 0.99, I2 = 38%; moderate-certainty evidence), but the evidence is very uncertain about the effect of moxibustion plus usual care on the need for ECV (4 trials, 692 women; RR 0.62, 95% CI 0.32 to 1.21, I2 = 78%; low-certainty evidence) because the CIs included both appreciable benefit and moderate harm. Adding moxibustion to usual care probably has little to no effect on the chance of caesarean section (6 trials, 1030 women; RR 0.94, 95% CI 0.83 to 1.05, I2 = 0%; moderate-certainty evidence). The evidence is very uncertain about the effect of moxibustion plus usual care on the the chance of premature rupture of membranes (3 trials, 402 women; RR 1.31, 95% CI 0.17 to 10.21, I2 = 59%; low-certainty evidence) because there were very few data. Moxibustion plus usual care probably reduces the use of oxytocin (1 trial, 260 women; RR 0.28, 95% CI 0.13 to 0.60; moderate-certainty evidence). The evidence is very uncertain about the chance of cord blood pH less than 7.1 (1 trial, 212 women; RR 3.00, 95% CI 0.32 to 28.38; low-certainty evidence) because there were very few data. We are very uncertain whether the combination of moxibustion plus usual care increases the chance of adverse events (including nausea, unpleasant odour, abdominal pain and uterine contractions; intervention: 27/65, control: 0/57), as only one study presented data in a way that could be reanalysed (122 women; RR 48.33, 95% CI 3.01 to 774.86; very low-certainty evidence). When moxibustion plus usual care was compared with sham moxibustion plus usual care, we found that moxibustion probably reduces the chance of non-cephalic presentation at birth (1 trial, 272 women; RR 0.74, 95% CI 0.58 to 0.95; moderate-certainty evidence) and probably results in little to no effect on the rate of caesarean section (1 trial, 272 women; RR 0.84, 95% CI 0.68 to 1.04; moderate-certainty evidence). No study that compared moxibustion plus usual care with sham moxibustion plus usual care reported on the clinically important outcomes of need for ECV, premature rupture of membranes, use of oxytocin, and cord blood pH less than 7.1, and one trial that reported adverse events reported data for the whole sample. When moxibustion was combined with acupuncture and usual care, there was very little evidence about the effect of the combination on non-cephalic presentation at birth (1 trial, 226 women; RR 0.73, 95% CI 0.57 to 0.94) and at the end of treatment (2 trials, 254 women; RR 0.73, 95% CI 0.57 to 0.93), and on the need for ECV (1 trial, 14 women; RR 0.45, 95% CI 0.07 to 3.01). There was very little evidence about whether moxibustion plus acupuncture plus usual care reduced the chance of caesarean section (2 trials, 240 women; RR 0.80, 95% CI 0.65 to 0.99) or pre-eclampsia (1 trial, 14 women; RR 5.00, 95% CI 0.24 to 104.15). The certainty of the evidence for this comparison was not assessed. AUTHORS' CONCLUSIONS: We found moderate-certainty evidence that moxibustion plus usual care probably reduces the chance of non-cephalic presentation at birth, but uncertain evidence about the need for ECV. Moderate-certainty evidence from one study shows that moxibustion plus usual care probably reduces the use of oxytocin before or during labour. However, moxibustion plus usual care probably results in little to no difference in the rate of caesarean section, and we are uncertain about its effects on the chance of premature rupture of membranes and cord blood pH less than 7.1.  Adverse events were inadequately reported in most trials.

Training for breech deliveries with the mother in an upright position: An innovative adaptation of a simulation model.

BACKGROUND: Delivery of a breech baby with the mother in an upright position or on all fours has gained a renewed interest. In these positions, the obstetrician or midwife needs to learn new landmarks and maneuvers. A realistic simulation model would be a valuable adjunct for breech on all fours teaching programs. MATERIAL AND METHODS: This article describes the simulation model and training program we have developed to train an interprofessional team to assist breech births when the mother is on all fours. A questionnaire was used to evaluate the realism of the adapted mannequin and the impact of training on the confidence level of the participants. RESULTS: On a Likert scale of 1 to 5, 92% of participants agreed or strongly agreed that the adapted mannequin used was realistic for training obstetric maneuvers for complicated breech births. After training, their confidence level supporting a breech birth in an upright position rose from an average of 2.5 to 5.7 on a scale of 1 to 10. CONCLUSION: Learning the skills for breech deliveries on all fours is made possible by targeted training with this adapted simulation model.

