Keywords
yoga - breech - spinning babies - chiropractic care - pregnancy
In the United States, there has been a recent rise in women being delivered by cesarean
section (C-section) to the current rate of approximately 33%. Although a C-section
can be a lifesaving surgery, it comes with an increased risk of maternal morbidity
when compared with a vaginal delivery. The top three reasons for performing a C-section
are: arrest of labor (34%), nonreassuring fetal heart rate tracing (23%), and malpresentation
(17%).[1]
Breech presentation, the most common malpresentation, at 37 weeks onward, is estimated
to complicate 3 to 4% of pregnancies and approximately 86.9% of persistent breech
presentations are delivered by C-section.[1]
[2] Etiologies for a breech fetus in the third trimester include conditions that change
the vertical polarity of the uterus such as a uterine malformation, fibroids, or lack
of laxity of the maternal abdominal wall. Conditions that affect the ability of the
fetus to turn vertex such as fetal congenital anomalies, abnormal amniotic fluid volumes,
or prematurity, also increase the risk. In 2000, a large multicenter randomized trial,
the Term Breech Trial, demonstrated significantly lower perinatal and neonatal morbidity
and mortality when women underwent a planned C-section for breech compared with a
planned vaginal delivery.[2] Hence, the current American College of Obstetricians and Gynecologists recommendation
is to perform a C-section as the preferred mode of delivery for a breech fetus. However,
an external cephalic version (ECV), as a mean to reduce the rate of C-sections, is
standard of care and should be offered to all women who have a breech fetus after
37 weeks who desire a vaginal delivery and have no contraindications.[3] When an ECV is performed successfully, women are more likely to undergo a vaginal
delivery, have a lower likelihood of developing complications from delivery, and tend
to have a shorter hospital stay.[3]
The application of complementary and alternative therapies (CT) in medicine is increasingly
common and the literature to support its use in pregnancy is also widely prevalent.
Moxibustion, chiropractic techniques, massage, yoga, hypnosis, acupressure, and acupuncture
are common CAM therapies used in pregnancy for a variety of reasons, including the
management of breech fetuses.[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11] Traditional Chinese medicine proposes the utilization of moxibustion—the burning
of moxa, a root of the herb Artemisia vulgaris, near the BL67 point (outer aspect
of pinky toe)—to turn breech fetuses. In 2012, a Cochrane Review[4] that included eight randomized controlled trials (RCTs) found limited evidence to
support the use of moxibustion for breech fetuses. When compared with no treatment,
moxibustion did not significantly reduce the number of breech fetuses (p = 0.45); however, when combined with acupuncture (at the same BL67 point) or postural
techniques, a significant reduction in breech fetuses and C-sections occurred.[4] Since this publication, two more RCTs were published that did not show a significant
reduction in breech fetuses with moxibustion.[5]
[6] Although most of these RCTs recruited patients at 32 to 36 weeks' gestation, the
duration of the intervention varied, ranging from twice daily to two times a week,
which may explain the discrepancies in conclusions.
In 1978, Dr. Larry Webster developed the “Webster technique,” a chiropractic approach
for correction of sacral movement restriction utilizing the chiropractic adjustment
and soft tissue work to improve the neurobiomechanical function of the pelvis.[7] When employed, practitioners noticed a “side effect” of the technique was conversion
of a breech fetus to a vertex position. In theory, by correcting motion restriction
of sacrum or sacroiliac joints and by releasing tension and balancing pelvic muscles
and uterine ligaments, this technique facilitates more tissue mobility surrounding
the uterus and the pelvis, thus allowing the fetus to move into optimal positioning
for labor.[7] This technique is taught by the International Chiropractic Pediatric Association
in a comprehensive 13-hour hands-on seminar. Certification requires passing the Webster
Proficiency Exam, which includes three components: a practical assessment, a written
test, and a principles and practice agreement. Successful completion of all three
parts is necessary to achieve Webster Certification.[8] It remains in the scope of practice for a chiropractor as a technique to assess
and correct maternal pelvic imbalance and uterine constraints and not as an obstetric
procedure to correct the breech fetus. A survey of licensed chiropractors who provide
care for pregnant women demonstrated that all the respondents (n = 112) had performed the Webster's technique within the past 6 months with a self-reported
success rate of approximately 90%.[9] Currently, there are no RCTs that have assessed the effectiveness of this technique
and all assumptions are based on case reports and expert opinion.[7]
Relaxation therapies may play a vital role in the management of breech fetuses, as
some believe that stress, activation of the sympathetic nervous system, and tension
in muscles may prevent a fetus from turning vertex. Hypnosis, a deeply relaxed state,
has been assessed in two separate studies.[10] First, a case series of 100 women were offered up to 10 hours of in-person hypnosis
after 37 weeks. When compared with 100 matched controls, the spontaneous conversion
rate was significantly higher (81 vs. 26% in the control group; p-value not provided) and C-section rate was significantly lower in the hypnosis group.[11] Implementing 20 minutes of hypnosis right before an ECV was also shown to significantly
increase the success rate of the ECV (41.6 vs. 27.3% of controls; p < 0.05).[12]
Theoretically, massage and yoga are two CAM modalities that can also lead to relaxation
of muscles supporting pregnancy and assist with conversion of a breech fetus. However,
there are no peer-reviewed studies assessing their specific effects for this indication.
