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Ask an expert - body - women's health - pregnancy

16 questions

Q:  I am 37 weeks pregnant and was told this week my baby is in a breech position. I am rhesus negative. I've heard that it's not a good idea with my blood type. Surely this is a natural process as to whether the baby decides to move or not. It's not like the cpv procedure that forces the baby to move.  I'm booked into see an acupuncturist and she said she had not heard about this.

A:  As we are sure that you know from your own research, the use of acupuncture and moxibustion, mainly the latter, for breech presentation is well documented. The technique has been used in Chinese medicine for thousands of years, and involves the use of moxa, a smouldering herb, on a specific point on the foot. If the treatment is performed around the 33rd or 34th week of the pregnancy there is a significant amount of evidence which seems to show that the treatment works. Indeed, if you google acupuncture/moxibustion and breech presentation, you will find at least a dozen reasonably well constructed trials which appear to confirm this.
 
Of course, one of the factors which you have to take into account is that many babies spontaneously fall into the correct position after the 35th week anyway, so one has to take this into account in assessing the efficacy of the treatment. However, the technique is now being used by other healthcare professionals, and while we do not endorse the cherry-picking of our work, this is something of an empirical treatment, i.e. it works because it works, and this expert has never heard a conclusive argument for why this specific point should have this effect which would mean that its use was only legitimate in the hands of a professional acupuncturist.
 
However, when we look at your question small but significant alarm bells ring. 37 weeks is at the very end of the range of possibilities for this treatment working. At this point the baby is usually too large to encourage this movement. That said, many women, with the approval and encouragement of their midwives and obstetricians, try the treatment in order to head off a C-section. In your case, however, the Rhesus negative factor becomes slightly more crucial. We always advise members to speak to the medical team in charge of the pregnancy if someone is Rhesus negative. This is one of a number of conditions which we believe warrant additional care. In this case, if the treatment does encourage vigorous movement and a minor bleed, there could be serious consequences for the baby. A practitioner needs to know whether the woman has been given anti-D treatment, less likely on a first pregnancy but still possible, and also whether the risk assessment made by the obstetric team favours the use of the technique. If the midwife or consultant advises against it, that's the end of the discussion.
 
We are a little surprised that this is news to the practitioner. If she is a BAcC member, not only is the advice printed in or Guide to Safe Practice and also on our members' website, but it also forms a part of the training which all entrants have. If she is not a BAcC member, we are sure that most of the reputable professional associations take the same view. The increase in risk is sufficient to warrant conversation with the obstetric team.
 
We have had some lively and vigorous debates inside the profession about some aspects of treating late stage pregnancy, and the question of whether we are intervening to make something happen that otherwise would not or whether we are simply encouraging a natural process is a vexed one. Sometimes it is important to be clear what one is actually trying to achieve, and many practitioners regard themselves as simply trying to encourage a natural process, which is generally how we perceive what we are doing. This line can get a little blurry when people start to talk about induction by acupuncture because the very use of an imported conventional term implies a level of direct causation, not simply a speeding up of a 'stuck' rhythm. There are also a number of points whose use is expressly forbidden during pregnancy because they can cause serious problems, so not all treatment can be perceived as 'helping nature along'.
 
We would put this treatment in that same category, as something which is done with a specific and predictable effect in mind, this time for the benefit of the patient. If doing 'x' causes 'y', then it is crucial to ask oneself what might go wrong if the desired effect takes place. We would be reassured to know that either you or the acupuncturist has contacted your midwife or obstetrician to get advice and clearance for the use of this treatment, and if they say 'go ahead' we wish you every success and in any event, a trouble-free delivery!  
 

Q:  I am  39 weeks pregnant and was wondering if you do acupressure massages to induce labour? I'm desperate and my doctor has given the go ahead.

A:  This topic, at least for acupuncture rather than acupressure, was the cause for a very heated debate inside the profession a few years ago. We had received a number of enquiries from women who wanted to choose the time of their delivery, and one in particular who wanted to speed up the labour process so that she could give birth before, rather than during, her holiday. On the one side were practitioners who argued that a woman had a right to control her own health, and that this extended to choosing when she wanted to go into labour. On the other side were those who argued that childbirth is a natural process and it is not appropriate to interfere with its timing. Indeed, many argued that you couldn't force a natural process to speed up anyway, only make sure that there were no sticking points in the transitions which held things up.

In the event, as a regulator our decision was much more prosaic and driven by medical concerns. In conventional medicine no consultant, doctor or midwife would agree to any attempts to a medical induction of labour until the baby was at term and already overdue, usually at least 41 weeks, and our members were entitled, with the express permission of the person in charge of the delivery, to attempt to help the labour to start if and only if a medical induction was pending and acupuncture was tried to see if the use of drugs could be avoided.

