Acupuncture or acupressure for relieving pain during labour

We examined the evidence from randomised controlled trials on the use of acupuncture or acupressure in helping women to manage pain during labour. This is an update of a review last published in 2011.

What is the issue?

The pain women experience during labour can be intense, with body tension, anxiety and fear making it worse. Pain is caused by contractions of the uterus, the opening of the cervix and, in the late first and second stages, by stretching of the vagina and pelvic floor as the baby moves down the birth canal. Effective, satisfactory pain management needs to be individualised for each woman. Women may also use strategies to try to break the fear-tension-pain cycle and work with the pain. Working with the pain involves offering women support and encouragement, finding comfortable positions, immersion in water and self-help techniques.

Many women would like to go through labour without using drugs. Women may turn to acupuncture or acupressure to help reduce their pain and improve management of the pain.

Why is this important?

Acupuncture has a long history of use in Asia, including China, Korea and Japan. Technical needling skills are needed to apply the needles at the correct points. Acupressure also has its origins in early China. To apply acupressure, the therapist uses their hands and fingers to activate the same points as in acupuncture. Sometimes only a few points are needed to alleviate pain or bring about a feeling of relaxation. Other times a combination of points may be required for greater effect. Some forms of acupressure are applied by trained health professionals, while others can be applied by the individual as a form of self-massage.

What evidence did we find?

Our updated search in February 2019 identified 17 new trials.

This review now includes 28 trials reporting on 3960 women, with 27 trials contributing results. The trials compared acupuncture or acupressure with sham treatment as placebo, no treatment or usual care for pain management during labour. Thirteen trials reported on acupuncture and 15 trials reported on acupressure. For 18 of the 27 trials women were in spontaneous labour. In other studies labour may have been induced.

Eight studies applied individualised traditional Chinese medicine while set acupuncture points were used in the majority of studies. We noted wide variation in how stimulation was applied (manually or with electro-stimulation), duration of needling, number of points used, and depth of needling. It is unclear how representative the trial treatments were of acupuncture in practice.

Most comparisons suggest a small beneficial effect from acupuncture, though the supporting evidence was limited. We are uncertain if acupuncture reduces the intensity of pain when compared with sham acupuncture (2 trials, 325 women), usual care (4 trials, 495 women) and no treatment (1 trial, 163 women). The certainty of the evidence was low or very low. Acupuncture may increase satisfaction with pain relief compared to sham acupuncture (one trial, moderate-certainty evidence). It slightly reduced the use of pharmacological analgesia compared to sham acupuncture (2 trials, 261 women, moderate-certainty evidence). Use of acupressure was associated with a reduction in pain intensity in labour when compared to a combined control (2 trials, 322 women, moderate-certainty evidence). Acupuncture did not appear to have any effect on the need for assisted vaginal births or caesarean births, but acupressure reduced the rate of caesarean section when compared to sham acupressure.

What does this mean?

Acupuncture may increase satisfaction with pain relief and reduce use of pharmacological pain relief. Acupressure may help relieve pain during labour, although the pain reduction may not be large. However, for other comparisons of acupuncture and acupressure, we are uncertain about the effects on pain intensity and satisfaction with pain relief due to very low-certainty evidence. Acupuncture or acupressure may have little to no effect on assisted vaginal birth, but women having acupressure maybe less likely to need a caesarean section. Studies were conducted in different countries, which may reflect the different styles of applying acupuncture. A weakness of a number of trials continues to be that very few outcomes were measured and no safety outcomes were reported. More high-quality research is needed.

Authors' conclusions: 

Acupuncture in comparison to sham acupuncture may increase satisfaction with pain management and reduce use of pharmacological analgesia. Acupressure in comparison to a combined control and usual care may reduce pain intensity. However, for other comparisons of acupuncture and acupressure, we are uncertain about the effects on pain intensity and satisfaction with pain relief due to very low-certainty evidence. Acupuncture may have little to no effect on the rates of caesarean or assisted vaginal birth. Acupressure probably reduces the need for caesarean section in comparison to a sham control. There is a need for further high-quality research that include sham controls and comparisons to usual care and report on the outcomes of sense of control in labour, satisfaction with the childbirth experience or satisfaction with pain relief.

Read the full abstract...
Background: 

Many women would like to avoid pharmacological or invasive methods of pain management in labour and this may contribute towards the popularity of complementary methods of pain management. This review examined evidence about the use of acupuncture and acupressure for pain management in labour. This is an update of a review last published in 2011.

Objectives: 

To examine the effects of acupuncture and acupressure for pain management in labour.