Spinning Babies, a program created by a midwife Gail Tully, promotes the use of specific
postures and practices, similar to yoga and the Miles Circuit,[13] during pregnancy to facilitate turning of a breech fetus.[14]
The causes of a breech fetus are multifactorial; therefore, a one-size-fits-all approach
is not pragmatic. The evidence to support the use of CAM therapies is mixed; thereby,
there is not a singular best CAM therapy to implement. Therefore, we devised this
study to offer a comprehensive and individualized approach to the breech fetus incorporating
several CAM modalities.
We hypothesized that implementation of a combination of complementary and alternative
therapies (CCAT) over a short duration of time may result in a decrease rate of breech
fetuses after 37 weeks. Our primary objectives include: (1) to determine the feasibility
of implementing a CCAT approach to evert a breech fetus and (2) to assess the acceptability
of CCAT as measured by patient perception and percentage of patients who opt to enroll
in the study. Our secondary objectives include: (1) to obtain preliminary measures
of effectiveness to determine if a CCAT for the management of a breech fetus will
result in a decreased rate of breech fetuses at term and (2) to determine the rate
of C-sections for breech fetuses at term in women who engage in this program.
Methods
Trial Design
This is a single-group, feasibility, pilot study.
Participants
We included women who were ≥18 years of age, English speaking with a singleton, well-dated
pregnancy by first trimester ultrasound or known/sure last menstrual period with a
fetus in the breech position. These women were also included if they planned to deliver
at our hospital to allow for collection of delivery information from our electronic
medical records.
Our exclusion criteria included the following: any unstable maternal or fetal condition
that requires urgent delivery, any contraindication to vaginal delivery (i.e., placenta
previa, placenta accreta, macrosomia, etc.), evidence of labor (i.e., regular contractions,
cervical dilatation), women with known uterine malformations, fetal anomalies, or
aneuploidy. Those who would not be a candidate for an ECV at the time of their ultrasound
in our clinic, i.e., fetal growth restriction, low amniotic fluid volume, premature
rupture of membranes, multifetal gestation, nonreactive nonstress test, nuchal cord,
etc., were also excluded.
Participants were recruited from the Maternal-Fetal Specialists (MFS) clinic, a high-risk
pregnancy consultative practice that relies on the referrals from obstetrics and gynecology
physicians who plan to deliver their patients at the main hospital. Participants were
referred to our clinic when they were determined to have a breech fetus on ultrasound
examination in their physician's office between 340/7 and 376/7 weeks gestation. Patients are routinely sent to our MFS clinic for evaluation and
management of breech fetus including performance of ECVs for breech fetuses when indicated.
However, the ECV was not included as an intervention for this research study.
Intervention
The intervention was conducted over three study visits. Study visit number 1 was initiated
on the day that they were referred to our clinic for evaluation. Each participant
had a formal ultrasound evaluation using a GE Voluson ultrasound machine (GE Healthcare,
Chicago, IL) to determine fetal position, estimated fetal weight, amniotic fluid assessment,
placenta location, and to evaluate for any contraindications to an ECV. An intake
form was also completed that included questions about their obstetric, nonobstetric,
physical activity, and pain history. We also inquired about their personal use of
integrative therapies before or during the current pregnancy. A 9-question survey
regarding their stress levels over the past 2 weeks was also completed. After obtaining
verbal and written consent, the participant met with a licensed chiropractor who specializes
in pregnancy to initiate the intervention. Upon reviewing their history and performing
a physical assessment, a soft tissue treatment and a chiropractic adjustment were
performed if deemed necessary.
