The Efficacy and Safety of Acupoint Stimulation for Fetal Malpresentation/Malposition During Pregnancy,Labor,or Birth: A Scoping Review

Introduction

Fetal malpresentations/malpositions during pregnancy and labor are deviations from normal that can lead to medical intervention. ¹ There is pertinent interest in complementary and alternative therapies to assist pregnant women ^2,3 ; however, evidence around the value of acupoint stimulation (AS) for correcting fetal malpresentations/malpositions has not previously been summarized together. The evidence on the efficacy and safety of AS for fetal malpresentations/malpositions during pregnancy, labor, and/or birth, and AS intervention regimes for future research on midwifery acupuncture for posterior position are the subject of this letter.

Methods

The framework of Arksey and O'Malley, ⁴ whereby the search for evidence sources was structured to reflect population: women with a singleton pregnancy with fetal malpresentation or malposition during pregnancy, labor, or birth; intervention: AS—acupuncture (auricular excluded as out of scope for midwives), moxibustion, or acupressure; comparison: usual care, postural technique, or no treatment in or without a control group; outcome: efficacy and safety were followed. The Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews Checklist ⁵ was also adhered to. Literature was sought from November 2019 to September 2020 from the following databases: CINAHL, CBM, CNKI, EMBase, PsycINFO, MEDLINE, VIP, WANFANG, and Web of Science, and from clinical trial registry websites, gray literature, and reference list hand screening. CINAHL full search included (1) malpresentation, (2) “fetal malpresentation,” (3) breech, (4) “breech presentation,” (5) “shoulder presentation,” (6) “brow presentation,” (7) “face presentation,” (8) “compound presentation,” (9) “transverse lie,” (10) “oblique lie,” (11) malposition, (12) “fetal malposition,” (13) “occip* posterior,” (14) “occip* transverse,” (15) acupuncture, (16) electroacupuncture, (17) electro-acupuncture, (18) “laser acupuncture,” (19) moxibustion, (20) moxa, (21) acupressure, (22) 1OR2OR3OR4OR5OR6OR7OR8OR9OR10OR11OR12OR13OR14, (23) 15OR16OR17OR18OR19OR20OR21, and (24) 22AND23. No data parameters were set to gain a broad view.

Results

Titles and abstracts were screened for eligibility and imported into endnote; Chinese articles were entered into an Excel charting form. Total records sourced 1099, 628 duplications, 471 records screened, 351 records excluded, 120 full-text records assessed, 81 excluded for other language and not meeting population, intervention, comparison, outcomes (PICOs), 39 full-text articles included: 24 randomized controlled trials (RCTs) and 15 non-RCTs. Twenty-seven were written in Chinese and 12 in English.

Table 1 summarizes AS used in intervention groups, control groups, efficacy rates, and adverse events (AEs). No trials were found in which AS was used during labor or birth. Only one trial studied malposition. There was a total efficacy rate of 74.35% after intervention with 3399 women receiving AS, and an efficacy rate of 46.48% with 1988 women randomized to a control group. Bladder 67 was the main acupoint used, and treatment generally lasted between 15 and 30 minutes, once or twice daily up to 14 days.

Discussion

AS trials varied greatly but did show positive findings for efficacy and safety in line with two systematic reviews looking at breech presentation, ^6,7 (another did not find it effective ² ). Efficacy rates for AS groups are reportedly between 60.09% (moxibustion alone) and 99.21% (moxibustion plus electroacupuncture); however, we identified the quality of trials to be a limitation of the reviewed studies, meaning results cannot be considered conclusive. Assertions made over the past decade that the role of moxibustion in correcting breech to a cephalic presentation “remains elusive” ⁸ and that further high-quality studies are needed to definitively determine its efficacy, ⁹ both still hold true according to our review.

AEs related to AS are reportedly minimal, which corresponds with two trials and a systematic review studying its safety. ^10,11,12 Most AEs in pregnancy have not been found to be definitively caused by AS and are seemingly comparable with those that occur in the course of usual care. ¹³ AS intervention regimes varied significantly across trials and did not align with recommendations from a Delphi study where treatment for breech should commence from 34 weeks' gestation with moxibustion self-administered for 30 minutes daily for a minimum of 10 days. ¹⁴

In summary, our scoping review confirms that the evidence base for AS use in fetal malpresentation and malposition is not dependable. There is a need for high-quality research in this area.