---
title: "Breech presentation"
url: "https://acuiq.com/wiki/evidence/breech-presentation"
updated: 2026-10-12
last_verified: 2026-10-12
license: CC-BY-4.0
license_url: "https://creativecommons.org/licenses/by/4.0/"
section: "evidence"
basis: "Modern research"
audience: "Anyone"
published: "2026-10-12"
reading_minutes: 9
sources: 12
---

# Breech presentation

_What the 2023 Cochrane review, later reviews, the main trials and RCOG, NICE and French guidance report on moxibustion and acupuncture at BL67 to turn a breech baby._

A baby is in breech presentation when it lies bottom or feet first in the womb rather than head down. Moxibustion, which burns the dried herb mugwort close to the skin, has been applied at [`BL67`](/points/BL67) (Zhiyin), a point on the little toe, to try to turn the baby head down. The [2023 Cochrane review](https://doi.org/10.1002/14651858.CD003928.pub4) by Meaghan Coyle, Caroline Smith and Brian Peat, the third version of a review first published in 2005, included 13 trials with 2,181 women. It found that moxibustion added to usual care probably reduces the chance that a baby is still not head down at birth, on moderate-certainty evidence, and probably makes little or no difference to the chance of a caesarean section. The Royal College of Obstetricians and Gynaecologists (RCOG) says women may wish to consider moxibustion at 33 to 35 weeks under a trained practitioner; French national guidance recommends against it.

## The Cochrane review

The review searched to November 2021 for randomised and quasi-randomised trials in women with a single baby in breech presentation, comparing moxibustion, alone or with acupuncture or postural techniques, with usual care, a sham, acupuncture or postural therapy. Its main outcomes were the baby’s presentation at birth and the need for external cephalic version (ECV), in which an obstetrician turns the baby by hand through the mother’s abdomen. In seven trials the women, or a family member or friend, applied the moxibustion themselves; most trials applied it for 20 minutes a session, over one to two weeks. Results are risk ratios for the baby not being head down at birth, so a ratio below 1 favours moxibustion. The review rates each finding with GRADE, the standard scale of how far evidence can be trusted, from high to very low.

| Comparison | Trials and women | What the review found | Certainty |
| --- | --- | --- | --- |
| Moxibustion plus usual care against usual care alone | 7 trials, 1,152 women (presentation at birth); 4 trials, 692 women (ECV); 6 trials, 1,030 women (caesarean) | Probably fewer babies not head down at birth (risk ratio 0.87). Very uncertain effect on the need for ECV. Probably little or no difference in caesarean sections (risk ratio 0.94). One trial of 260 women found less use of oxytocin, the drug used to start or strengthen labour. | Moderate (presentation, caesarean, oxytocin); low (ECV) |
| Moxibustion plus usual care against sham moxibustion plus usual care | 1 trial, 272 women | Probably fewer babies not head down at birth (risk ratio 0.74). Probably little or no difference in caesarean sections. | Moderate |
| Moxibustion against acupuncture | 1 trial, 25 women | Fewer babies not head down at birth with moxibustion (risk ratio 0.25); the review called this very little evidence. | Not stated |
| Moxibustion plus acupuncture plus usual care against a control | 1 trial, 226 women (presentation at birth); 2 trials, 240 women (caesarean) | Very little evidence; fewer babies not head down at birth (risk ratio 0.73) and fewer caesarean sections (risk ratio 0.80). | Not assessed |
| Moxibustion plus postural therapy against postural therapy alone | 1 trial, 206 women | Fewer babies not head down at birth (risk ratio 0.50); very little evidence. | Not stated |

The authors noted that several trials had been published since the 2012 version and that the conclusions had changed. They found a benefit in subgroups of trials in Asian and non-Asian women alike. Adverse events were inadequately reported in most trials.

## Other reviews

A [2021 meta-analysis](https://doi.org/10.3390/healthcare9060619) by Liao and colleagues in Taiwan pooled 16 randomised trials with 2,555 participants, including trials of acupuncture without moxibustion. It found more babies head down at birth with moxibustion than with controls (risk ratio 1.39), more so in trials of Asian women (1.42) than of non-Asian women (1.20). After a sensitivity analysis, its results for acupuncture alone were inconsistent.

