Rédacteurs : Johan Nguyen, Olivier Goret, Claude Pernice, Jean-Luc Gerlier, Franck Gavand

breech presentation

Version foetale : évaluation de l'acupuncture

1. Systematic Reviews and Meta-Analysis

GRADE ratings and their interpretation

Symbol Quality Interpretation
⊕⊕⊕⊕ High We are very confident that the true effect lies close to that of the estimate of the effect.
⊕⊕⊕⊖ Moderate We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
⊕⊕⊖⊖ Low Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
⊕⊖⊖⊖ Very low We have very little confidence in the effect estimate: the true effect is likely to be
☆☆☆ Evidence for effectiveness and a specific effect of acupuncture
☆☆ Evidence for effectiveness of acupuncture
Limited evidence for effectiveness of acupuncture
Ø No evidence or insufficient evidence

1.1. Acupuncture générique

1.1.1. Liao 2021

Liao JA, Shao SC, Chang CT, Chai PYC, Owang KL, Huang TH, Yang CH, Lee TJ, Chen YC. Correction of Breech Presentation with Moxibustion and Acupuncture: A Systematic Review and Meta-Analysis. Healthcare. 2021;9(6):619. [212237]. doi

AimAcupuncture-type interventions (such as moxibustion and acupuncture) at Bladder 67 (BL67, Zhiyin point) have been proposed to have positive effects on breech presentation. The aim of this systematic review and meta-analysis was to evaluate the effectiveness and safety of moxibustion and acupuncture in correcting breech presentation.
MethodsWe searched PubMed, MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), the Chinese Electronic Periodical Services (CEPS), and databases at ClinicalTrials.gov to identify relevant randomized controlled trials (RCTs).
ResultsIn this study, sixteen RCTs involving 2555 participants were included. Compared to control, moxibustion significantly increased cephalic presentation at birth (RR = 1.39; 95% CI = 1.21–1.58). Moxibustion also seemed to elicit better clinical outcomes in the Asian population (RR = 1.42; 95% CI = 1.21–1.67) than in the non-Asian population (RR = 1.20; 95% CI = 1.01–1.43). The effects of acupuncture on correcting breech presentation after sensitivity analysis were inconsistent relative to control. The effect of moxibustion plus acupuncture was synergistic for correcting breech presentation (RR = 1.53; 95% CI = 1.26–1.86) in one RCT.
ConclusionsOur findings suggest that moxibustion therapy has positive effects on correcting breech presentation, especially in the Asian population.

1.1.2. Li 2009 ☆☆

Li X, Hu J, Wang X, Zhang H, Liu J. Moxibustion and other acupuncture point stimulation methods to treat breech presentation: a systematic review of clinical trials. Chin Med. 2009;4(1):4.[153149].

Background Moxibustion, acupuncture and other acupoint stimulations are commonly used for the correction of breech presentation. This systematic review aims to evaluate the efficacy and safety of moxibustion and other acupoint stimulations to treat breech presentation.
Methods We included randomized controlled trials (RCTs) and controlled clinical trials (CCTs) on moxibustion, acupuncture or any other acupoint stimulating methods for breech presentation in pregnant women. All searches in PubMed, the Cochrane Library (2008 Issue 2), China National Knowledge Information (CNKI), Chinese Scientific Journal Database (VIP) and WanFang Database ended in July 2008. Two authors extracted and analyzed the data independently.
Results Ten RCTs involving 2090 participants and seven CCTs involving 1409 participants were included in the present study. Meta-analysis showed significant differences between moxibustion and no treatment (RR 1.35, 95% CI 1.20 to 1.51; 3 RCTs). Comparison between moxibustion and knee-chest position did not show significant differences (RR 1.30, 95% CI 0.95 to 1.79; 3 RCTs). Moxibustion plus other therapeutic methods showed significant beneficial effects (RR 1.36, 95% CI 1.21 to 1.54; 2 RCTs). Laser stimulation was more effective than assuming the knee-chest position plus pelvis rotating. Moxibustion was more effective than no treatment (RR 1.29, 95% CI 1.17 to 1.42; 2 CCTs) but was not more effective than the knee-chest position treatment (RR 1.22, 95% CI 1.11 to 1.34; 2 CCTs). Laser stimulation at Zhiyin (BL67) was more effective than the knee-chest position treatment (RR 1.30, 95% CI 1.10 to 1.54; 2 CCTs,).
Conclusion Moxibustion, acupuncture and laser acupoint stimulation tend to be effective in the

