1.1 The worldwide incidence of breech presentation is 3-4% of all term pregnancies. Although possible, vaginal breech birth is believed to be associated with higher risk to the fetus, compared to delivery by caesarean section. Nonetheless, caesarean section is also associated with fetal and maternal risks. Therefore, interventions to turn the breech foetus into a cephalic presentation have been the focus of research in recent years (Sierra 2021, RCOG 2017b, Vas et al 2013, Waites 2003). Although different approaches are believed to assist in the process of turning the breech baby into a cephalic presentation, such as ECV, postural advice and acupuncture; this guideline aims to focus on the impact that moxibustion has in achieving this goal.

1.2 The Ockenden report (Ockenden, 2022) has highlighted the importance of involving women in the decision-making process; regarding the planning and delivery of flexible maternity services that meet their expectations. For those women experiencing breech presentation, this means the provision of care choices and services that contribute to their wellbeing and the achievement of their expectations.

2.1 Moxibustion is a treatment method of traditional Chinese medicine that consists of burning a herb specie called ‘Artemisia Vulgaris’ or ‘mugwort’ in the form of a moxa stick. This is made from the dried leaves of the herb into a compacted roll (Tiran 2004). This is lit and burned near the skin at the acupuncture point ‘Bladder 67’, which is located at the outer aspect of the tip of the fifth toe, in both feet (Coyle et al 2023 Cardini & Weixin 2023). This causes adrenocortical stimulation, myometrial contractility, and increased foetal heart rate, leading to the turning of the foetus thus correcting the breech presentation. Various research studies have investigated this effect, reporting a variation in success rates from 66.6% (Cardini & Weixin 1998) to 92% (Kanakura et al 2001).

2.2 Not only has moxibustion been shown to turn the breech presenting foetus, but it has also been found to increase success rate of ECV, when used prior to this intervention. A prospective study undertaken by Manyande and Grabowska (2009) reported that moxibustion, independently used and combined with ECV, had success rates of 40.8% and 43.4% respectively. This concluded a success rate of 88% for the cohort in the study.

2.3 Although the absence of randomised controlled trials originally contributed to some scepticism amongst healthcare professionals (Coyle et al 2023, recent research findings continue to increase interest in practitioners and women. This is reflected in a 20% of the UK population using some form of complementary and alternative medicine (Ernst and White 2000).

2.4 Moxibustion has shown positive success rates and its use is also proven to be cost-effective, non-invasive and no significant complications have been reported after its use. This therapy is also easy to teach and perform, which allows healthcare practitioners to educate women to undertake this at home. This further optimises cost, ensures health and safety measures and allows flexibility (Tiran 2006). Women may wish to consider the use of moxibustion for breech presentation at 33–35 weeks of gestation, under the guidance of a trained practitioner (Green top guidelines RCOG 2017b).

If breech presentation is suspected, a presentation scan is to be performed. This can be performed in the midwifery hub where available or via referral to the breech clinic via EPIC.

Once breech presentation has been confirmed between 33 and 35 weeks gestation, A midwife who has undertaken the ‘expectancy’ training on the use of moxibustion should follow the steps in section 6. Procedure: Teaching How to Perform Moxibustion.

Arrange for a follow up appointment for a presentation scan 2 weeks later. (This can either be a routine AN appointment in the midwifery hub or via the breech clinic). If the baby is cephalic, arrange for further routine antenatal care. If the baby remains in the breech position, refer to the breech clinic (WP).

4.1 Inclusion Criteria

Primigravida and multipara women at 34 weeks gestation or more and presenting breech, who have been given unbiased and consistent information about moxibustion at the breech clinic, consented to treatment and have no factors identified in the exclusion criteria.

4.2 Exclusion Criteria

Moxibustion should not be recommended to pregnant women with any of the following (Tiran & Kenyon 2009):

• Gestation below 34.

• Unstable lie.

• Previous caesarean section.

• Multiple pregnancy.

• Placenta praevia.

• APH or any bleeding disorder.

• Hypertension or Pre-eclampsia.

• Diabetes mellitus (pre-existing or gestational).

• Asthma or other severe respiratory disease.

• Pyrexia or infection.

• Known uterine or pelvic abnormality.

• History of pre-term labour or premature rupture of membranes.

• Oligohydramnios or polyhydramnios.

• Abnormal foetus or intrauterine death.

• In established labour.

• Cephalic presentation.