At least some of the argument which kicked off was about trust. If someone says 'my doctor has said it is OK', then in 99 times out of a hundred, this is likely to be the case. The retort, that 'this is what someone would say, wouldn't they?', was correct in at least one case we were made aware of where the mother chose not to involve her care team but told her practitioner that she had done. We had to tell members that for their own protection they had no choice but to ensure that they spoke directly for the midwife or consultant. Our view was that if anything went wrong it was extremely likely that the mother's permission would exonerate them from liability.

We think that you could usefully talk to one of our members who spends a great deal of time working with late stage pregnancy for personal advice. We do not keep a database of members who have expert skills in this area (not until we have finally agreed standards for what counts as being an expert) but if you google 'acupuncture' and 'childbirth' together with where you live we are certain that you will find a BAcC member local to you from whom you can get face to face advice on what to do for the best. The fact that your doctor has given the go-ahead suggests that there may be reasons to expedite labour, but formally at 39 weeks we have to say that this decision rests with him or her and that our member would not proceed unless and until this consent had been gained.

Q:  My daughter is expecting a 2nd baby in Jan. Her first delivery was by 'C' section as she was so slow to dilate the baby became distressed (3cm after several hours) She is convinced that a 2nd delivery would be similar and is considering an elective 'C' section. I wonder if acupuncture before/during labour may assist dilation & help labour progress at a more reasonable pace. If this is the case, how many sessions & how close to due date. Would an acupuncturist attend the birth & would this be tolerated in an NHS hospital.

A:  A growing number of our members now offer treatment around the late stages of pregnancy and during childbirth itself, and there are several sub-organisations and interest groups within the BAcC which have sprung up which network to share best practice. We cannot name individual groups because of our commitment to our members as a whole to maintain a level playing field, but a google seach of 'acupuncture', 'childbirth' and the place where you live should quickly generate a few useful leads. The advice you get from these groups will be much more specific than we can give here.

Broadly speaking, acupuncture treatment helps to ensure that the stages of delivery follow their natural pace more easily, and especially help during the transitions which occur. We have to be a little cautious in our advice because the research evidence for this is not available, not because there is no evidence but because the format of the trials which count as evidence which we could cite are not well suited to areas like childbirth. There are many confounding factors in play which make it difficult to establish that 'x causes y'. Word of mouth has meant, however, that a growing number of women now actively seek out practitioners who are ready, willing and able to assist at the birth. Most NHS hospitals and childbirth units have no objection to the presence of a practitioner, and most practitioners who undertake this kind of work know how to work around, and keep out of the way of when necessary, the staff dealing with the delivery.

The number of sessions is impossible to determine. Generally speaking, the practitioner does the least possible to achieve the most effect, and intensive treatment would be unusual. Since the treatment is aimed at ensuring the transitions between stages are as smooth as possible, there would be times during the labour when treatment might have to be more specific, but in the absence of any direct cause and effect relationship between treatment and effect (i.e. no point which directly causes dilation), the practitioner's judgement and professional skill would determine how much treatment and when.

It is very, very important that your daughter feels entirely comfortable if she chooses to have acupuncture treatment, however. If she is worried about whether she is doing the right thing when the labour kicks off, this might be counter-productive and end up in the same result as the last time. The practitioner would also have to work very closely with the midwives as well. There would have to be a point where treatment ceased and a C-section take place if the baby becomes agitated, and a trained practitioner will know when to draw a line.

On the positive side, though, many hundreds of women every year now report very good outcomes from having treatment near or at the birth, and there is every reason to hope that your daughter will be able to benefit too.

 

Q: I  have been having accupunture for birth preparation.  I would like to know how accupunture during labour could be helpful for labour other then as pain relief.  I am also wondering if it is difficult to have the needles inserted during labour and contractions, and if it reduces mobility since the needles are in?

A:  The received wisdom of using acupuncture during labour is that as well as providing some pain relief it helps to facilitate the transitions through the various stages. This is, of course, only based on the experience of members who regularly attend and assist at births, and women who have had both acupuncture assisted and unassisted births. This could hardly count as research for the purpose of making authoritative claims, but as out fact sheet shows
 
http://www.acupuncture.org.uk/a-to-z-of-conditions/a-to-z-of-conditions/childbirth.html
 
there is a small amount of evidence supporting claims for pain reduction, and studies such as this one
 
http://www.ncbi.nlm.nih.gov/pubmed/12118641
 
repeated on a larger scale may make the treatment more acceptable and accordingly more available.
 
