COMMENTARY

A Reader Responds to "Sterile Water Is Better Than Acupuncture in Relieving the Pain of Labor"

Shaheen E. Lakhan, MS, MEd, AFACB, MICR, PhD, MD(c.)

Disclosures

July 31, 2008

To the Editor:

It was indeed interesting to read your editorial regarding the use of sterile water as a better alternative to acupuncture to relieve labor pain.[1] It is surprising that alternative methods of treatment for an issue like labor pain -- a common problem and phenomenon worldwide -- have received the most attention only from countries like Sweden, Norway, Austria, and Croatia.

Sterile water has been touted as a "placebo" by many and it has been considered "unethical" to use a placebo in medical practice. From a layman's point, whether sterile water is termed as a placebo or not, or what makes sterile water a placebo, does not make any difference. All that would matter to patients probably is that it is providing some respite from the usual throes of painful labor. One might argue that there has not been much research done on this issue, apart from the Swedish and Norwegian studies, and so sterile water cannot be offered to patients. For that matter, epidurals and other analgesics are extensively used all over the world. But not many mothers going into labor know enough about the side effects of epidurals or other analgesics, or the amount of clinical research that has been done on the use of epidurals or other analgesics, or how many physicians discuss these factors in great detail with their patients. Most of the time, these medications are administered routinely with patient consent. The perception of the side effects or the benefits of receiving the medication/analgesics almost always depends on how the physician puts it forth to the patient and how the patient understands it.

It is important to note that there is a strong basis for theory of sterile water injection to relieve pain during labor. It is based on Melzack and Wall's gate control theory of pain.[2] This theory was reinforced in 1975 when the basis for TENS (transcutaneous electrical nerve stimulation) therapy was first introduced. The short stinging pain of the sterile water injections (skin signals) slows down and stops the labor pain (internal signals) from reaching the brain. The effectiveness of using sterile water has been supported by trials conducted by Lytzen, Cederberg, and Moller-Nielsen[3] in 1989 on 83 women who were experiencing low back pain during the first stage of labor. All but 6 women, experienced instant relief from the labor pain and experienced the relief up to 3 hours. A reduction in total pain score from 6.05 to 2.92 was seen after 1 hour with no further analgesia given.

Similar trials done on 128 women, but with a parallel arm receiving acupuncture[4] as stated in your editorial, all show promising hope that there is some light at the end of the tunnel for believers in this alternative method of treatment. However, more trials need to be conducted in order to make this a more concrete method that would be embraced by a larger fraternity of medics.

Acupuncture, on the other hand, has been used effectively for more than 2000 years to treat various other forms of ailments, like headaches, toothaches, sexually transmitted diseases, etc. It is a form of treatment which most people in the Asian countries, especially China, believe in as a "mainstream" method of treatment, rather than as an "alternative" method, just as Ayurveda is still believed to be a very effective mainstream method of treatment in many parts of India. Unfortunately, acupuncture has very few trials to its credit to prove its effectiveness in reducing labor pain -- or perhaps very little about it has been published.

However, there is some concrete evidence in a randomized, unblinded, controlled study done in a university hospital labor ward.[5] This study showed that fewer subjects in the group receiving acupuncture required the use of meperidine and other analgesics compared with the group that did not receive acupuncture at all. There have been more studies in Austria, Norway, and Sweden that support the use of acupuncture to reduce pain during labor and/or reduce the need for other analgesics during labor.

In order for acupuncture to be effective, it needs to be done in a precise manner, which needs substantial expertise and exposure to the science. For people who have never had acupuncture treatments done before (ie, for any other ailments), offering a treatment which would mean pricking some needles into their lower back and letting those needles stay there for some time while they are already in labor would probably seem like a very uncomfortable, nightmarish idea.

In order to gauge the effectiveness of acupuncture in reducing labor pain, it would probably be worthwhile to conduct a study on a group of expectant mothers at term who have had previous exposure to acupuncture for some other ailment (basically, that they are comfortable with the idea of a considerable number of needles sticking out from their body), as mental preparedness definitely would play a great role in such instances. Countries like China and Singapore, which practice acupuncture more widely for treating other ailments, should undertake clinical trials in this direction to help better establish this fact.

In conclusion, there is clearly a need to conduct more trials worldwide and on a greater number of subjects in order to establish the effectiveness of either of the forms of treatments, and to prove that the benefits of alternative treatment A or alternative treatment B outweigh the risks.

Shaheen E. Lakhan, MS, MEd, AFACB, MICR, PhD, MD(c.)
Executive Director
Global Neuroscience Initiative Foundation (GNIF)
Los Angeles, California
slakhan@gnif.org
http://slakhan.gnif.org

References

  1. Lundberg GD. Sterile water is better than acupuncture in relieving the pain of labor. Medscape J Med. 2008;10(6):151.

  2. DeLeo JA. Basic science of pain. J Bone Joint Surg Am. 2006;88(Suppl 2):58-62. Abstract

  3. Lytzen T, Cederberg L, Moller-Nielsen J. Relief of low back pain in labor by using intracutaneous nerve stimulation (INS) with sterile water papules. Acta Obstet Gynecol Scand. 1989;68:341-343. Abstract

  4. Martensson L, Stener-Victorin E, Wallin G. Acupuncture versus subcutaneous injections of sterile water as treatment for labour pain. Acta Obstet Gynecol Scand. 2008;87:171-177. Abstract

  5. Nesheim BI, Kinge R. Performance of acupuncture as labor analgesia in the clinical setting. Acta Obstet Gynecol Scand. 2006;85:441-443. Abstract

Editor's Note:
This letter was shown to the author who has chosen not to respond.


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