The therapies provided during the intervention were divided into three categories:
Spinning Babies, Yoga, and mindset techniques with lifestyle modifications. Participants
were advised to come with a partner or support person and were taught 3 Spinning Babies
techniques, which included belly sifting, side lying release, and forward-leaning
inversion. Yoga postures incorporated into our intervention were cat–cow pose, puppy
pose, supported bridge pose, child's pose, down dog, and hip figure of 8s. The mindset
component of the intervention included visualization, meditation, a list of positive
affirmation mantras, and lifestyle modifications that focused on being mindful of
posture when sitting, standing, or engaging in activities of daily living. A booklet
was created with instructions for all interventions and was provided to each participant
([Supplementary Material S1]). Acupuncture and moxibustion were excluded from the intervention because the chiropractor
was not trained in these modalities at the time. Participants were encouraged to practice
the techniques at home daily or as frequently as they felt comfortable between visits.
This study visit lasted approximately 2 hours, which included the ultrasound component.
The second study visit took place 3 to 5 days after the first visit. At this visit,
a bedside ultrasound using the Butterfly iQ handheld ultrasound probe (Butterfly Network
Inc., Guilford, CT) was performed by a Maternal–Fetal Medicine physician (S.B.) to
determine fetal position. The participant then met with the chiropractor to review
their home practice and engaged in exercises that were previously taught and underwent
soft tissue work and Chiropractic adjustment. If the fetus was vertex, new yoga postures
were taught to the participant to help keep the fetus in a vertex position. These
included standing lunge with or without chair support, malasana (deep squat), goddess
pose, and floor lunges. Participants were again encouraged to practice these techniques
at home before their next visit.
Study visit three took place 3 to 5 days after study visit number 2. The same intervention
occurred as study visit number 2. These appointments lasted approximately 1 hour each.
At the end of study visit number 3, a feedback survey was completed by the participants.
The survey had seven questions assessing the program and each study visit and contained
the same stress survey that was completed prior to the initiation of the intervention.
Delivery data were collected by chart review of the electronic medical record.
Statistical Analysis and Sample Size
Statistical analysis was conducted with SPSS v28.0.1. Descriptive statistics were
obtained on the data that were collected. Wilcoxon matched-pairs signed-ranks test
was used to compare stress levels before and after the intervention. Our sample size
was estimated pragmatically given the feasibility nature of the study. A brief review
of our labor and delivery unit statistics between July to December 2021 was performed.
During that 6-month timeframe, there were approximately 400 births per month. Of those,
C-section for breech occurred at a rate of 5%. Therefore, we anticipated that during
the 6-month feasibility study, there would be approximately 120 women with breech
fetuses eligible for participation. As our gestational age for recruitment began at
34 weeks instead of 37 weeks, we anticipated that approximately 48 to 50 women referred
to our clinic with a breech fetus who would opt to participate in the study.
Results
This feasibility study was conducted from February 1, 2023 to June 15, 2023. It was
initially planned to be a 6-month study period; however, the study period was truncated
at 4.5 months of study period due to a lack of institution research support for coverage
during maternity leave for one of the primary investigators. As this study was based
on referrals from obstetric providers, taking a hiatus to return and complete the
6-month study period was not feasible.
A total of 24 women were referred to our clinic for the management of a breech fetus
during the study period. Two women were greater than 38 weeks at the time of their
initial visit, which excluded them from our study. Six women declined to schedule
an appointment in our clinic, because their fetus was vertex and intervention was
not needed. We had a total of 16 women present to our clinic for ultrasound evaluation
with the intention of participating in our study. Of these women, 5 were excluded
(n = 3 had a vertex fetus, n = 2 had nuchal cord), leading to 11 women who enrolled and completed the study intervention.
No participants declined to participate in the study after hearing about the details
of the study intervention.
