Can Moxibustion Help Turn Breech Babies?

By Rebecca Dekker, PhD, RN, APRN

Occasional Science & Sensibility contributor Rebecca Dekker of www.EvidenceBasedBirth.com examines the practice of Moxibustion to help turn breech babies head down.  Rebecca looks at what the current research shows on this ancient treatment for turning babies and shares the results with Science & Sensibility readers in an article that can be easily shared with students, clients and patients. – Sharon Muza, Science & Sensibility Community Manager.

About 3-4% of pregnant women end up with a baby who is in breech (bottom first) position at term. The vast majority of these babies (90%) are born by planned cesarean section. In order to avoid a cesarean section, many women try various ways to turn their babies into a head-down position. I have written in the past about using external cephalic version (ECV), also called the hands-to-belly procedure, for turning breech babies. However, although ECV is safe and frequently effective, it can be uncomfortable and women may want to try different options for turning a breech baby. One potential option is moxibustion.

What is moxibustion?

Moxibustion is a type of Chinese medicine where you burn an herb (Artemesia vulgaria) close to the skin of the fifth toes of both feet. The fifth toe is a traditional acupuncture point called Bladder 67.

How do you use moxibustion?

There is no one recommended way to use moxibustion, but many women burn the moxa sticks close to their toes for about 15-20 minutes, from anywhere to 1-10 times per day, for up to two weeks. This treatment is usually started between 28 and 37 weeks of pregnancy.

How could moxibustion work?

The burning of the moxa stick stimulates heat receptors on the skin of the toe. It is thought that the heat encourages the release of two pregnancy hormones—placental estrogen and prostaglandins—which lead to uterine contractions. These contractions can then stimulate the baby to move (Cardini & Weixin, 1998).

So, does moxibustion work?

In 2012, researchers combined results from eight studies where 1,346 women with breech babies were randomly assigned to moxibustion, no treatment, or an alternative treatment (like acupuncture). The women in these studies lived in Italy, China, and Switzerland (Coyle et al., 2012).

For the women who were assigned to receive moxibustion, some used moxibustion alone, some had moxibustion plus acupuncture, and some used moxibustion plus posture techniques.

When moxibustion alone was compared to no treatment (3 studies, 594 women) there was:

• No difference in the percentage of babies who were breech at birth

• No difference in the need for external cephalic version

• No difference in cesarean section rates

• No difference in the risk of water breaking before labor began

• No difference in Apgar scores at birth

• A 72% decrease in the risk of using oxytocin for women in the moxibustion group who ended up with a vaginal birth

Side effects of the moxibustion included smelling an unpleasant odor, nausea, and abdominal pain from contractions.

When moxibustion alone was compared to acupuncture alone, fewer women in the moxibustion group had breech babies at birth compared to the acupuncture group. However, there were only 25 women in the single study that compared moxibustion alone to acupuncture alone, so this doesn’t really tell us that much.

When moxibustion plus acupuncture was compared to no treatment (1 study, 226 women), women who had moxibustion plus acupuncture had a:

• 27% decrease in the risk of having a breech baby at birth

• 21% decrease in the risk of having a cesarean section

When moxibustion plus acupuncture was compared to acupuncture alone, one study with only 24 women found no difference in the number of women who had breech babies at birth. Because this study was so small, it doesn’t really give us much meaningful information.

When moxibustion plus postural techniques was compared to postural techniques alone (3 studies, 470 women), women in the moxibustion plus postural group had:

• a 74% decrease in the risk of having a breech baby at birth

Are there any limitations to this evidence?

Overall, the studies that were used in this review were good quality. However, some of the studies were very small, and sometimes researchers did not measure things that we would be interested in—for example, when moxibustion plus postural techniques was compared to postural techniques alone, we have no idea if it made a difference in cesarean section rates or any other health results. Also, all of the researchers used different methods of moxibustion. Some women may have had more frequent or longer sessions, and some women may have been more compliant with the therapy than others.

Is there any other good evidence on moxibustion?

After the review above was published, evidence from a new randomized controlled trial that took place in Spain came out in 2013. In this new study, 406 low-risk pregnant women who had a baby in breech position at 33-35 weeks were randomly assigned to true moxibustion, “fake” moxibustion, or regular care.

What kind of treatments did the women receive?

In the true moxibustion group, the women laid face up, and the hot moxa stick was held near the outside of the little toenail 20 minutes per day for two weeks, changing from one foot to the other when the heat became uncomfortable. The women did the moxibustion at home with the help of a family member. In the fake moxibustion group, the same treatment was carried out, except that the moxa stick was applied to the big toe, which is not a true acupuncture point. Women in all of the groups were educated on how to use a knee-chest posture to try and turn the baby.