1.1.3. Liu 2009

Liu Mai-Lan, Lan Lei, Tang Yong, Liang Fan-Rong. [Acupuncture and moxibustion for breech presentation: a systematic review]. Chinese Journal of EBM. 2009;9(8):840-3. [167341].

Objective To evaluate the efficacy of acupuncture and moxibustion (acup-moxi) therapy for breech presentation.
Methods We electronically searched The Cochrane Library (Issue 1, 2008), PubMed (1980 to Mar. 2008), MEDLINE (1966 to 2008), Ovid EBM Database (1991 to 2008), CBMdisc (1978 to Mar. 2008), VIP (1989 to Mar. 2008), CNKI (1979 to Mar. 2008), and WangFang Database (1983 to Mar. 2008), as well as handsearched seven traditional Chinese medicine journals to obtain randomized control trials (RCTs) about acup-moxi for breech presentation. Quality assessment was conducted according to the Cochrane Handbook for Systematic Reviews of Interventions 5.0.1. Metaanalyses were performed for the results of homogeneous studies using RevMan 5.0 software.
ResultsEight RCTs involving 1 341 patients met the inclusion criteria. Five trials were of relatively high quality and 3 were of low quality. The pooled analysis of six trials showed that acup-moxi was superior in cephalic presentation with RR=1.38, and 95%CI 1.20 to 1.58.
Conclusion Acup-moxi can increase the successful rate of cephalic presentation in the treatment of breech presentation compared with no (routine care) or knee-chest position treatment.

1.1.4. Van Den Berg 2008 ☆☆

Van Den Berg I et al. Effectiveness of acupuncture-type interventions versus expectant management to correct breech presentation: a systematic review. Complement Ther Med. 2008;16(2):92-100.149428

Purpose A system a tic review of studies assessing the effectiveness of acupuncture-type interventions (moxibustion, acupuncture, or electro-acupuncture) on acupuncture point BL 67 to correct breech presentation compared to expectant management, based on controlled trials.
Methods Articles published from 1980 to May 2007 in databases of Medline, EMBASE, the Cochrane Central Register of Controlled Trials, AMED, NCCAM, Midirs and reference lists. Study selection: studies included were original articles; randomised controlled trials (RCT or controlled cohort studies; acupuncture-type intervention on BL 67 compared with expectant management; ultrasound confirmed breech presentation and position of the fetus after treatment confirmed with ultrasound, position at delivery, and/or the proportion of caesarea sections reported.
Results Of 65 retrieved citations, six RCT's and three cohort studies fulfilled the inclusion criteria. Data were pooled using random-effects models. ln the RCT's the pooled proportion of breech presentations was 34% (95% Cl: 20-49%) following treatment versus 66% (95% Cl: 55-77%) in the control group (OR 0.25 95% Cl: 0.11-0.58). The pooled proportion in the cohort studies was 15% (95% Cl: 1-28%) versus 36% (95% Cl: 14-58%), (OR 0.29, 95% Cl: 0.19-0.43). lncluding all studies the pooled proportion was 28% (95% Cl: 16-40%) versus 56% (95% Cl: 43-70%) (OR 0.27, 95% Cl: 0.15-0.46).
Conclusion Our results suggest that acupuncture-type interventions on BL 67 are effective in correcting breech presentation compared to expectant management. Some studies were of inferior quality to others and further RCT's of improved quality are necessary to adequately answer the research question.

1.1.5. Van den Berg 2005

Van Den Berg I, Jacobs B, Bouman I, Bosch JL, Hunink MGM. Effectiveness of acupuncture-type interventions to resolve breech presentation compared to expectative policy, a meta-analysis. Focus on Alternative and Complementary Therapies. 2005;10(1):9. [144431].