The mean maternal age of participation was 29 years. Most of our participants were
of white/European race (91%), married (91%), with a college degree (82%) and primiparous
(64%); [Table 1]). The majority of women (n = 8, 73%) had engaged in multiple CAM therapies prior to pregnancy as well as during
pregnancy, which included acupuncture, acupressure, chiropractic care, massage, yoga,
and meditation.
Table 1
Baseline demographics
|
Characteristic
|
N = 11
N (%) or mean ± SD
|
|
Age (years)
|
29.1 ± 3.7
|
|
Race
|
|
|
White/European descent
Black/African descent
Asian
Mixed
Other
|
10 (91)
0
0
1 (9)
0
|
|
Latin/Hispanic ethnicity (yes)
|
0
|
|
Marital status
|
|
|
Never married
Married/Living with partner
Divorced/widowed/separated
|
1 (9)
10 (91)
0
|
|
Education level
|
|
|
Less than high school
High school graduate
Some college
College graduate
Missing data
|
0
0
1 (9)
9 (81.8)
1 (9)
|
|
Primiparous (n %)
|
7 (63.6)
|
|
Previous C-section
|
1 (9)
|
The average gestational age at visit number 1 was 36.8 weeks. All participants completed
this visit and were advised to complete home exercises from all three intervention
categories. The average gestational age at visit number 2 was 37.3 weeks. All participants
completed this visit and all fetuses were found to be breech at this visit. Eight
(72%) women reported engaging in daily home practice of the recommended therapies,
whereas 27% (n = 3) stated that they engaged in therapies at home but not daily. Ten of the 11 participants
were advised to complete home exercises from all three intervention categories at
the end of visit number 2. The average gestational age at visit number 3 was 37.8
weeks. The completion rate for visit number 3 was 73% (8/11). All fetuses remained
breech at this visit.
After completing the intervention visits, a significant reduction in stress levels
pertaining to pregnancy and breech positioning was found. Specifically, reduced stress
related to having a breech fetus (p = 0.02), having a C-section for a breech fetus (p = 0.01), the process of labor and delivery (p = 0.04), and recovery after delivery (p = 0.01) occurred. There were no significant differences in other stress factors such
as home life, work life, family, finances, or general health ([Table 2]). Half of the participants chose to undergo an ECV (n = 6; 54.5%) at the completion of the pilot study. The average gestational age at
ECV was 38.3 weeks. The ECV procedure had a 50% success rate (n = 3), and all three fetuses remained vertex at the time of induction of labor. Two
(18%) of these women delivered vaginally and the other participant underwent a C-section
for failure to progress. The remainder of the participants underwent a C-section at
delivery (82%). The average gestational age at delivery was 39.4 weeks for the cohort
with an average neonatal birth weight of 3644.5 g. The 5-minute Apgar score was 9
for all participants, and there were no neonatal intensive care unit admission or
neonatal deaths.
Table 2
Pre-post intervention stress survey responses
|
Stressor
|
Preintervention
Median (SIQ)
|
Postintervention
Median (SIQ)
|
p-value
|
|
Having a breech fetus
|
3 (2)
|
1.5 (2)
|
0.02
|
|
Having a C-section if my fetus is breech
|
3 (2)
|
2 (1)
|
0.01
|
|
My life at home
|
1 (1)
|
0 (0)
|
0.10
|
|
My general health during this pregnancy
|
1 (1)
|
0.5 (1)
|
0.73
|
|
My life at work
|
1 (2)
|
0.5 (2)
|
0.71
|
|
My family
|
0 (1)
|
0 (0)
|
0.32
|
|
The process of labor and delivery
|
1 (2)
|
1 (0)
|
0.04
|
|
My current financial situation
|
1 (1)
|
0 (1)
|
0.10
|
|
My recovery after delivery
|
3 (1)
|
1 (1)
|
0.01
|
0= no stress, 1 = slight stress, 2 = somewhat stress, 3= mod stress, 4= extreme stress.
Wilcoxon Matched-Pairs Signed-Ranks Test used for analysis.
[Table 3] provides the feedback survey responses. Although the fetuses remained breech at
the end of the intervention, all women felt the intervention was beneficial. The majority
felt that the overall study program duration was sufficient (73%), as was each study
visit. Over 90% of participants reported that the homework was sufficient with one
participant feeling like it was too much work to do. We received overwhelming positive
open feedback regarding the program. Several women wished they had started the intervention
earlier.
