Can acupressure or acupuncture help with pain management during labor?

A 2020 Cochrane Systematic Review (1) looked at the evidence from 28 studies to determine if currently available studies show that either acupressure or acupuncture can help with pain management during labor. 13 studies used acupuncture and 15 involved acupressure. All the studies were performed in a hospital setting and a variety of acupoints were chosen for stimulation.

Acupuncture Studies:

The 2020 Cochrane Systematic Review (1) looked at 13 acupuncture studies. These studies used either acupuncture with no needle stimulation after insertion, manual stimulation or electro-acupuncture stimulation. These groups were compared to others who had sham acupuncture (the researchers did their best to make the participants think they were getting true acupuncture when they were not), usual care, no treatment or sterile water injections for pain relief. 8 of the studies used an individualized set of points that was adjusted based on the woman’s needs, and 5 studies used a predetermined set of acupuncture points for all women. Study participants rated their pain on a numeric scale with lower numbers corresponding to less pain.

After analyzing the data from all 13 studies, the review authors concluded that when compared to sham acupuncture, true acupuncture may increase satisfaction with pain management and decrease the use of pharmacological pain relief methods. The evidence is rated as moderate for these two outcomes. When compared with usual care they concluded that acupuncture has an uncertain effect on pain intensity or satisfaction with pain relief. There may be little to no effect on rates of c-section or assisted vaginal birth.

Aside from the 2020 Cochrane Review, one review of 16 systematic reviews (Bergamo et al 2018) concluded that “Acupuncture might be an option for alleviating pain during labor” (2). One individual study by Citkovitz et al showed potentially useful results and is worth noting (3). It involved 45 people in labor at an urban hospital in New York City, and studied individualized acupuncture points used throughout the labor and delivery process (even if an epidural was requested). Although the study was small and not a randomized controlled trial, it is interesting because it found a decreased cesarean rate (7% with acupuncture vs 20% without) and higher reported levels of satisfaction of the birthing parent. 87% of participants reported they felt the acupuncture had helped them. The study also showed that acupuncture may be feasible in a hospital setting because a high level of safety was found (no needlestick injuries or other adverse effects reported) and 83% of nurses said the acupuncture didn’t interfere in their work. This was a unique study because it used individualized points which were chosen based on a study protocol manual, and allowed the acupuncture to be continued even if an epidural was given (almost all other studies discontinued it after an epidural).

For more detailed information on the evidence on acupuncture during labor, please scroll down to the “Detailed Research Summaries” section.

Acupressure Studies

The 15 studies included in the Cochrane Review which involved acupressure each used a fixed set of acupoints, meaning that every laboring person in each individual study had the same points stimulated. The points were not chosen or adjusted based on the individual or their feedback. However the points used were not the same in each study. The most commonly used points across all studies were LI 4 and SP 6 (one or borth of these points was used in 13 studies). One study looked at ear (auricular) point stimulation only, while another study used a completely different and clinically unusual set of points. The acupressure group was compared to either sham acupressure (light touch, gentle massage or stimulation of non-acupressure points), usual care or a combined control of both. The researchers measured outcomes such as pain intensity, the amount of pharmacological analgesia used, c-section rates and overall satisfaction with pain relief. Researchers measured the intensity of pain using a rating system called a Visual Analog Scale (VAS), in which the person in labor rated their pain on a scale of either 1 to 10 or 1 to 100, with lower numbers indicating less pain.

When the authors of the Cochrane Review compiled the results of all the studies and performed a statistical analysis, they concluded that acupressure may help relieve pain and reduce c-sections. For other outcomes, the researchers were uncertain about the effects because the evidence was of low quality. This means that the number of studies that currently exist don’t allow firm conclusions to be drawn- we need more studies of a similar nature so that we can be confident in the data.

One study which deserves mention although it was not included in the 2020 Cochrane Review included 176 low risk, nulliparous participants in Australia (4). Roughly half were assigned to attend a 2 day antenatal education course where they were taught 6 techniques for pain management during labor called The Complementary Therapies for Labor and Birth Protocol (CTLB). This included education in acupressure, visualization and relaxation, breathing, massage, yoga techniques and facilitated partner support. The other half, the control group, received standard care alone. The participants in the CTLB group had a statistically significant reduction in epidural use (63% relative reduction) and cesarean section rate (44% relative reduction), and statistically significant reductions in the rates of labor augmentation, length of the second stage of labor and reduced perineal trauma. The acupressure points and their descriptions can be found in this simple guidebook created by one of my mentors, Debra Betts. Although this is just one study, it was well designed and demonstrates the potential impact of using a variety of noninvasive, non-pharmacological complementary techniques which are tailored to the individual in labor.