Did the moxibustion work?

Women who did moxibustion plus postural techniques were 1.3 times more likely to have a baby in head-down position at birth when compared to both the fake moxibustion and the usual care groups. If you look at the exact numbers, 58% of the women who used moxibustion had a baby who was head-down at birth, compared to 43% of the fake moxibustion group and 45% of the usual care group. The number of women who would need to use moxibustion in order to successfully turn one baby is, on average, eight women.

There was no statistical difference in cesarean section rates among the three groups, but it looked like the numbers were trending in favor of true moxibustion: 51% of the women in the true moxibustion group had cesarean sections, compared to 62% of the fake moxibustion group and 59% of the usual care group.

Were there any safety concerns?

Overall, evidence showed that moxibustion treatment was safe. About 1 out of 3 women reported having contractions during the treatment, but there was no increase in the risk of preterm birth. Some women (14%) said they felt heart palpitations. One woman experienced a burn from the moxibustion. Other complaints from women in all three groups included heartburn, nausea and vomiting (2%), dizziness (1.7%), mild high blood pressure problems (1.7%), stomach pain (1.5%), and baby hiccups (1.2%). However, there were no differences among the three groups in the number of women who had these complaints. There were also no differences in newborn health issues or labor problems among the three groups. All of the babies had good Apgar scores five minutes after birth.

So what’s the bottom line?

• Evidence suggests that moxibustion—when combined with either acupuncture or postural techniques—is safe and increases your chances of turning a breech baby

• We still don’t know for sure which kind of moxibustion method (timing during pregnancy, number of sessions, length of sessions, etc.) works best for turning breech babies. However it appears that using moxibustion twice per day for two weeks (during 33-35 weeks of pregnancy) will work for 1 out of every 8 women.

• If women are interested in using Chinese medicine (moxibustion and acupuncture) to help turn a breech baby, they may want to consult a licensed acupuncturist who specializes in treatment of pregnant women.

As a childbirth educator or other birth professional, do you share information on moxibustion as a method that mothers might use to turn a breech baby?  How do you present this information?  How do the families you work with feel after learning about this option? If you did not cover this before, do you feel like you might start to include this information in your classes after reading Rebecca’s information here and on her blog? Are you aware of physicians who also encourage patients to try this treatment?  Please share your experiences in our comments section. I welcome your discussions. – SM

Pre-Birth Acupuncture Starting week 37

We provide pre-birth acupuncture sessions weekly, beginning at 37 weeks pregnancy. These sessions allow for a more efficient labor and can help women avoid induction, or if induction is required, acupuncture can shorten the duration of induction time and medicine needed. The first study on how acupuncture can affect labor onset and duration was performed in 1974 by Kubista and Kucera. (Kubista E Kucera H. Geburtshilfe Perinatol. 1974; 178 224-9)

Debra Betts is our mentor for Pre-birth Acupuncture. She has a background in nursing and graduated from the London College of Acupuncture in 1989. Returning to New Zealand she established a private practice specialising in pregnancy and women’s health care. She began specifically developing and teaching acupuncture courses to midwives in 1997. This led to the publication of articles on the use of acupuncture and acupressure in obstetric practice in 1999 and her book “The Essential Guide to Acupuncture in Pregnancy & Childbirth” in 2006, with subsequent translations into German and French. Debra completed her PhD on the use of acupuncture in threatened miscarriage in 2014 through the University of Western Sydney and is currently the Director of Postgraduate Programmes for an online Masters course through New Zealand School Acupuncture and Traditional Chinese Medicine. She is also a clinical supervisor at a hospital antenatal acupuncture clinic Wellington New Zealand, and lectures internationally on the use of acupuncture in obstetric care.

Debra Betts free acupressure booklet is available here: http://acupuncture.rhizome.net.nz/download-booklet/

Addressing Estrogen Dominance in Perimenopausal Women Using TCM

By Jill Blakeway, MS, LAc

“I have more perimenopausal patients with estrogen dominance than I used to and they worry me. How can Chinese medicine help with that?”

This question came from a colleague of mine who is a gynecologist, oncologist and a surgeon. Her focus is preventing and treating cancers of the female reproductive organs and her question was part of a broader conversation about how we can use our different skill sets to collaborate to keep our patients healthy and thriving after menopause.

Women who have excess levels of estrogen in the run up to menopause can have an increased risk of breast, uterine, and ovarian cancers, as well as of cervical dysplasia. They are also more likely to have intense and unpleasant menopausal symptoms. That’s why my colleague was keen to find solutions for her patients. My answer to her question was that Chinese medicine is really helpful when it comes to addressing this kind of hormone imbalance, because identifying patterns of disharmony and creating balance between different systems is one the medicine’s strengths.