Table 3
Feedback survey
|
Questions
|
Responses
N (%)
|
|
1. How beneficial do you think this program was for you?
|
|
|
□ Waste of time/completely useless
□ Somewhat beneficial
□ Very beneficial
□ Excellent- best new thing!
|
0
0
3 (27)
8 (73)
|
|
2. What did you think about our study program length? (i.e., total of 3 study visits)
|
|
|
□ Not enough time
□ Perfect length of time
□ Too many visits
□ Other (please specify):
i. Did not get to finish program (due to delivery)
ii. Wanted 4 visits
|
1 (9)
8 (73)
0
2 (18)
1
1
|
|
3. What did you think about the body balancing tools homework?
|
|
|
□ Not enough for me to do at home
□ Just enough for me to do at home
□ Too much work to do at home
□ Other (please specify):
|
0
10 (91)
1 (9)
0
|
|
4. What did you think about the duration of your first study visit?
|
|
|
□ Not enough time
□ Perfect length of time
□ Too long of a visit
□ Other (please specify):
|
0
11 (100)
0
0
|
|
5. What did you think about the duration of your 2nd study visit?
|
|
|
□ Not enough time
□ Perfect length of time
□ Too long of a visit
□ Other (please specify):
i. Didn't get to finish the program *
□ Not applicable
i. I didn't need the appointment because …
ii. I missed the appointment because …
|
0
10 (91)
1 (9)
1
0
|
|
6. What did you think about the duration of your 3rd study visit?
|
|
|
□ Not enough time
□ Perfect length of time
□ Too long of a visit
□ Other (please specify):__________________________________________________
□ Not applicable
|
0
7 (64)
0
4 (36)
|
|
i. I didn't need the appointment because:
1. I delivered
2. I scheduled an ECV instead of the 3rd visit
ii. I missed the appointment because…
|
2 (50)
2 (50)
|
|
7. Open ended feedback responses:
|
|
|
Think this is a great idea, no recommendations for improvement
|
|
|
Starting off earlier
|
|
|
Liked the flexible appts
|
|
|
Loved the program
|
|
|
Great program, felt supported, gave exercise and lifestyle skills, offer to any mom
with breech baby
|
|
|
Great program, love holistic parts of it
|
|
|
Maybe have a min & max time per day
|
|
|
Wished she would have known baby was breech sooner so could have tried intervention
sooner
|
|
|
Offer earlier
|
|
|
100% think this should be integrated w/services
|
|
* This participant was delivered after completing her 2nd visit and did not complete the entire program.
Discussion
In this feasibility pilot study, we assessed the implementation of a comprehensive
complementary and alternative therapies intervention for managing breech fetuses between
34 and 37 weeks of gestation. Although none of the fetuses turned to a vertex position
by the end of the intervention, participants reported a significant reduction in stress
levels associated with concerns about their breech fetus, the likelihood of a C-section,
and the overall labor and recovery process. These findings suggest that CCAT may have
a role in reducing maternal anxiety, even if it does not directly influence fetal
positioning. The positive responses to the program, 100% enrollment rate for eligible
participants, and high completion rate of visits demonstrated acceptability and feasibly
of implementing this approach.
The findings of our study provide an interesting contrast to the existing literature,
which suggests that complementary therapies, such as acupuncture, moxibustion, and
chiropractic techniques, may facilitate fetal turning in some instances, although
the evidence remains mixed and dependent on specific conditions (e.g., gestational
age, fetal size, and maternal anatomy) (Cochrane Review, 2012). Notably, the success
rates of chiropractic methods, like the Webster technique, have primarily been based
on case reports and expert opinions, with success rates up to 90% reported by practitioners.[9] However, our study did not observe such high rates of spontaneous vertex conversion,
indicating that further RCTs with larger sample sizes are needed to validate these
anecdotal success rates.
One of the key findings of this study was the significant reduction in stress levels
among participants postintervention. This outcome is noteworthy, as elevated maternal
stress is associated with adverse pregnancy outcomes, including preterm labor and
increased C-section rates. By introducing relaxation-focused modalities such as yoga,
meditation, and postural techniques (e.g., Spinning Babies), the intervention may
have indirectly influenced participants' mental health and preparedness for delivery.
