Tag Archives: moxibustion

“No time to put a plan in place”

Thinking through the practicalities of breech advocacy.

Midwives and obstetricians who would like give women with breech presenting babies more support to plan a vaginal breech birth (VBB) need to think through the wider picture of how this happens in order to become effective advocates. In my experience of doing breech advocacy throughout the post-Term Breech Trial era, women often get in touch after 38 or 39 weeks to try to organise support for a VBB. Achieving this requires quite a bit of discussion and negotiation in quite a short period of time.

This post makes visible some ‘common experiences’ in women’s vaginal breech birth journeys. Services differ in every area, so it won’t be every woman’s experience. And increasingly, forward-thinking NHS Trusts are working with advocacy organisations (such as the Coalition for Breech Birth, Breech Birth UK and BBANZ) to develop woman-centred care pathways which meet women’s needs rather than restrict their choices, like this team in Sheffield.

Common experienceOther possibilities
33 weeksAntenatal clinic visit. Midwife or woman suspects breech. Woman told not to worry, most babies will turn.Informed about / referred for moxibustion treatment. Not associated with risk of harm. Shown to reduce breech and CS when used with acupuncture. Shown to reduce use of syntocinon before and during labour regardless of presentation. (Coyle et al, Cochrane Review, 2012)
36 weeksPalpation in antenatal clinic. Midwife suspects breech and refers for USS. Woman receives counselling re: ECV, to return at a later date. Is told discussion re: mode of birth will occur after unsuccessful ECV.One-stop shop breech clinic. Scan, counselling and ECV performed by a midwife or doctor with specialist training. If unsuccessful/declined, mode of birth preference documented. To return for further counselling.
37 weeksCounselling repeated by a different professional, who may have different personal preferences. External cephalic version attempted. If unsuccessful, asked to return for counselling re: mode of birth in consultant clinic.Returns to breech clinic for second attempt at ECV. Sees same practitioner, who is also part of the breech birth team. After unsuccessful/declined second attempt, confirms choice of mode of birth. Wider team made aware of planned VBB.
38 weeksReturns to antenatal clinic and sees another consultant or registrar. Majority of UK hospitals reluctant to support planned VBB. Advised to have CS. In some cases, a managed breech delivery in lithotomy is offered.Woman and her birth partner prepare for the up-coming birth.
39 weeks +After a return visit to antenatal clinic to attempt to negotiate support for an active VBB, meeting yet another consultant, and lots of research on the internet, woman seeks out external sources of support for VBB. Advocate (Supervisor of Midwives, doula, independent midwife) attempts to liaise with hospital staff, who ask, “Why do they all leave it to the last minute? There’s no time to put a plan in place now!Returns to breech clinic at 41 weeks to revisit choice of mode of birth, taking factors such as fetal growth and length of pregnancy into consideration. Talks to the same or another experienced member of the breech team.

Questions for reflection:

  • Consider your current work setting. If a woman tells you she would like to consider a VBB but is not receiving support to plan one, what can you do?
  • Who needs to be involved in her plan?
  • Who will support you to support her? To what extent are you comfortable being involved?
  • How can you build a local breech team, who can be ready to meet this need when it arises?
  • Consider working with your team to develop an informational resource for women, like this leaflet from King’s College Hospital.

Please share your positive experiences and good examples of breech teams in the comments.

Shawn

References:

Beuckens, A., Rijnders, M., Verburgt-Doeleman, G., Rijninks-van Driel, G., Thorpe, J., Hutton, E., 2016. An observational study of the success and complications of 2546 external cephalic versions in low-risk pregnant women performed by trained midwives. BJOG An Int. J. Obstet. Gynaecol. 123, 415–423. doi:10.1111/1471-0528.13234

Catling, C., Petrovska, K., Watts, N.P., Bisits, A., Homer, C.S.E., 2015. Care during the decision-making phase for women who want a vaginal breech birth: Experiences from the field. Midwifery. doi:10.1016/j.midw.2015.12.008

Coyle ME  Peat B, S.C.A., 2012. Cephalic version by moxibustion for breech presentation (Review). Cochrane Database Syst. Rev. doi:10.1002/14651858.CD003928.pub3

Walker, S., Perilakalathil, P., Moore, J., Gibbs, C.L., Reavell, K., Crozier, K., 2015. Standards for midwife practitioners of external cephalic version: A Delphi study. Midwifery 31, e79–e86. doi:10.1016/j.midw.2015.01.004

Moxibustion: A Smoke Screen?

Screen Shot 2014-06-13 at 01.38.38Professionals: Concerned about women waving giant sticks of burning wacky weed around their wee toes in a desperate attempt to turn their breech babies?! Take action NOW! Ensure that these women can access support for a vaginal breech birth with an experienced, trusted professional, and you will no longer have to busy yourself trying to root out such madness!

Screen Shot 2014-06-13 at 06.51.12Last week the results of a trial (Coulon et al 2014) were released which appeared to show moxibustion with acupuncture ineffective in causing more babies to turn head-down. The trial had its good points. A reasonable number of women randomised (328) at the appropriate point in pregnancy (33+4 – 35+4) to use moxibustion for maximum effectiveness. This in itself was impressive, as most centres do not bother about breech presentation until 36 weeks, making recruitment for studies during this time period difficult. The team looked at the percentage of babies who remained breech at 37+2, the point when ECV (a procedure to manually try to turn the baby in the uterus to a head-down position) would be offered, and found that 72% who had the treatment were still breech, compared with 63.4% who had the placebo. They reported this was not statistically different, but superficially it looks like the treatment had the opposite of the desired effect.