Rebozo and External Cephalic Version in breech presentation (RECEIVE): A randomised controlled study.

OBJECTIVE: To investigate if a hospital-initiated home-based rebozo intervention performed by the pregnant woman and her partner before external cephalic version (ECV) would increase the rate of cephalic presentations at birth. DESIGN: A multicentre randomised controlled trial. SETTING: Three university hospitals in Copenhagen, Denmark. POPULATION: Pregnant women with a breech or transverse presentation at 35 weeks or more of gestation eligible for ECV. METHODS: We compared rebozo before ECV with ECV alone. The randomisation was computer-generated in blocks and stratified by parity. The woman and her partner were instructed in the technique by a project midwife and performed the technique at home three times daily for 3-5 days before the scheduled ECV. Analyses were by intention-to-treat. MAIN OUTCOME MEASURE: The number of cephalic presentations at the time of birth. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. RESULTS: A total of 372 women were randomly assigned (1:1) to either rebozo intervention (n = 187) or control (n = 185). At birth, 95 (51%) in the intervention group versus 112 (62%) in the control group had a fetus in cephalic presentation (OR 0.61; 95% CI 0.40-0.95). No adverse events were observed in relation to the intervention. CONCLUSIONS: In breech or transverse presentation, home-based rebozo exercise before ECV lowered the overall rate of cephalic presentation at birth. TWEETABLE ABSTRACT: Home-based rebozo for breech presentation before external version reduces the rate of cephalic presentation at birth.

Effectiveness of Moxibustion for Breech Presentation: A Prospective Study.

OBJECTIVE: To evaluate the moxibustion for turning fetuses from breech to vertex presentation. MATERIALS AND METHODS: This was a single-center prospective study. All pregnant women carrying a fetus in breech presentation between the 32 and 35 gestational weeks were offered moxibustion application. The primary outcomes were vertex presentation at 37 weeks of gestation, vertex presentation at birth, and vaginal birth rates. A secondary analysis was performed to understand the effect of parity, type of breech presentation, body mass index (BMI), placental location, gender, and fetal birth weight on the presentation at birth. RESULTS: There were 63 cases in the study group and 245 cases in the control group. The rate of vertex presentation at term was found to be higher in the moxibustion group compared to controls (66.7 vs. 48.2%, p=0.022). There were 45 (71.4%) and 131 (53.5%) fetuses with vertex presentation at birth in the study and control groups, respectively (p=0.020). Overall, vaginal delivery rate was higher in the study group (50.8 vs. 37.1%, p=0.048). Multiparity and higher birth weight were associated with increased rates of vertex presentation in the moxibustion and control groups. CONCLUSION: Moxibustion application increased the rate of vertex presentation at birth and also vaginal delivery rate compared with expectant management. Offering moxibustion between the 32nd and 36th week of gestation may provide women with a singleton fetus in breech presentation an opportunity for a vaginal birth.

Smoke or smokeless moxibustion treatment for breech presentation: A three-arm pilot trial.

AIMS: We conducted a pilot trial to compare the effects of smoke and smokeless moxibustion with a control as a possible supplement to external cephalic version (ECV) for converting breech to cephalic presentation and increasing adherence to cephalic position, and to assess their effects on the well-being of the mother and child. METHODS: We used a quasi-experimental design with 3 arms: a smoke moxibustion (SM) (n = 20) and smokeless moxibustion (SLM) (n = 20) groups (20-min acupoint BL67 stimulation once or twice daily for 10-14 days), and a control group (n = 20). The participants had singleton breech presentations between 33 and 35 gestation weeks. The primary outcome was cephalic presentation at the conclusion of intervention. The secondary outcomes were cephalic presentation at birth and effects on mother and child well-being. RESULTS: At the conclusion of intervention, cephalic presentation was higher in the SLM (60.0%) than the control groups (25.0%), Relative Risk 2.40, 95% Confidence Interval [1.04-5.56]; there was no significant difference for SM. At birth, there were no significant differences in cephalic presentation or well-being. CONCLUSION: SLM treatment showed an increasing trend towards cephalic presentation at the conclusion of intervention. Although significant differences were not observed at birth possibly due to the small samples and non-randomization, moxibustion was safe, and not associated with perinatal morbidity and mortality. A randomized controlled trial with a larger sample is warranted to ascertain SLM treatment as a possible ECV supplement for converting and increasing adherence to cephalic position.