Midwives who have undertaken the expectancy complementary therapy training on moxibustion should provide the breech services information leaflet, which contains information regarding moxibustion and a diagram for safe use of moxa sticks. Furthermore, midwives should follow these steps when teaching women on performing moxibustion:

a) Check inclusion and exclusion criteria and ensure there are no contraindications to treatment.

b) Provide the information sheet on ‘How to use moxibustion and go through the following:

c) Explain the procedure to the woman, ensuring a full understanding and gain informal consent.

d) Inform the woman that treatment should take place in a room with no smoke alarm, as the burning of the moxa stick may activate it.

e) The woman should be sitting comfortably, in a relaxed position with her feet raised (use a stool or pillow).

f) Light the moxa stick and wait until the end of the stick is red.

g) Hold the moxa stick and place it close to the outer aspect of the little toe in either foot reaching the acupuncture point ‘Bladder 67’. Inform the woman not to hold the stick above the toe: falling ash could cause the skin to burn.

h) After 2 minutes, the area may become uncomfortable and/or too hot. Remove the stick at this point and repeat the procedure on the other foot. This procedure should be repeated alternating feet for 20 minutes or when the process is performed for 7 times.

i) Once treatment is completed, cut off the end of the stick and place the cut end under water, for the stick to be safely extinguished. Make sure none of the remaining stick is burning.

j) Ensure hydration.

k) Complete the audit form and store safely.

This procedure should be performed twice daily for a maximum of 10 days (Tiran & Kenyon 2009).

The process for monitoring compliance with this guideline, review of results and subsequent monitoring of action plans will be part of the ongoing review of the Obstetric Clinical Governance Group (OCGG). Learning from guidelines, future audits, meetings, and action plans will feed inform future updates of the guideline.

• Antenatal detection of breech.

• Percentage of women diagnosed with breech presentation offered moxibustion.

• Success rate of moxibustion.

• Complications of/after moxibustion.

• Maternal perception of moxibustion.

• Cardini, F. & Weixin, H.(1998) ‘Moxibustion for correction of breech presentation: a randomised controlled trial’. Journal of American medical Association 280(18), p.1580-1584. Available at: https://jamanetwork.com/journals/jama/fullarticle/188144 (Accessed: 02.07.24).

• Coyle ME, Smith C, Peat B. Cephalic version by moxibustion for breech presentation. Cochrane Database of Systematic Reviews 2023, Issue 5. Art. No.: CD003928. DOI: 10.1002/14651858.CD003928.pub4. Accessed 23 September 2024.

• Ernst, E. & White, A. (2000) ‘The BBC survey of complementary medicine use in the UK’. Complementary Therapies in Medicine 8(1), pp.32-36.

• Kanakura, Y., Kometani, K., Nagata, T., Niwa, K., Kamatsuki, H., Shinzato, Y., Tokunaga. Y. (2001) ‘Moxibustion treatment of breech presentation’. American Journal of Chinese Medicine 29(1), p.37-45.

• Manyande, A. & Grabowska, C. (2009). Factors affecting the success of moxibustion in the management of a breech presentation as a preliminary treatment to external cephalic version. Midwifery 25(6), p.774-780.

• RCOG, Royal College of Obstetricians and Gynaecologist (2017b). External Cephalic Version and Reducing the Incident of Term Breech Presentation. London: RCOG green-top guideline. Available at: https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/external-cephalic-version-and-reducing-the-incidence-of-term-breech-presentation-green-top-guideline-no-20a/ (Accessed: 02.07.24).b

• Sierra A (2021) Women’s perception of choice and support in making decisions regarding management of breech presentation. British Journal of Midwifery, 29(7), p 392-400.

• Tiran, D. & Kenyon, C.A. (2009) Implementing Complementary Therapies in Midwifery Practice. Draft Clinical Guidelines: Moxibustion. London: Expectancy.

• Tiran, D. (2004) Breech presentation: increasing maternal choice. Complementary therapies in nursing and midwifery 10(4), p.233-238. Available at:https://www.sciencedirect.com/science/article/abs/pii/S1353611704000368)%20%5baccessed) [Accessed September 2024]

• Tiran D (2006) Complementary therapies in pregnancy: midwives’ and obstetricians’ appreciation of risk. Complement Therapies in Clinical Practice. 12(2); p.126-31.

• Waites, B. (2003) Breech Birth. London: Free Association.

• Vas J, Aranda-Regules JM, Modesto M, Ramos-Monserrat M, Barón M, Aguilar I, et al. (2013) Using moxibustion in primary healthcare to correct non-vertex presentation: a multicentre randomised controlled trial. Acupuncture in Medicine;31:31–8.

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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