1.2. Specific Acupuncture Techniques

1.2.1. Moxibustion

1.2.1.1. Coyle 2023
⊕⊕⊕⊖ Moderate
⊕⊕⊖⊖ Low

Coyle ME, Smith C, Peat B. Cephalic version by moxibustion for breech presentation. Cochrane Database Syst Rev. 2023 May 9;5:CD003928. https://doi.org/10.1002/14651858.cd003928.pub4

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.
ObjectivesTo 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.
Methods 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 ResultsThis 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.
1.2.1.2. Zhang 2019 ( 67V)

Zhang Lu, Sun Weipeng, Cai Yinhe, Lu Ke, Yang Yaqin, Zeng Lei, Chen Baoyan. [Meta-analysis of Efficacy of Moxibustion at Zhiyin Point for Breech Presentation]. Journal of Hubei University of Chinese Medicine. 2019;5:117-21. [100163].

Objective To systematically evaluate the clinical efficacy of moxibustion at Zhiyin point alone or in combination with knee-chest decubitus position in treatment of fetal malposition.
Methods PubMed, Cochrane library, CNKI, VIP, Wanfang and CBM were searched electronically. The search time was limited to June 15,2017. All relevant literatures about moxibustion at Zhiyin point or treatment of fetal malposition with knee-chest decubitus position were detected. Two researchers independently and strictly carried out quality evaluation and data extraction for the study. Meta-analysis was carried out with Stata 14 software, and sequential analysis was carried out with TSA v0.9 software.
Results Totally 2331 patients were included in 12 eligible literatures. Meta-analysis showed that compared with knee-chest decubitus position, the positive rate of fetal position in simple group increased by 44%[RR=1.44,95%CI(1.33,1.55),P<0.001],while that in combined group increased by 35% [RR=1.32,95%CI(1.22,1.42),P<0.001],all with statistical significance. Subgroup analysis showed that the positive rate of fetal position in simple group or combined group was related to the course of treatment and moxibustion time,and both groups had the best curative effect on pregnant women with 30~34 gestational weeks. Sequential analysis of the tests indicated that moxibustion at Zhiyin point or combined with knee-chest decubitus was effective.
Conclusion Moxibustion at Zhiyin point alone or combined with knee-chest decubitus position can increase the rate of positive fetal position, and moxibustion at Zhiyin point alone has better effect on correcting abnormal fetal position. Both groups have the best effect on pregnant women with 30~34 gestational weeks, which is worthy of clinical promotion
1.2.1.3. Wu 2018

Wu Yan. [A Meta-analysis of treating malpresentation by moxibustion]. Clinical Journal of Chinese Medicine. 2018;(2). [27280].

ObjectiveTo evaluate the clinical efficacy of different moxibustion on malposition.
Methods According to the Cochrane evaluation method, the literature of treating malposition by moxibustion were comprehensively collected; a Meta-analysis was performed statistically by Rev Man 5. 2.
Result8 literatures were included in the study.
Conclusion The effect of moxibustion and moxibustion plus other therapies on malposition was better than knee-chest position; moxibustion on malposition is superior to moxibustion plus postural therapy
1.2.1.4. Zhang 2013 ☆☆

Zhang QH, Yue JH, Liu M, Sun ZR, Sun Q, Han C et al. Moxibustion for the correction of nonvertex presentation: a systematic review and meta-analysis of randomized controlled trials. Evid Based Complement Alternat Med 2013. [160352].

Objectives This study aims to assess the effectiveness and safety of moxibustion for the correction of nonvertex presentation.
Methods Records without language restrictions were searched up to February 2013 for randomized controlled trials (RCTs) comparing moxibustion with other therapies in women with a singleton nonvertex presentation. Cochrane risk of bias criteria were used to assess the methodological quality of the trials.
ResultsSeven of 392 potentially relevant studies met the inclusion criteria. When moxibustion was compared with other interventions, a meta-analysis revealed a significant difference in favor of moxibustion on the correction of nonvertex presentation at delivery (risk ratio RR 1.29, 95% confidence interval (CI) 1.12 to 1.49, and I 2 = 0). The same findings applied to the cephalic presentation after cessation of treatment (RR 1.36, 95% CI 1.08 to 1.71, and I 2 = 80%). A subgroup analysis that excluded two trials with a high risk of bias also indicated favorable effects (RR 1.63, 95% CI 1.42 to 1.86, and I 2 = 0%). With respect to safety, moxibustion resulted in decreased use of oxytocin.
ConclusionOur systematic review and meta-analysis suggested that moxibustion may be an effective treatment for the correction of nonvertex presentation. Moreover, moxibustion might reduce the need for oxytocin.
1.2.1.5. Coyle 2012 ☆