Evaluation of the effectiveness of transcutaneous nerve stimulation during labor in breech presentation: a case series.

Objective: To analyze the effectiveness of pain relief with transcutaneous electrical nerve stimulation (TENS) dispositive during labor in breech vaginal delivery and also to describe its tolerance and satisfaction.Design: A randomized, double-blind, and placebo-controlled trial was conducted.Setting: Labor room of Complejo Hospitalario Universitario Insular-Materno Infantil (Spain).Participants: Ten women who met the inclusion criteria of the clinical trial and also had a fetus breech presentation were randomly assigned to three groups.Interventions: A portable TENS, Cefar Rehab 2pro®, unit was used to apply the experimental intervention, with different doses in the three groups in women during labor. The device intensity (amplitude) was individually adjusted to each participant's maximum sensory level. The pain was evaluated with visual analog scale (VAS). COMFORTS scale was used to measure women's satisfaction.Results: A significant association of VAS was detected depending on the type of TENS over time. Active TENS2 was the only group that obtained an improvement with clinically significant results. In connection with women satisfaction, active TENS2 group was also the group that presented higher values.Conclusions: We can recommend the use of TENS dispositive to relieve pain during labor, also in those women with breech presentation.

Face-to-pubes rotational maneuver for bilateral nuchal arms in a vaginal breech birth, resolved in an upright maternal position: A case report.

BACKGROUND: A physiological breech birth is one in which the woman is encouraged to remain active throughout her labor and able to assume the position of her choice for the birth. Use of this strategy within the United Kingdom National Health Service has led to the use of innovative maneuvers to relieve obstruction when women give birth in upright positions, for example, kneeling or standing. This includes use of the face-to-pubes rotational maneuver to relieve extended nuchal arm(s). In this paper, we report a case where the face-to-pubes rotational maneuver was used to relieve bilateral nuchal arm entrapment in a breech birth. METHODS: Single-case study. We aimed to generate an in-depth understanding of how this maneuver works and how professionals decide to use it by exploring its use in a real-life context. RESULTS: The face-to-pubes rotational maneuver appears to be an effective method of relieving nuchal arm entrapment when used by experienced hands. In cases of bilateral nuchal arm entrapment, elevation to a higher station may be necessary to dis-impact the arms above the pelvic inlet before the fetus can be rotated. After face-to-pubes rotation and release of arms, the head should be realigned in an occiput anterior position for delivery. CONCLUSION: The face-to-pubes rotational maneuver can be taught for resolution of nuchal arms in an upright position. Parents should be informed of the availability or not of a specialist midwife trained in physiological breech birth, as this may be important to their decision-making.

[Breech Presentation: CNGOF Guidelines for Clinical Practice - External Cephalic Version and other Interventions to turn Breech Babies to Cephalic Presentation]. / Présentation du siège. Recommandations pour la pratique clinique du CNGOF ­ Version par manœuvre externe et techniques de version alternatives.