## Trials

A [1998 trial in JAMA](https://doi.org/10.1001/jama.280.18.1580) by Cardini and Weixin, which its authors described as the first randomised trial of the method, enrolled 260 women expecting their first baby at two hospitals in Jiangxi province, China, in the 33rd week of pregnancy. Half applied moxibustion at BL67 for one to two weeks, and half had routine care. At birth 75.4% of babies in the moxibustion group were head down, against 62.3% in the control group, even though 24 women in the control group and one in the moxibustion group had ECV. Mothers in the moxibustion group counted more fetal movements during the treatment week.

A [2005 Italian trial](https://doi.org/10.1111/j.1471-0528.2005.00634.x) by Cardini and colleagues at six obstetric departments set out to repeat the result in women outside China. It stopped after 123 of the planned 260 women had been recruited, because many women interrupted the treatment. At that point 34% of babies in the moxibustion group and 36% in the observation group were head down in the 35th week. The authors wrote that the results supported neither the effectiveness nor the ineffectiveness of moxibustion, and pointed to the difficulty of testing a traditional treatment in a different culture.

The [2013 Spanish trial](https://doi.org/10.1136/acupmed-2012-010261) by Vas and colleagues, run in primary care health centres in Andalusia, randomised 406 women at 33 to 35 weeks to moxibustion at BL67, moxibustion at [`SP01`](/points/SP01) (Yinbai) as a sham, or usual care alone. At term 58.1% of babies in the BL67 group were head down, against 43.4% in the sham group and 44.8% with usual care. The trial reported no severe adverse effects. The Cochrane authors later observed that using another acupuncture point as a sham is controversial, and that the assumption that SP01 has no effect on a breech baby has not been tested.

Two French trials of methods closer to acupuncture found no clear effect. A [2014 trial](https://doi.org/10.1097/AOG.0000000000000303) by Coulon and colleagues at a French university hospital gave 328 women six sessions of acupuncture at BL67 with the needle heated by moxa, or an inactivated laser as a placebo. At 37 weeks 72.0% of babies in the treatment group and 63.4% in the placebo group were still breech, a difference that was not statistically significant. A [2016 trial](https://doi.org/10.1016/j.ejogrb.2016.07.492) by Sananès and colleagues in Strasbourg randomised 259 women at 32 to 34 weeks to fire needling at BL67 or a sham. At 35 to 36 weeks 37.7% of babies were head down with acupuncture and 28.7% with the sham, and after adjustment for previous births the authors concluded that the acupuncture did not promote turning.

## What guidance says

The RCOG’s [Green-top Guideline No. 20a](https://doi.org/10.1111/1471-0528.14466), External Cephalic Version and Reducing the Incidence of Term Breech Presentation, was published in March 2017 as the second edition of a 2006 guideline. It states that women may wish to consider moxibustion for breech presentation at 33 to 35 weeks, under the guidance of a trained practitioner, graded C, and calls the quality of the data poor. It says the effect of moxibustion should be weighed against the share of babies that are breech at 32 weeks, which it gives as 43%. It summarises the 2012 Cochrane review as finding no fewer breech births with moxibustion than with no treatment. It advises that there is no evidence that postural management alone turns the baby. The [RCOG’s page for the guideline](https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/external-cephalic-version-and-reducing-the-incidence-of-term-breech-presentation-green-top-guideline-no-20a/) still lists the 2017 edition and says the guidelines committee regularly assesses whether it needs updating. It predates the 2023 Cochrane review.

The French college of obstetricians, CNGOF, reached the opposite conclusion in its [2020 guidelines](https://doi.org/10.1016/j.gofs.2019.10.024) on turning breech babies, written by Ducarme, which state that for a breech presentation at term acupuncture, moxibustion and postural methods do not reduce breech presentation at birth and are not recommended, graded B. NICE’s [antenatal care guideline (NG201)](https://www.nice.org.uk/guidance/ng201/chapter/Recommendations), published in August 2021 and amended since, tells staff to discuss ECV, vaginal breech birth and planned caesarean birth with a woman whose baby is breech after 36 weeks, and to offer ECV to women who want a head-first vaginal birth. It does not mention moxibustion or acupuncture. [Clinical guidelines](/wiki/evidence/clinical-guidelines) compares other bodies’ positions on acupuncture.