Coyle Me, Smith Ca, Peat B. Cephalic version by moxibustion for breech presentation. Cochrane Database Syst Rev. 2012. May 16:. [159289].

Background Moxibustion (a type of Chinese medicine which involves burning a herb close to the skin) to the acupuncture point Bladder 67 (BL67) (Chinese name Zhiyin), located at the tip of the fifth toe, has been proposed as a way of correcting breech presentation.
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 for breech presentation.
Methods Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (26 March 2012), MEDLINE (1966 to 1 August 2011), EMBASE (1980 to August 2011), CINAHL (1982 to 1 August 2011), MIDIRS (1982 to 1 August 2011) and AMED (1985 to 1 August 2011) and searched bibliographies of relevant papers. Selection criteria: The inclusion criteria were published and unpublished randomised controlled trials comparing moxibustion (either alone or in combination with acupuncture or postural techniques) with a control group (no moxibustion), or other methods (e.g. external cephalic version, acupuncture, postural techniques) in women with a singleton breech presentation. DATA collection and analysis: Two review authors independently assessed eligibility and trial quality and extracted data. The outcome measures were baby's presentation at birth, need for external cephalic version, mode of birth, perinatal morbidity and mortality, maternal complications and maternal satisfaction, and adverse events.
Main resultsSix new trials have been added to this updated review. One trial has been moved to studies awaiting classification while further data are being requested. This updated review now includes a total of eight trials (involving 1346 women). Meta-analyses were undertaken (where possible) for the main and secondary outcomes. Moxibustion was not found to reduce the number of non-cephalic presentations at birth compared with no treatment (P = 0.45). Moxibustion resulted in decreased use of oxytocin before or during labour for women who had vaginal deliveries compared with no treatment (risk ratio (RR) 0.28, 95% confidence interval (CI) 0.13 to 0.60). Moxibustion was found to result in fewer non-cephalic presentations at birth compared with acupuncture (RR 0.25, 95% CI 0.09 to 0.72). When combined with acupuncture, moxibustion resulted in fewer non-cephalic presentations at birth (RR 0.73, 95% CI 0.57 to 0.94), and fewer births by caesarean section (RR 0.79, 95% CI 0.64 to 0.98) compared with no treatment. When combined with a postural technique, moxibustion was found to result in fewer non-cephalic presentations at birth compared with the postural technique alone (RR 0.26, 95% CI 0.12 to 0.56).
Authors' conclusionsThis review found limited evidence to support the use of moxibustion for correcting breech presentation. There is some evidence to suggest that the use of moxibustion may reduce the need for oxytocin. When combined with acupuncture, moxibustion may result in fewer births by caesarean section; and when combined with postural management techniques may reduce the number of non-cephalic presentations at birth, however, there is a need for well-designed randomised controlled trials to evaluate moxibustion for breech presentation which report on clinically relevant outcomes as well as the safety of the intervention.
1.2.1.6. Vas 2009 ☆☆

Vas J et al. Correction of nonvertex presentation with moxibustion: a systematic review and metaanalysis. Am J Obstet Gynecol. 2009;201(3):241-59. [154014].