OBJECTIVES: To provide guidelines regarding efficiency and safety of external cephalic version (ECV) attempt and alternatives methods to turn breech babies to cephalic presentation. METHODS: MedLine and Cochrane Library databases search in French and English and review of the main foreign guidelines between 1980 and 2019. RESULTS: ECV is associated with a decreasing rate of breech presentation at birth (LE2), and potentially with a lower rate of cesarean section (LE3) without an increase of severe maternal (LE3) and perinatal morbidity (LE3). It is therefore recommended to inform women with a breech presentation at term that ECV should be attempt (Professional consensus). ECV attempt should be performed with immediate access to an operating room for emergency cesarean (Professional consensus). The ECV attempt before 37 weeks, compared to ECV attempt after 37 weeks, increases the rate of cephalic presentation at birth (LE2) but with a small increase risk of moderate prematurity (LE2). ECV attempt should be performed from 36SA (Professional consensus). The main factors associated with successful ECV attempt are multiparity (LE3) and no maternal obesity (LE3). Parenteral tocolysis (ß mimetic or atosiban), for ECV attempt at term is associated with a higher success rate (LE2), higher rate of achieved cephalic presentation in labor (LE2) and a lower cesarean section rate (LE2). It is recommended to use parenteral tocolysis for ECV attempt at term in order to increase its success rate (grade B). The ECV attempt is associated with an increase in transient FHR abnormalities (LE3), it is therefore recommended that cardiotocography should be performed prior and during 30minutes after the procedure (Professional consensus). There is no argument for recommending the practice of delayed cardiotocography after ECV attempt (Professional consensus). The risk of significant positivity (>30mL) of the Kleihauer test after ECV attempt is low (<0.1%) (LE3), it is not recommended to systematically perform a Kleihauer test after ECV attempt (professional consensus). In case of RH-1 negative women, it is recommended to ensure systematic RH-1 prophylaxis (Professional consensus). In case of breech presentation at term, acupuncture, moxibustion and postural methods are not effective in reducing breech presentation at birth (LE2), and are therefore not recommended (Grade B). CONCLUSION: According to the clear benefits and the low risks of ECV attempt, all women with a breech presentation at term should be informed that ECV should be attempted to decrease breech presentation at birth and cesarean section.

Moxibustion for Cephalic Version of Breech Presentation.

Moxibustion, a form of traditional Chinese medicine (TCM), is the burning of the herb moxa (Folium Artemisiae argyi or mugwort) over acupuncture points. It is often used in China to facilitate cephalic version of breech presentation. This article reviews the history, philosophy, therapeutic use, possible mechanisms of action, and literature pertaining to its use for this indication. For moxibustion, moxa can be rolled into stick form, placed directly on the skin, or placed on an acupuncture needle and ignited to warm acupuncture points. Studies have demonstrated that moxibustion may promote cephalic version of breech presentation and may facilitate external cephalic version. However, there is currently a paucity of research on the effects of moxibustion on cephalic version of breech presentation, and thus there is a need for further studies. Areas needing more investigation include efficacy, safety, optimal technique, and best protocol for cephalic version of breech presentation.

Women's Health: Pregnancy and Conception.

Preconception is an ideal time to assist women contemplating pregnancy to modify health behaviors. Dietary needs in pregnancy are critical and may require supplementation. The use of mind-body medicine in the antenatal period assists patients in childbirth preparation. Integrative medicine techniques can be safely and effectively used for common third-trimester obstetric complications of pregnancy.

Evaluación de la eficacia de la aplicación de la moxibustión en presentaciones no cefálicas en gestantes asistidas en atención primaria / Evaluation of the effectiveness of the moxibustion in non-cephalic presentations in pregnant women assisted in Primary Care

OBJETIVO: Evaluar la eficacia de la moxibustión, combinada con la posición genupectoral, para versionar fetos en presentaciones no cefálicas a cefálica, durante el tercer trimestre de gestación. Como objetivos secundarios se planteó evaluar la seguridad de la técnica de moxibustión e identificar el tipo de parto, las semanas de gestación (SG) y el peso del recién nacido. MATERIAL Y MÉTODOS: Ensayo clínico aleatorizado, controlado y multicéntrico, realizado en consultas de 9 centros de atención a la salud sexual y reproductiva de la comarca del Baix Llobregat (Barcelona). La selección de gestantes se hizo tras la ecografía del tercer trimestre. Si se observaba una presentación no cefálica, se invitaba a las gestantes a participar. Tras firmar el consentimiento, se procedía a la asignación aleatoria a un grupo de intervención (GI) o a un grupo control (GC). El GI recibió 1 semana de tratamiento con moxibustión en el punto BL67 y posición genupectoral. El GC recibió tratamiento con moxibustión en un punto neutro y posición genupectoral. Las participantes recibieron las explicaciones necesarias para la aplicación de la técnica 2 veces al día durante 1 semana. RESULTADOS: Participaron 88 gestantes entre las 32 y 36 SG. Hubo 47 gestantes en el GI y 41 en el GC, con características similares al inicio del estudio. El número de sesiones aplicadas fue similar en ambos grupos, sin complicaciones. El 44,7% de los partos del GI fueron en presentación cefálica, frente al 43,9% del GC (p= 0,6). El número de partos vaginales en el GI fue de 18 (38,3%), frente a 13 (31,7%) en el GC (p= 0,3). No se observaron diferencias en las SG en el momento del parto ni en el peso de los recién nacidos. CONCLUSIONES: El uso de la moxibustión aplicada durante 7 días en el punto BL67 junto con la posición genupectoral entre las 32 y 36 SG no demostró en este estudio un aumento de las versiones de fetos en posiciones anómalas a cefálica. La técnica no presentó complicaciones