## Safety

Only one trial in the Cochrane review, the 2005 Italian trial, reported adverse events by group: 27 events in the moxibustion group and none in the control group, including nausea, the unpleasant smell of the moxa, with or without throat problems, and abdominal pain from contractions, some of which led women to withdraw. The review rated this very low in certainty. Its authors list burns, increased fetal movements, uterine contractions, nausea and headaches as the adverse events that seem most common, and suggest that women be told about them. They note a suggestion that moxa smoke irritates the airways, for which they found no evidence, and that the effect of smoke on the unborn baby is unknown; they advise good ventilation, and say smokeless moxa sticks may reduce the risk. [Moxibustion](/wiki/techniques/moxibustion) describes the technique, and [burns from moxibustion and cupping](/wiki/safety/burns-from-moxibustion-and-cupping) reports what case series record about skin burns. A [2015 review](https://pmc.ncbi.nlm.nih.gov/articles/PMC4680134/) by David Carr of the safety of obstetric acupuncture lists BL67 among the points most often cited as forbidden in pregnancy, at least before 37 weeks; [pregnancy and the forbidden points](/wiki/safety/pregnancy-and-the-forbidden-points) explains why the points avoided while a pregnancy is meant to continue are the ones chosen near term.

## What the reviews could not settle

The Cochrane review could not say whether moxibustion reduces the need for ECV, since the trials disagreed and the estimate ranged from a large benefit to moderate harm. It found no reduction in caesarean sections, and no trial reported why each caesarean was done. Its sham comparison rests on a single trial whose sham point is itself untested, and its comparisons with acupuncture and postural therapy each rest on one small trial. The trials did not agree on when to start, how often to treat or who should apply the moxa, and adverse events were reported too inconsistently to pool. A protocol for self-administration agreed by expert consensus, starting at 34 to 35 weeks with smokeless sticks, had not been tested in a trial when the review was written. The Cochrane review did not include acupuncture without moxibustion, and the 2021 review found its effects inconsistent.

AcuiQ’s [breech presentation page](/symptoms/breech-presentation) lists the protocols individual studies prescribed, each with its citation.

### Sources

1. Coyle ME, Smith C, Peat B, Cephalic version by moxibustion for breech presentation, Cochrane Database of Systematic Reviews 2023 — https://doi.org/10.1002/14651858.CD003928.pub4
2. Liao JA, Shao SC, Chang CT, et al., Correction of breech presentation with moxibustion and acupuncture: a systematic review and meta-analysis, Healthcare (Basel) 2021 — https://doi.org/10.3390/healthcare9060619
3. Cardini F, Weixin H, Moxibustion for correction of breech presentation: a randomized controlled trial, JAMA 1998 — https://doi.org/10.1001/jama.280.18.1580
4. Cardini F, Lombardo P, Regalia AL, et al., A randomised controlled trial of moxibustion for breech presentation, BJOG 2005 — https://doi.org/10.1111/j.1471-0528.2005.00634.x
5. Vas J, Aranda-Regules JM, Modesto M, et al., Using moxibustion in primary healthcare to correct non-vertex presentation: a multicentre randomised controlled trial, Acupuncture in Medicine 2013 — https://doi.org/10.1136/acupmed-2012-010261
6. Coulon C, Poleszczuk M, Paty-Montaigne MH, et al., Version of breech fetuses by moxibustion with acupuncture: a randomized controlled trial, Obstetrics and Gynecology 2014 — https://doi.org/10.1097/AOG.0000000000000303
7. Sananes N, Roth GE, Aissi GA, et al., Acupuncture version of breech presentation: a randomized sham-controlled single-blinded trial, European Journal of Obstetrics, Gynecology and Reproductive Biology 2016 — https://doi.org/10.1016/j.ejogrb.2016.07.492
8. Carr DJ, The safety of obstetric acupuncture: forbidden points revisited, Acupuncture in Medicine 2015 — https://pmc.ncbi.nlm.nih.gov/articles/PMC4680134/
9. 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: Green-top Guideline No. 20a, BJOG 2017 — https://doi.org/10.1111/1471-0528.14466
10. Royal College of Obstetricians and Gynaecologists, External Cephalic Version and Reducing the Incidence of Term Breech Presentation (Green-top Guideline No. 20a), guideline page — https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/external-cephalic-version-and-reducing-the-incidence-of-term-breech-presentation-green-top-guideline-no-20a/
11. Ducarme G, Breech presentation: CNGOF guidelines for clinical practice, external cephalic version and other interventions to turn breech babies to cephalic presentation, Gynécologie Obstétrique Fertilité & Sénologie 2020 — https://doi.org/10.1016/j.gofs.2019.10.024
12. National Institute for Health and Care Excellence, Antenatal care (NG201), recommendations, published August 2021, last amended December 2025 — https://www.nice.org.uk/guidance/ng201/chapter/Recommendations