Purpose We searched systematically for randomized controlled trials, comparing moxibustion with a nonmoxibustion control group or other methods such as external cephalic version, postural methods, and acupuncture in databases, both Western and Chinese, up to June 2007.
Methods Six studies, with 1087 subjects and a high degree of heterogeneity, compared moxibustion vs observation or postural methods. and reported a rate of cephalic version among the moxibustion group of 72.5% vs 53.2% in the control group (relative risk, 1.36; 95% confidence interval, 1.17-1.58); the number needed to treat was 5 (95% confidence interval, 4-7). In terms of safety, no significant differences were found in the comparison of moxibustion with other techniques.
Results These studies reported a rate of cephalic version among the moxibustion group of 72.5% vs 53.2% in the control group (relative risk, 1.36; 95% confidence interval, 1.17-1.58); the number needed to treat was 5 (95% confidence interval, 4-7). In terms of safety, no significant differences were found in the comparison of moxibustion with other techniques.
Conclusion Moxibustion at acupuncture point BL67 has been shown to produce a positive effect, whether used alone or in combination with acupuncture or postural measures, in- comparison with observation or postural methods alone, for the correction of nonvertex presentation, although these results should Abe viewed with caution, given the considerable. heterogeneity,found among-studies.
1.2.1.7. Coyle 2005 Ø

Coyle M, Smith C, Peat B. Cephalic version by moxibustion for breech presentation. Cochrane Database Syst Rev. 2005. (2):CD003928. [136184].

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 for breech presentation.
Methods Search strategy: We searched the Cochrane Pregnancy and Childbirth Group trials register (30 August 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2004), MEDLINE (1966 to March 2004), EMBASE (1980 to March 2004), CINAHL (1982 to March 2004), MIDIRS (1982 to March 2004), CISCOM (9 March 2004) and bibliographies of relevant papers. Selection CRITERIA: The inclusion criteria were published and unpublished randomised controlled trials comparing moxibustion (either alone or in combination with acupuncture) with a control group (no moxibustion), or other methods (e.g. external cephalic version, acupuncture) in women with a singleton breech presentation. Data collection and analysis: Both authors assessed eligibility and quality of trials independently. The outcome measures were baby's presentation at birth, need for external cephalic version, mode of birth, perinatal morbidity and mortality, maternal complications and maternal satisfaction, and adverse events.
Main resultsThree trials involving a total of 597 women were included. Due to differences in interventions and sample size it was not appropriate to perform a meta-analysis for the main outcome. Only one trial reported on other outcome measures relevant to this review. Moxibustion reduced the need for ECV (relative risk (RR) 0.47, 95% confidence interval (CI) 0.33 to 0.66) and resulted in decreased use of oxytocin before or during labour for women who had vaginal deliveries (RR 0.28, 95% CI 0.13 to 0.60).
Authors' conclusionsThere is insufficient evidence to support the use of moxibustion to correct a breech presentation. Moxibustion may be beneficial in reducing the need for ECV, and decreasing the use of ocytocin, however there is a need for well-designed randomised controlled trials to evaluate moxibustion for breech presentation which report on clinically relevant outcomes as well as the safety of the intervention.

2. Cost-effectiveness

3. Clinical Practice Guidelines

⊕ positive recommendation (regardless of the level of evidence reported)
Ø negative recommendation, (or lack of evidence)

3.1. National Institute for Health and Care Excellence (NICE, UK) 2021 Ø

NICE guideline NG201 : Antenatal care [M] Management of breech presentation. National Institute for Health and Care Excellence (NICE). 2021. [218449]. URL

Complementary therapy: No evidence was identified. [Note: only 1 study included (acupuncture), all moxibustion studies excluded].

3.2. Danish Society of Obstetrics and Gynecology (DSOG, Denmark) 2020 ⊕

Breech delivery and external cephalic version. Danish Society of Obstetrics and Gynecology (DSOG). 2020:74P. [182690]. URL

There is limited evidence for the effect of Moxa, but a positive effect on fetal reversal from lower body to head position cannot be ruled out. (1a)

3.3. Collège national des gynécologues et obstétriciens français (CNGOF, France) 2019 Ø

Ducarme G. Présentation du siège. Recommandations pour la pratique clinique du CNGOF — Version par manœuvre externe et techniques de version alternatives. Gynecol Obstet Fertil Senol. 2020;48(1):81-94. [201194].
Sentilhes L, Schmitz T, Azria E, Gallot D, Ducarme G, Korb D, Mattuizzi A, Parant O, Sananès N, Baumann S, Rozenberg P, Sénat MV, Verspyck E. Présentation du siège . Recommandations pour la pratique clinique du CNGOF – Texte court Gynecol Obstet Fertil Senol. 2019. [200905].