AIM: To evaluate moxibustion efficacy, combined with knee-chest position, for foetus version from no cephalic presentation to cephalic presentation during the 3rd trimester of gestation. To evaluate the security of the moxibustion technique and to identify type of delivery, weeks of gestation and the weight of the newborn. Subjects, material and methods: Multicenter, randomized, controlled trial conducted in 9 primary care centres focused on sexual and reproductive health of the Baix Llobregat (Barcelona) region. Selection was done after the 3rd trimester ultrasound scan. When a non-cephalic presentation was found, women were asked to join the study. After signing the informed consent, random allocation took place and they were divided into intervention group (IG) and control group (CG). IG received a one week treatment with moxibustion at point BL67 combined with knee-chest position. CG received moxibustion treatment at a neutral point combined with knee-chest position too. For both groups they were given the necessary explanations for a correct application twice a day during a week. RESULTS: A total 88 pregnant women between 32-36 weeks of gestation were studied, 47 pregnant mothers enrolled in IG and 41 in CG, with similar characteristics at the beginning of the study. Number of performed sessions was similar for both groups and without complications

Principles of physiological breech birth practice: A Delphi study.

OBJECTIVE: to establish a multi-professional consensus on shared principles underlying the practice of physiological breech birth. DESIGN: three-round Delphi e-survey. SETTING: multi-national. PARTICIPANTS: a panel of thirteen obstetricians and thirteen midwives, experienced in facilitating physiological breech births in varied settings, and involving varied maternal birthing positions, and two service user representatives. METHODS: an initial survey contained open-ended questions. Answers were coded and amalgamated into 60 statements in Round 1 and a further 6 statements in Round 2. Participants considered statements in the following categories: first principles (14), maternal positioning (12), birth environment (18), fetal positions (14), safe progress (8). The panel indicated the extent of their agreement using a 5-point Likert scale. The pre-determined level of consensus was 70% of respondents indicating 4 or 5 on the Likert scale (agreement or strong agreement). FINDINGS: the panel indicated consensus on 37 of 66 proposed statements concerning 'Principles of Practice.' Negative data (29/66 statements) are also reported, highlighting areas of divergent opinions. The findings suggest a paradigm shift away from risk management strategies based on prediction and control, and towards facilitation strategies based on relationship and response. Upright positions are a tool and not a rule of physiological breech birth. CONCLUSION: the parameters of 'normal for breech' require further exploration to support professionals working within a paradigm of complex normality. The principles articulated in this research can be used to design further research exploring the influence of physiological breech practices on neonatal and maternal outcomes, including women's experiences of maternity care.

Acupuncture version of breech presentation: a randomized sham-controlled single-blinded trial.

