Update on Nonpharmacologic Approaches to Relieve Labor Pain and Prevent Suffering

Penny Simkin, PT; April Bolding, PT

Disclosures

J Midwifery Womens Health. 2004;49(6) 

In This Article

Acupuncture and Acupressure (Shiatsu)

Acupuncture, an important and ancient component of traditional Chinese medicine, is gradually being integrated with conventional medicine in the West. Acupuncture is believed to initiate, control, or accelerate physiologic functions, and thus, correct organ malfunctions, heal illnesses, or relieve discomforting symptoms through insertion of fine needles into the skin at a combination of specific points along meridians (channels of energy, called "Qi," pronounced "chee") in the body, followed by rotation, heating, or electrical stimulation (electro-acupuncture) of the needles.[48] There are 12 meridians and 365 acupuncture points along those meridians. The decision on where and how deep to place the needles is based on numerous general factors, including the nature of the ailment, the person's lifestyle, diet, work, emotional state, pulse, and the appearance of the person's tongue. For labor pain, placement of needles depends on degree and location of pain, stage of labor, level of maternal fatigue, tension, or anxiety, and a variety of other factors.[49]

Midwives in the United Kingdom and Scandinavia may obtain additional training in the use of acupuncture during childbearing, and many now offer it to their clients. In North America, acupuncture is rarely used during childbirth, but when it is, trained acupuncturists do it at the request of the laboring woman or the midwife, and it is used almost exclusively in out-of-hospital birth settings.

Acupressure, or Shiatsu, a simple alternative to acupuncture, is pressure with fingers or small beads on acupuncture points. It is used for numerous ailments and discomforts in pregnancy, as well as for labor pain. Because acupressure can be done with minimal instruction by the woman's partner, it may be desired by some laboring women. There are no published trials of its efficacy in relieving labor pain.

Effectiveness of Acupuncture in Reducing Pain and Suffering During Labor

Although numerous positive descriptive and retrospective reports on acupuncture had been published over the previous decades,[50,51] it was not until 2002[52,53] and 2003[49] that the first 3 RCTs of acupuncture for pain relief in labor were published. These included a total of 598 women. All compared pain assessments by either a visual analog scale during or after labor or by comparing the use of epidural analgesia or intravenous narcotics between those women randomly allocated to acupuncture and a control group (receiving either no acupuncture or "false acupuncture"). They also evaluated patient satisfaction with acupuncture. Women's reports of pain were significantly lower in the acupuncture groups in all 3 trials. Maternal satisfaction was high among all the women in both the acupuncture and control groups.

Skilnand et al. compared a "real" acupuncture group (n = 106) with a "false" or "minimal" acupuncture group (i.e., needles were inserted shallowly in non-acupuncture points) (n = 102).[52] Pain assessments on an 11-point visual analog scale before the acupuncture was started were the same in the 2 groups but significantly lower in the real acupuncture group 30, 60, and 120 minutes after acupuncture was given. Assessments at 2 hours postpartum of their total pain during labor were also lower in the real acupuncture group. Furthermore, in the real acupuncture group, there was significantly less need for epidural analgesia (10% vs 25.5%, P = .01) or Pethidine (Demerol) (14% vs 35%, P < .001).

Ramnero et al. studied pain and relaxation with and without acupuncture in 100 women (n = 46 in the acupuncture group and n = 44 in the no acupuncture group).[53] Although there was no difference in pain assessments between the groups on an 11-point rating scale, there was significant improvement in relaxation in the acupuncture group: mean score on a visual analog scale measuring tension of 4.2 in the study group and 5.1 in the control group (mean difference, −0.93, 95% CI −1.66 to −0.20). The acupuncture group also used less epidural analgesia (12% vs 22%; RR 0.52, 95% CI 0.30-0.92). Maternal satisfaction was high in both groups.

A third RCT by Nesheim et al. compared the use of meperidine (Demerol) in 3 groups: acupuncture (n = 106), a "no acupuncture" control group (n = 92), and a second control group (n = 92).[49] The first 2 groups were cared for by the same midwives, who were trained and experienced in the use of acupuncture. To control for bias that might result from unblinded caregivers for the 2 groups, another control group was added, consisting of women who had not been invited to take part in the trial. These women were matched with women in the no acupuncture group but were cared for by midwives other than those in the trial. Meperidine was used by 11% in the acupuncture group and 37% in the no acupuncture group (P < .0001) and 29% in the control group (P = .01 compared with the acupuncture group).

There are no known risks to women who use acupuncture, when practiced by trained practitioners using disposable needles. It requires extra training for midwives or doctors, or an acupuncturist must be a member of the maternity care team.

In conclusion, three RCTs of acupuncture found that it provides an effective alternative to pharmacologic pain relief. It may be useful for those women who want to avoid or delay pain medications or in settings where pain medications are not available. Satisfaction was high with acupuncture, but this was also true in the control groups. Because extra surveillance of the fetus and assistance from anesthesiologists are not needed, care of the laboring woman is simpler and less expensive with acupuncture than with an epidural. More large studies are warranted to establish cost-effectiveness, implementation in maternity care settings, and acceptance by childbearing women.

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