For more detailed information on the evidence on acupressure during labor, please scroll down to the “Detailed Research Summaries” section.

Acupressure Arm

Why do women want alternatives to pharmaceutical pain relief during labor?

There is a high level of interest in complementary pain relief techniques during labor. People often describe wanting a “natural birth” (6) and want to do everything possible to reduce medical interventions during birth. A 2014 Systematic Review by Chaillet found that “tailored nonpharmacologic approaches, based on continuous support, were the most effective for reducing obstetric interventions”. These continuous support approaches helped to reduce pain, reduce interventions, increase satisfaction with the overall birth experience and feelings of support and control and improved outcomes.

In a 2010 article (7), Leap et al discuss the concepts of the “working with pain” approach vs the “pain relief” approach. Supportive, nonpharmacological methods tend to aid birthing people in “working with pain” and include methods such as acupuncture, acupressure, sterile water injections, hypnotherapy, yoga, breathing. In contrast, “pain relief” methods seek to completely eliminate pain and include pharmacological methods such as epidurals. For more information on this concept please see the link to the article in the references section.

How might acupuncture and acupressure work to relieve pain?

Several mechanisms appear to be at work (source). Researchers have proposed that diffuse noxious inhibitory control may explain acupuncture’s ability to relieve pain as well as gate control theory. In addition there is evidence that acupuncture stimulates the body’s endogenous opioid system- causing the release of endorphins which act to relieve pain. There is also evidence that acupuncture stimulates the part of the brain that releases serotonin, which affects our mood.

Pregnancy pain illustration

What are acupuncture and acupressure? How might they be used in a real life setting?

Acupressure is the application of firm, continuous pressure to stimulate an acupoint in order to achieve a specific, patient-centered goal. Most commonly it is performed using the thumbs but you can also use other fingers, the elbow, knuckles or an instrument that doesn’t pierce the skin such as the end of a large wooden spoon. Acupressure during labor would ideally be performed by someone with training in using a variety of points and knowledge of which points help with particular symptoms or situations. They have the ability to slightly adjust the point location, the pressure or even the point selection based on feedback from the birthing person and what makes the most difference for them. This can be your spouse or partner or any other support person such as a doula. At a basic level, it doesn’t require extensive training but it is certainly ideal for the birthing person and their support person to have practiced correct location and stimulation of the points before labor gets started.

Acupuncture is performed by a person with extensive training and licensure who stimulates acupoints via inserting fine needles. It is one of the primary modalities used in East Asian Medicine. Many times since labor is an active process where the birthing person is moving around quite a bit, only a few needles are used at a time or they can be securely taped in place to increase safety. As with acupressure, an expert method of practice in using acupuncture during labor and delivery is for the point selection and method of stimulation to be adjusted to the birthing person’s feedback and the situation at hand.

There is a wide range of depth and complexity of how acupressure and acupuncture might be used during labor and delivery- it can be as simple as a support person knowing one or two acupressure points to stimulate or as advanced as having a licensed acupuncturist primarily working in a hospital labor and delivery unit with decades of experience in utilizing many different points and channels. Both methods can be helpful; the method used is a matter of the birthing person’s preference, the setting (hospital, birthing center or home) and the availability of a Licensed Acupuncturist experienced in labor support.

Claudia Citkovitz PhD, LAc is an advanced hospital acupuncturist who has authored a book on acupuncture and acupressure during birth which serves as a guide to acupuncturists and other birth professionals (midwives, doulas, etc.) (5). Her comprehensive text illustrates the possibilities of depth and breadth of the field of using physical East Asian Medicine techniques (such as acupuncture and acupressure) during labor and delivery as well as postpartum.

Detailed Research Summaries

The most recent Cochrane Review, published in 2020, looked at 28 studies. 13 studies looked at acupuncture and 15 looked at acupressure. It’s notable that the authors graded the quality of the acupuncture studies using a new system called a NICMAN Scale. This scale takes things into account such as the training of the persons performing the acupuncture or acupressure in the study, whether certain details of the acupuncture itself were reported (needle depth, diameter, stimulation) and whether or not the points used and number of treatments given were clinically relevant. This scale makes it possible to grade whether or not a study is of good quality from the point of view of acupuncture researchers because it includes items that would determine how clinically relevant the study was. An ideal acupuncture study would achieve a high grade on the NICMAN scale and would be well designed from a traditional clinical research point of view.