En cas de présentation du siège, l’acupuncture, la moxibustion, les méthodes posturales (position genu-pectorale et pont indien) n’ont pas montré leur efficacité pour réduire le nombre de présentations du siège à la naissance (NP2), et ne sont pas recommandées (Grade B).

3.4. Royal College of Obstetricians and Gynaecologists (RCOG, UK) 2017 ⊕

Impey LWM, Murphy DJ, Griffiths M, Penna LK on behalf of the Royal College of Obstetricians and Gynaecologists. External Cephalic Version and Reducing the Incidence of Term Breech Presentation. BJOG. 2017;124:e178–e192. [201232].

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.

4. Overviews of Clinical Practice Guidelines

4.1. Tsakiridis 2019

Tsakiridis I, Mamopoulos A, Athanasiadis A, Dagklis T. Management of Breech Presentation: A Comparison of Four National Evidence-Based Guidelines. Am J Perinatol. 2019. [201249].

OBJECTIVE: The management of breech presentation may improve perinatal outcomes. The aim of this study was to synthesize and compare published evidence of four national guidelines on breech presentation. STUDY DESIGN: A descriptive review of four recently published national guidelines on breech presentation and external cephalic version (ECV) was conducted: Royal College of Obstetricians and Gynaecologists guideline on “External Cephalic Version and Reducing the Incidence of Term Breech Presentation” and “Management of Breech Presentation”, American College of Obstetricians and Gynecologists guideline on “External Cephalic Version” and “Mode of Term Singleton Breech Delivery”. Society of Obstetricians and Gynaecologists of Canada guideline on “Vaginal Delivery of Breech Presentation” and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists guideline on “Management of breech presentation at term.” RESULTS: Regarding ECV, there is no recommendation by the SOGC, whereas all other national guidelines recommend this technique. Regarding breech vaginal delivery, there are limited recommendations by the ACOG, whereas all other guidelines provide similar recommendations. The RANZCOG makes no special recommendations on the intrapartum period. CONCLUSION: The differences among national guidelines point out the need for the adoption of an international consensus on the management of breech presentation.

5. Randomized Controlled Trials

5.1. Sources

  1. Acudoc2: base de données du Centre de Documentation du GERA (ECR non inclus dans les revues systématiques sources).
  2. Coyle 2023: Coyle ME, Smith C, Peat B. Cephalic version by moxibustion for breech presentation. Cochrane Database Syst Rev. 2023 May 9;5:CD003928. https://doi.org/10.1002/14651858.cd003928.pub4
  3. Liao 2021 : Liao JA, Shao SC, Chang CT, Chai PYC, Owang KL, Huang TH, Yang CH, Lee TJ, Chen YC. Correction of Breech Presentation with Moxibustion and Acupuncture: A Systematic Review and Meta-Analysis. Healthcare. 2021;9(6):619. [212237]. https://doi.org/10.3390/healthcare9060619
  4. Zhang 2019: Zhang Lu, Sun Weipeng, Cai Yinhe, Lu Ke, Yang Yaqin, Zeng Lei, Chen Baoyan. [Meta-analysis of Efficacy of Moxibustion at Zhiyin Point for Breech Presentation]. Journal of Hubei University of Chinese Medicine. 2019;5:117-21. [100163].
  5. Zhang 2013 : Zhang QH, Yue JH, Liu M, Sun ZR, Sun Q, Han C et al. Moxibustion for the correction of nonvertex presentation: a systematic review and meta-analysis of randomized controlled trials. Evid Based Complement Alternat Med 2013. [160352].
  6. Coyle 2012: Coyle Me, Smith Ca, Peat B. Cephalic version by moxibustion for breech presentation. Cochrane Database Syst Rev. 2012. May 16:. [159289].
  7. Li 2009: Li X, Hu J, Wang X, Zhang H, Liu J. Moxibustion and other acupuncture point stimulation methods to treat breech presentation: a systematic review of clinical trials. Chin Med. 2009;4(1):4.[153149].
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