BACKGROUND: Several studies have investigated the efficacy of moxibustion with or without acupuncture for fetal version, but the results are discordant. Meta-analyses pointed out the need for robust, methodologically sound, randomized controlled trials. OBJECTIVE: The objective of this study was to assess the effectiveness of acupuncture with fire needling on acupoint BL67 for version of breech presentation. STUDY DESIGN: This was a randomized, sham-controlled, single-blinded trial, which took place in Strasbourg teaching maternity hospital, France. A total of 259 patients between 32 and 34 weeks of gestation have been randomized and analyzed. Patients were randomized to either acupuncture with fire needling or sham group, and were analyzed in their initial allocation group. Statistical analysis was conducted using Bayesian methods, in univariate analysis and in multivariate analysis after adjustment on parity. RESULTS: The primary outcome was the rate of cephalic presentations at ultrasound examination performed between 35 and 36 weeks of gestation. A total of 49 (37.7%) fetuses were in cephalic presentation in the acupuncture group, versus 37 (28.7%) in the sham group: RR 1.34 [0.93-1.89], Pr RR>1=94.3%. After adjustment on parity, the acupuncture did not increase the rate of fetal cephalic version: OR 1.47 [0.84-2.42], Pr OR>1=90.3%. CONCLUSIONS: Our study suggests that acupuncture with fire needling on acupoint BL67 does not promote fetal cephalic version. Further studies might investigate effectiveness of other protocols of acupuncture. Randomization should be stratified for nulliparous and parous patients.

Moxibustion did not have an effect in a randomised clinical trial for version of breech position.

INTRODUCTION: In Chinese traditional medicine, the stimulation of acupuncture point no. 67 - the bladder meridian - is recommended to favour cephalic version in case of foetal breech presentation. The point can be stimulated by an acupuncture needle, ginger application, fingertip pressure, laser or moxibustion; moxibustion is heat generated by a burning stick containing the herb Artemisia vulgaris. A Cochrane review concluded that more research on the effectiveness of moxibustion is needed. This study aimed to estimate the effectiveness of moxibustion for version of breech presentation. METHODS: We included 200 women in gestational week 33 who had a singleton foetus in breech position. They were randomised to moxibustion treatment daily for two weeks or control without moxibustion. The randomisation was performed for nulliparous and parous women separately. RESULTS: After the trial, which lasted on average 16 days, the breech position was confirmed in 68 of the 92 nulliparous and in 50 of the 108 parous women (74% versus 46%, p < 0.01); furthermore, cephalic position was verified in 76 women and other positions in six women. No significant difference regarding the incidence of breech position was found in the moxibustion group compared with the control group (risk ratio (RR) = 1.05, 95% confidence interval (CI): 0.8-1.38); nor in nulliparous (RR = 1.17, 95% CI: 0.77-1.76) or in parous women (RR = 1.0, 95% CI: 0.69-1.46); an RR > 1 favours moxibustion). CONCLUSIONS: No significant effects of moxibustion were found in correcting the breech position in primiparous and parous women after their 33rd gestational week. FUNDING: none. TRIAL REGISTRATION: This trial was registered with ClinicalTrials.gov as NCT02251886.

An observational study of the success and complications of 2546 external cephalic versions in low-risk pregnant women performed by trained midwives.

OBJECTIVE: To evaluate the success of an external cephalic version (ECV) training programme, and to determine the rates of successful ECV, complications, and caesarean birth in a low-risk population. DESIGN: Prospective observational study. SETTING: Primary health care and hospital settings throughout the Netherlands (January 2008-September 2011). POPULATION: Low-risk women with a singleton fetus in breech presentation, without contraindications to ECV, were offered ECV at approximately 36 weeks of gestation. METHODS: Data were collected for all ECVs performed by midwives, and were entered into a national online database. MAIN MEASURES: Successful ECV was defined as the fetus having a cephalic presentation immediately following the procedure and at birth. Complications were observed at ≤ 30 minutes and between 30 minutes and 48 hours after the ECV procedure. All serious pregnancy outcomes that occurred after the ECV procedure until birth were reported. RESULTS: A total of 47% had a successful ECv and a cephalic at the time of birth: 34% of nulliparous and 66% of multiparous women. After ECV, 57% of women gave birth vaginally: 45% of nulliparous women and 76% of multiparous women. Within 30 minutes after ECV, and between 30 minutes and 48 hours after ECV, the proportion of women experiencing a complication or serious pregnancy outcome was 0.9% and 1.8%, respectively. Serious pregnancy outcome at any time following ECV until birth was experienced by 58 (2.5%) of the women. CONCLUSIONS: The success rate of ECVs performed by trained midwives in primary health care or hospital settings is comparable with that of other providers, and the procedure is safe for low-risk women.