The symptoms of estrogen dominance include (but are not limited to):

• Breast swelling and tenderness
• Anxiety and mood swings
• “Fuzzy thinking”
• Irritability
• Fatigue
• Loss of ambition
• Slow metabolism
• Water retention
• Loss of libido
• PMS
• Weight gain
• Insomnia
• Thickening of endometrial lining, clotted menses
• Increased risk of uterine fibroids
• Increased incidence of ovarian cysts.

From a Chinese medicine perspective many of these symptoms are related to stagnation of qi, blood and damp against a background of qi or yang deficiency.

We know that women produce far less estrogen after menopause, so it would be logical to assume that estrogen steadily declines until women reach menopause. In fact, for many years, that was exactly what doctors did assume, and it was only in the last 25 years that research showed this wasn’t the case. Likewise, if you read Chinese medical textbooks you can be left with the impression that yin becomes increasingly vacuous until a woman stops having regular periods. In clinical practice, however, we often see a different picture. During the years before menopause, it is often levels of progesterone that decline, while estrogen levels remain stable or even increase. This leads to a situation where estrogen is relatively high in relation to progesterone, which is referred to as estrogen dominance. This is a term that was originally coined by Dr. John Lee, who was one of the first people to advocate natural progesterone supplementation.

Put another way, kidney yang becomes vacuous, often as a result of diminishing spleen qi. Because we need kidney yang to create movement and spleen qi to transform fluids, the result is often stagnation of qi, blood, and damp.

Estrogen is produced mainly in the ovaries and progesterone is produced predominantly by the corpus luteum, which is the outside lining of a mature egg after ovulation. As egg quality declines in perimenopause, so does the quality of the corpus luteum, leading to lower progesterone levels and relative estrogen dominance. Likewise, many perimenopausal women are periodically anovulatory, which means that estrogen goes unopposed during those cycles.

It’s noticeable that both biomedicine and Chinese medicine are identifying the same phenomena. The weak kidney yang correlates to low progesterone and the resulting estrogen dominance correlates to a stagnation of yin (blood and damp). The weak yang often has its root in declining spleen qi and this combination can lead to metabolic sluggishness. Many of my perimenopausal patients tell me how difficult it is for them to lose weight. Unfortunately, excess body fat causes the body to retain estrogen. This may be why overweight women have a lower incidence of osteoporosis, but have a higher breast and uterine cancer risk.

It becomes clear that supporting kidney yang and spleen qi is vital in this population, if we are to reduce their risk of reproductive cancers. Likewise for centuries Chinese doctors have identified the liver as playing a pivotal role in hormone balance alongside the kidney. Liver qi stagnation can be the result of kidney yang vacuity or it can be caused by stress, repressed emotions or a diet that puts a strain on the liver itself.

One of the liver’s functions is to filter excess estrogen. Anything that impairs the liver’s function can therefore result in estrogen not being broken down adequately. This is true for both men and women. Alcoholic men, for example, can develop a condition called gynomastia, where excess estrogen can lead to enlarged breasts and loss of pubic hair. In women, alcohol, environmental toxins, stress, and unresolved emotional issues can limit the liver’s ability to cleanse the blood of estrogen resulting in all the symptoms of estrogen dominance I listed above. The connection between stress and liver function has been recognized for thousands of years in Chinese medicine, but from a biomedical point of view stress can cause people to produce excess cortisol, insulin, and norepinephrine, which can play a role in the kind of hormonal imbalance we see in our patients with compromised livers, known in Chinese medicine as liver qi stagnation.

This stagnation leads to heat and inflammation, and one method that has been traditionally used in Chinese medicine to clear heat is to open the fu. In the case of heat from stagnation, this means making sure the intestines are functioning optimally. Physiologically, this makes sense, because excess estrogen is excreted through the bowel. When a patient is constipated and the stool remains in the intestines for a longer time, estrogen is reabsorbed. Correspondingly, studies have shown that women with a high fiber diet have lower levels of circulating estrogen than women with a low fiber diet.

My MD colleague believes she is seeing more estrogen dominance in women over 40 than she used to and I agree. Why is that? Our lives are speeding up. The internet has made communication very instant and the demands on us are now incessant. Many of us are constantly on the go and eating on the run. From a Chinese medical perspective an irregular diet and lifestyle taxes spleen qi, which leads to damp stagnation. Overscheduling depletes kidney yang and the stress of this disrupts the smooth flow of liver qi and blood.