This is in alignment with existing literature indicating that mind–body techniques,
including hypnosis and yoga, may enhance maternal well-being during pregnancy.[10]
[15]
An ECV, the application of external pressure to the maternal abdomen to rotate a fetus
in an either forward or backward roll into a vertex position, is currently the standard
of care, but widely underused as women commonly decline to proceed with an ECV after
adequate counseling.[1] Although there are no absolute contraindications to an ECV, there are factors that
decrease the likelihood of success, including low amniotic fluid volume, fetal growth
restriction, less than 37 weeks' gestation, obesity, anterior placenta, advanced cervical
dilatation or evidence of labor, low fetal station, and nulliparity.[3] The success rate of an ECV varies widely between the range of 16 to 100% with an
average of 58%. Our study demonstrated a 50% success rate of ECV, of which 66% delivered
vaginally. This is consistent with data obtained from our institution's labor and
delivery unit from July to December 2021 showed a 50% success rate for ECVs.
Strengths and Limitations
Strengths and Limitations
The strength of our feasibility study includes implementing a multiprong approach
to everting a breech fetus. This holistic approach allows for an individualized care
plan tailored to each participant's specific needs, preferences, and physical conditions.
This also allows for addressing multiple factors, which may be influencing fetal position,
as well as improved acceptance and engagement by the participants. The therapies are
noninvasive with minimal to no risk to the pregnancy and are easy to learn. Learning
self-driven therapies, such as mindfulness, meditation, and lifestyle modifications,
can be highly beneficial as it empowers mothers with the skills they can use whenever
needed, both during the pregnancy and postpartum period and in parenthood. In addition,
the intervention was delivered by a single provider well-versed in all the implemented
therapies. This streamlined approach enhanced the patient experience by eliminating
the need for multiple practitioners, ensuring continuity of care and a comprehensive
understanding of the patient's history, body, and treatment plan.
This feasibility study also has several limitations. The sample size was small (n = 11), and the study duration was truncated to 4.5 months due to institutional constraints,
resulting in fewer referrals than anticipated. As the study relied on external referrals
to our clinic, we addressed this at the onset of the study by meeting with each referring
group to discuss the study details and flyers were provided for display in their clinics;
however, we were unable to place a dedicated recruiter in each clinic, making us dependent
on individual providers' interest in referring patients. This limited our ability
to reach the anticipated target enrollment of 48 to 50 participants, reducing the
statistical power needed to detect a significant effect on fetal position change.
The average gestational age at the first intervention visit was 36.8 weeks. Five participants
self-reported that their fetus was identified as breech at their second-trimester
ultrasound. Given the positive feedback from participants who wished they had started
the intervention earlier, future studies could explore the optimal timing and duration
of CCAT, including whether initiating the intervention before 34 weeks leads to different
outcomes. Furthermore, participants were predominantly of White/European descent,
married, and well-educated, limiting the generalizability of our findings to more
diverse populations. Future studies should aim to include a larger, more diverse sample
and employ an RCT design to provide more robust evidence for the efficacy of CCAT.
Implications for Future Research and Practice
Implications for Future Research and Practice
Despite our limitations, our study provides valuable preliminary data suggesting that
a comprehensive CCAT approach is feasible and acceptable for patients with a breech
fetus. The significant reduction in maternal stress levels points to the potential
mental health benefits of incorporating complementary therapies into standard prenatal
care, even if the physical outcomes (fetal position change) are not directly affected.
The varying outcomes across studies, including our own, point to several areas for
future investigation. First, it is important to identify which specific factors contribute
to the success or failure of CT in facilitating fetal version. Future studies could
explore the timing, frequency, and combination of therapies to optimize effectiveness.
In addition, exploration of the integration of CCAT with conventional interventions
like ECV can be pursued to assess whether these therapies can enhance the success
rates of such procedures or improve overall maternal and neonatal outcomes.
Conclusion
In conclusion, while the CCAT did not result in a change of fetal position in our
small cohort, it did significantly reduce maternal stress related to breech presentation
and delivery. This suggests that CCAT may serve as a beneficial adjunctive therapy
in managing the emotional aspects of a breech pregnancy, highlighting the need for
larger, controlled studies to further explore its potential benefits and efficacy
in facilitating fetal version.