Search strategy: 

For this update, we searched Cochrane Pregnancy and Childbirth’s Trials Register, (25 February 2019), the Cochrane Central Register of Controlled Trials (the Cochrane Library 2019, Issue 1), MEDLINE (1966 to February 2019), CINAHL (1980 to February 2019), ClinicalTrials.gov (February 2019), the WHO International Clinical Trials Registry Platfory (ICTRP) (February 2019) and reference lists of included studies.

Selection criteria: 

Published and unpublished randomised controlled trials (RCTs) comparing acupuncture or acupressure with placebo, no treatment or other non-pharmacological forms of pain management in labour. We included all women whether nulliparous or multiparous, and in spontaneous or induced labour.

We included studies reported in abstract form if there was sufficient information to permit assessment of risk of bias. Trials using a cluster-RCT design were eligible for inclusion, but quasi-RCTs or cross-over studies were not.

Data collection and analysis: 

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the certainty of the evidence using the GRADE approach.

Main results: 

We included 28 trials with data reporting on 3960 women. Thirteen trials reported on acupuncture and 15 trials reported on acupressure. No study was at a low risk of bias on all domains. Pain intensity was generally measured on a visual analogue scale (VAS) of 0 to 10 or 0 to 100 with low scores indicating less pain.

Acupuncture versus sham acupuncture

Acupuncture may make little or no difference to the intensity of pain felt by women when compared with sham acupuncture (mean difference (MD) -4.42, 95% confidence interval (CI) -12.94 to 4.09, 2 trials, 325 women, low-certainty evidence). Acupuncture may increase satisfaction with pain relief compared to sham acupuncture (risk ratio (RR) 2.38, 95% CI 1.78 to 3.19, 1 trial, 150 women, moderate-certainty evidence), and probably reduces the use of pharmacological analgesia (RR 0.75, 95% CI 0.63 to 0.89, 2 trials, 261 women, moderate-certainty evidence). Acupuncture may have no effect on assisted vaginal birth (very low-certainty evidence), and probably little to no effect on caesarean section (low-certainty evidence).

Acupuncture compared to usual care

We are uncertain if acupuncture reduces pain intensity compared to usual care because the evidence was found to be very low certainty (standardised mean difference (SMD) -1.31, 95% CI -2.14 to -0.49, 4 trials, 495 women, I2 = 93%). Acupuncture may have little to no effect on satisfaction with pain relief (low-certainty evidence). We are uncertain if acupuncture reduces the use of pharmacological analgesia because the evidence was found to be very low certainty (average RR 0.72, 95% CI 0.60 to 0.85, 6 trials, 1059 women, I2 = 70%). Acupuncture probably has little to no effect on assisted vaginal birth (low-certainty evidence) or caesarean section (low-certainty evidence).

Acupuncture compared to no treatment

One trial compared acupuncture to no treatment. We are uncertain if acupuncture reduces pain intensity (MD -1.16, 95% CI -1.51 to -0.81, 163 women, very low-certainty evidence), assisted vaginal birth or caesarean section because the evidence was found to be very low certainty.

Acupuncture compared to sterile water injection

We are uncertain if acupuncture has any effect on use of pharmacological analgesia, assisted vaginal birth or caesarean section because the evidence was found to be very low certainty.

Acupressure compared to a sham control

We are uncertain if acupressure reduces pain intensity in labour (MD -1.93, 95% CI -3.31 to -0.55, 6 trials, 472 women) or assisted vaginal birth because the evidence was found to be very low certainty. Acupressure may have little to no effect on use of pharmacological analgesia (low-certainty evidence). Acupressure probably reduces the caesarean section rate (RR 0.44, 95% CI 0.27 to 0.71, 4 trials, 313 women, moderate-certainty evidence).

Acupressure compared to usual care

We are uncertain if acupressure reduces pain intensity in labour (SMD -1.07, 95% CI -1.45 to -0.69, 8 trials, 620 women) or increases satisfaction with pain relief (MD 1.05, 95% CI 0.75 to 1.35, 1 trial, 105 women) because the evidence was found to be very low certainty. Acupressure may have little to no effect on caesarean section (low-certainty evidence).

Acupressure compared to a combined control

Acupressure probably slightly reduces the intensity of pain during labour compared with the combined control (measured on a scale of 0 to 10 with low scores indicating less pain) (SMD -0.42, 95% CI -0.65 to -0.18, 2 trials, 322 women, moderate-certainty evidence). We are uncertain if acupressure has any effect on the use of pharmacological analgesia (RR 0.94, 95% CI 0.71 to 1.25, 1 trial, 212 women), satisfaction with childbirth, assisted vaginal birth or caesarean section because the certainty of the evidence was all very low.

No studies were found that reported on sense of control in labour and only one reported on satisfaction with the childbirth experience.

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