One of the groups which has organised itself to provide this service to women puts the overall perspective far more eloquently than we can:
 

Traditional acupuncturists believe that labour should be a natural process in which the progression is directed by the flow of energy in the mother’s body. Ideally labour should move smoothly from one stage to another. This does not mean that the labour is painless, but that the contractions are efficient, so that the mother does not become exhausted and can remain calm and in control. We believe that the woman in labour should enter a state in which she can focus totally on what is happening in her body, supported by birth attendants and free from distractions.

Acupuncture in labour also works towards this ideal. In the early stages of labour, the insertion of needles and massage of acupuncture points can be used to smooth the flow of energy to support the efficiency of contractions. Acupuncture can also be used during the transition between the first and second stages of labour. Once the baby has been born, acupuncture can be used to assist the physiological third stage.

Treatment in labour often requires that a few needles are inserted into points, and then left in place. Common sites include the ear, the lower back and the hands and feet. Deep massage of energy pathways or acupuncture points may also be used to help smooth the flow of energy and support the mother during contractions. An additional role of the acupuncturist is to encourage the mother to stay in a focused and calm state throughout the labour. Acupuncture treatment in labour can be used in conjunction with conventional methods of pain relief and will often complement their effectiveness.

We are not aware of anyone reporting difficulties with movement after the needles have been inserted. The practitioner would ensure that they were never placed anywhere where sudden movement might cause physical injury, and we are equally sure that it is unlikely that a fear of needles being displaced would prevent someone from moving pretty much as the contractions made them move.

There are now several groups of BAcC members working around the country who offer specialist support in this area, and while we are unable to make individual recommendations, it is a relatively straightforward matter to google acupuncture, childbirth and your geographical area to locate practitioners who attend births. Even if you choose not to go ahead with an acupuncture assisted birth, we are certain that anyone involved in these groups would be more than happy to offer you advice.


 

Q:   Iam  34 weeks pregnant but because my waters broke when I was 30 weeks,  I will need to be induced at 36 weeks. I would like to know whether inducing labour with acupuncture could work that early. If so, can you please advise me on when is good time to start and whether I can go to any acupuncturist or shall I look for a  specialist for inducing labour?

A:  The issue of early induction has been the subject of some very heated debate within the profession in the last few years, brought about by a request made to a member to try to induce a birth pre-term because it would be more convenient for someone's holiday arrangements to be carrying a baby than a large bump. The issue boiled down to whether someone could exercise their own right to have a baby whenever they chose, or whether the medical team retained control of the pregnancy to birth and afterwards.
 
Our decision was very clear. The only basis on which our members are allowed to use acupuncture to help to facilitate or speed up the delivery process is when it is medically necessary, when the medical team are considering either a drug-driven induction or a C-section and when the medical team have given someone express permission to go ahead. In this last condition it is important that the practitioner is able to speak to the midwife or consultant directly. I'm afraid this caution is a direct result of one patient telling one of our members that the doctor had OK'd an intervention when they hadn't.
 
We are always a little cautious too about the evidence for acupuncture and induction of labour. It is a matter of terminology. Acupuncture treatment can facilitate or speed up a natural process, but this is not quite the same as a direct causal relationship between a specific set of points and a defined outcome. The research studies which have been done, and most of which are inconclusive or report no effect, tend to be based on formula treatments which may not be appropriate for all of the subjects in the trial.
 
In an earlier response to a question about the safety of acupuncture as a potential inducer of labour we wrote:
 
There was considerable debate inside the BAcC some years ago about whether this could or should be done independently of the medical team looking after the mother, but our view was that it is far better for all efforts to be co-ordinated at this point than to have someone operating outside the system. In our experience most conventional teams are happy for the mother to have acupuncture as a means of avoiding medical induction or C-sections, and the crucial things is that if the labour does kick in then all of the next steps are already in place for the birth to take place.

Acupuncture for the induction of labour is a very gentle process and if it works is probably a little less of a jolt to the system than drugs which tend to kick in very quickly, so we would always recommend using it first if the medical team are OK with this. Many of our members now focus their work very much on treating pregnancy and late-stage pregnancy, and checking the websites of a few BAcC members local to you will quickly reveal who has this focus and often what postgraduate training they have had in this field.
 
This advice still holds good. Although we do not yet recognise specialisms, we have spent a great deal of time trying to define what counts as expert practice for those members who spend most of their time working with pregnant woment and who have undertaken postgraduate training in the field. When we ahev finally agreed standards we may be able to make definite recommendations, but in the interim a google search of 'BAcC member' with 'pregnancy' and the area where you live will almost certainly generate a number of options.
 
We wish you a safe and happy delivery, and a healthy baby!  
 

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