Plus, there’s one more piece of the puzzle that’s become much more prevalent over the last two decades: the amount of xenoestrogens we are exposed to. These are chemicals that mimic estrogen and act on estrogen hormone receptor sites. They’re found in everything from sunscreen to plastic water bottles. Even our water supply now contains synthetic estrogen because of the widespread use of birth control pills. Cooking with non-stick coated cookware releases xenoestrogens into our food, as does microwaving food in plastic containers. Hormone disrupting chemicals are in our meat supply because of the way hormones are used to plump up cattle and they’re on our vegetables because of the widespread use of pesticides.

So to answer my MD colleague’s question, there is much that Chinese medicine can do to help these patients. In my own practice I combine diet and lifestyle advice with acupuncture, herbs and supplements to help women achieve an appropriate balance between progesterone and estrogen as they head towards menopause.

I tend to use acupuncture to move the stagnations, in conjunction with herbs to address the deficiencies. And when it comes to herbs, I’ve found myself being inspired by the Pi Wei Lun (Treatise on the Spleen & Stomach), which was written by Li Dong-Yuan in 1249. I find it satisfying that a text from the 13^th century should have so much to say about a very modern phenomenon.

Li Dong-Yuan thought that the key to the diseases he was treating was in the digestive system. He observed that a combination of poor diet, irregular lifestyle and emotional strain damages the function of the spleen and stomach, which in turn damages yang qi. Weak kidney yang and spleen qi fail to raise the clear yang and descend the turbid yin, which leads to a buildup of damp in the lower jiao. The clear yang, instead of rising, sinks and stagnates, transforming into heat, which in turn can become damp-heat. Depressive heat and emotional agitation stir up the ming men, which counter-flows upwards causing heat in the upper jiao. He called this pattern Yin Fire.

If we look at the typical symptoms of estrogen dominance, we can see that Li Dong-Yuan’s theory of Yin Fire fits this pattern well.

Fatigue, loss of ambition, weight gain, water retention, slow metabolism, and loss of sex drive can all be attributed to a combination of spleen qi vacuity with damp and kidney yang vacuity.

Irregular periods, breast tenderness, PMS, mood swings and irritability are all related to stagnation of liver qi.

Heavy periods with clotted menstrual blood, fibroids, and ovarian cysts can all be explained by stagnation of blood and damp in the lower jiao leading in some cases to damp-heat.

Insomnia and anxiety can be caused by the heat rising up and harassing the heart, leading to heat yin vacuity.

I like this formula from the Pi Wei Lun for addressing this kind of hormonal complexity, even though it was originally intended to treat summer-heat.

Qing Shu Yi Qi Tang
(Clear Summerheat & Boost the Qi Decoction)

Huang Qi Radix Astragali Membranacei
Ren Shen Radix Panacis Ginseng
Cang Zhu Rhizoma Atractylodis
Bai Zhu Rhizoma Atractylodis Macrocephalae
Gan Cao mix-fried Radix Glycyrrhizae
Mai Men Dong Tuber Ophiopogonis Japonici
Ge Gen Radix Puerariae
Wu Wei Zi Fructus Schisandrae Chinensis
Dang Gui Radix Angelicae Sinensis
Chen Pi Pericarpium Citri Reticulatae
Qing Pi Pericarpium Citri Reticulatae Viride
Sheng Ma Rhizoma Cimicifugae
Huang Bai Cortex Phellodendri
Ze Xie Rhizoma Alismatis
Shen Qu Massa Medica Fermentata

And here’s the advice I give my patients when they ask me what they can do to help themselves:

• Take care of your liver. It is your best defense against estrogen dominance because it’s job is to eliminate excess estrogen. Minimize your alcohol intake and, to stimulate your liver, drink water with lemon juice first thing every morning. You can also promote healthy liver function by adding bitter greens such as dandelion greens, endive and radicchio to your food.

• Follow a hormone balancing diet by eating plenty of vegetables, adequate protein and some healthy fats.

• Make sure you eat enough fiber so that your bowels are able to eliminate excess estrogen.

• Eat cruciferous vegetables, such as broccoli, cabbage, cauliflower, kale and Brussels sprouts. These contain a phytonutrient called diindolylmethane (DIM), which supports the activity of enzymes that improve estrogen metabolism.

• Research endocrine-disrupting chemicals in cosmetics, processed foods, cookware, and cleaning materials and cut your exposure to xenoestrogens as much as you can.

• Talk to your doctor about progesterone supplementation. She may want to give you a transdermal 2% bioidentical progesterone cream to offset the effect of excess estrogen.

• Lose any excess weight and get regular exercise. Research shows that physical activity curtails the overproduction of estrogen.

Jill Blakeway is the founder of the YinOva Center in New York City, where she continues to treat patients. She is the host of CBS Radio’s Grow Cook Heal and the author of two books on women’s health. Jill teaches OB/GYN in the doctoral program at PCOM.