Screen Shot 2014-06-13 at 01.38.58On the other hand, they appear to have used actual needles, heated with moxibustion, rather than the method most commonly used in UK-based moxibustion practices, which involves using the heated sticks only. Also, the intervention and placebo were applied for only six sessions. Generally, women using moxibustion in the UK are usually taught to home-administer (usually with the help of her partner) and then instructed to follow a ten-day course, applying moxibustion twice a day, and continuing whether the baby turns or not. The ten-day, moxibustion-only practice follows a less treat-to-cure, and more treat-to-nourish philosophy, the idea being that the moxibustion nourishes the energy of the womb and promotes optimal positioning. (No swearing until I’ve finished the article, please!)

Screen Shot 2014-06-13 at 01.39.14I’m a fan of observing responses to research on Twitter. (See this previous discussion on hypnosis for childbirth.) And Twitter did not disappoint. The Green Journal announced the Coulon study, and obstetricians celebrated their vindication for having dismissed the practice years ago. There’s nothing like the joy of scientific confirmation of one’s deeply held beliefs. It was as if somebody walked into a room full of midwives and said, “Hey, guess what? Continuity of carer improves outcomes for everybody!” (By the way, it does.)

Screen Shot 2014-06-13 at 02.12.23But then a woman who had actually experienced a breech pregnancy pointed out the obvious: What are the alternatives? Generally, women are highly motivated to give birth vaginally (Raynes-Greenow et al 2004Guittier et al 2011). They instinctively feel what the research tells us – that  a normal birth, wherever possible, is beneficial for both babies and women. There are many hospitals throughout the Western world, including some in the UK, where women cannot even access an ECV, let alone a vaginal breech birth. I’ve had phone conversations where I’ve asked to speak with the person who performs ECVs and been told, “We don’t do that here for liability reasons.” Folks, it’s 2014.

Screen Shot 2014-06-13 at 01.38.22With evidence-based counselling based on the outcomes of the Term Breech Trial, Kok et al 2008 found at least 35% of women preferred to plan a vaginal breech birth. Evidence-based counselling includes the lack of evidence of any difference between two-year outcomes whether an elective caesarean section or a vaginal breech birth is planned (Whyte et al 2004). We can reasonably conclude that if approximately 1/3 of women are not planning a vaginal breech birth in a given setting, then they are probably being directively counselled towards a caesarean section. This would include feeling forced to choose a caesarean section because no plan will be put in place to ensure attendance at a vaginal breech birth by an experienced and supportive professional.

Screen Shot 2014-06-13 at 01.41.57Women resort to practices such as moxibustion and handstands in the swimming pool because they are constantly given the message that breech presentation is ‘wrong’ and should be corrected, with very few alternatives. Whereas the evidence indicates that turning babies, even with ECV, does not improve outcomes for those babies, though it certainly improves the chances of a vaginal birth in settings with minimal support for vaginal breech birth (Hofmeyr and Kulier, 2012 – Cochrane Review). I am increasingly uncomfortable with the current situation, where women do things they do not actually want to do because they cannot access a vaginal breech birth at all, or will not be supported to choose that option until they have done everything else (especially ECV).

Screen Shot 2014-06-13 at 01.40.36Personally, I have no strong opinion on the use of moxibustion itself, as I generally prefer to leave the use of complementary therapies up to what works for individual women, as long as they do not pose a threat to her or her baby. I have taken training to be able to offer women advice, and I have supported women through the use of moxibustion. (We usually spend the ‘treatment’ time talking through the issues around breech birth.) When I speak publicly about breech management, someone usually asks me why I have not included moxibustion. And I tend to dodge the question, not so much because I am convinced of its efficacy or not, but because I believe it is professionals’ attitudes towards breech presentation and not the breech itself that needs to be ‘corrected.’

Screen Shot 2014-06-13 at 06.19.23Let me propose this radical solution: Why don’t we channel some of that indignation over moxibustion practices into ensuring that breech services improve to a point where women will not need to look elsewhere? Let’s ensure every woman has access to a well-supported vaginal breech birth, an ECV attempted by a highly experienced practitioner, and/or a woman-centred caesarean section as late in her pregnancy as she wishes to plan it, including in early labour. Let’s ensure that women have sympathetic, experienced counselling and continuity from a midwife while they navigate these choices, and the attendance of a highly experienced consultant, ready to step up and be that expert in complications of childbirth, backing up the team at birth.

No Re-tweet, sadly ;-)

No Re-tweet, sadly 😉

While we must always make room for those who choose a different path, I suspect that if we got a bit more comfortable with breech in general, the debate over whether moxibustion has a place in the mainstream or not would fade into the distance. Stop blaming pregnant women for their misled attempts to avoid a caesarean section, and the sympathetic midwives who are desperate to help them, and sort out primary breech services.

Shawn

 

 

 

 

 

Choice 1 Choice 2 Choice 3

 

 

 

[Note: I can only access the abstract to Coulon et al at the moment, as it has been posted ahead-of-print. I’ll update the post when it’s published, if there’s anything more to say.]