Detailed Research Summary on Acupuncture for Pain Relief During Labor

2020 Cochrane Review Findings:

A 2020 Cochrane Systematic Review looked at the evidence from 13 acupuncture studies (1). In most of these studies, women were asked to rate their pain level on a Visual Analog Scale, which ranked pain on a scale of 1 to 10 or 1 to 100, with lower numbers indicating less pain. The researchers found that when compared to sham (placebo) acupuncture, there is some evidence that acupuncture may increase satisfaction with pain management and reduce the use of pharmacological analgesia. It is interesting to note that 8 of these studies used individualized point prescriptions, which more accurately reflects actual clinical practice. This is in comparison to studies that used standardized point prescriptions for all patients. When acupuncture was compared to usual care, no treatment or other methods of pain relief (such as sterile water injection) the evidence on reduction of pain intensity was rated as low or very low certainty. This means that the researchers are uncertain about its effects and more studies are needed to determine its effects in this area. The largest of the studies reviewed (Borup 2009), with 607 participants, also ranked highest on the NICMAN Scale (a measure of the quality of the acupuncture performed in the study) and found that acupuncture decreased the use of pharmacological and invasive methods during labor and delivery, and was a useful complement to other methods of pain relief.

Notable findings from other studies:

A review of 16 systematic reviews (Bergamo et al 2018) concluded that “Acupuncture might be an option for alleviating pain during labor” (2).
A case-control pilot study in a hospital setting by Claudia Citkovitz’s group in 2009 (3) looked at acupuncture in the labor and delivery unit of an urban hospital setting in New York City. Although it was a small study and not a randomized controlled trial, it is interesting because it found that those receiving acupuncture had a decreased cesarean rate and higher reported levels of satisfaction of the birthing parent. 87% of the participants reported that the acupuncture had helped them. Nurses reported that subjectively the patients seemed to do better with acupuncture, noting increased efficiency of contractions and that the acupuncture seemed to help with dilation. From the point of view of feasibility in a hospital setting, a high level of safety was found. No needlestick injuries or other adverse effects (minor or major) were reported, and 83% of nurses said the acupuncture did not interfere with their work. This is a unique study for a few reasons: first, individualized points were used. Second, most studies looking at acupuncture for pain relief during labor discontinued acupuncture once an epidural was given. In this study, it was allowed to be continued.

Findings on Rates of Cesarean Sections after Acupuncture:

In the 2020 Cochrane Review, most of the studies did not show any reduction in C-Section rate. Citkovitz (3) proposed two possible reasons for this:

First, Citkovitz points out that the baseline c-section rate where most of these trials were performed is quite low. Many took place in Nordic Countries (Iceland, Finland, Sweden and Norway) with average rates between 15-17%. It is thought that the majority of the c-sections performed in these countries were truly not preventable. In contrast, in countries where the c-section rates are much higher (ranging from 31.7% in the USA in 2019 (source) to 55.8% average in Brazil (source)), there are likely a large number of preventable surgeries. Supportive therapies may show a greater impact in these countries. In this Cochrane Review, most studies took place in countries with a low baseline c-section rate. For patients receiving acupuncture, across the board no change was found in c-section rates. All studies that looked at this outcome took place in low c-section rate countries with the exception of 1 study from China (Huang 2008) which included a small number of participants and found no significant difference. We need more studies with a larger sample size taking place in countries with a high baseline rate of c-sections. It is interesting to note that studies which looked at acupressure compared with sham acupressure showed a significant decrease in c-sections. The 4 studies that looked at this outcome were all high c-section rate countries (2 studies from Iran, 2 from Brazil).

The second reason Citkovitz proposes is that in most studies, the set of acupuncture points used was strictly prescribed and was unable to be altered based on the situation at hand. In Citkovitz’s study as well as one Norwegian study (Skilnand et al 2002), the person performing the acupuncture was given more room to use their professional judgement and experience, choosing from multiple points. Both of these studies found a decreased rate of cesareans. It would be useful to have pragmatic trial design studies which look at individualized point usage as determined by experienced acupuncture practitioners.

Detailed Research Summary on Acupressure for Pain Relief During Labor

2020 Cochrane Review Findings:

A 2020 Cochrane Review (1) looked at evidence from 15 acupressure studies. The studies all used a fixed set of acupoints, meaning that every laboring person in each individual study had the same points stimulated. The points were not chosen based on the individual or their feedback. However the points used were not the same in each study. The most commonly used points across all studies were LI 4 and SP 6, though these points were not used in every study. The acupressure group was compared to either sham acupressure (light touch, gentle massage or stimulation of non-acupressure points), usual care or a combined control of both. The researchers measured outcomes such as pain intensity, the amount of pharmacological analgesia used, length of labor, c-section rates and overall satisfaction with pain relief. Researchers measured the intensity of pain using a rating system called a Visual Analog Scale (VAS), in which the person in labor rated their pain on a scale of either 1 to 10 or 1 to 100, with lower numbers indicating less pain.

The Cochrane Review authors concluded that acupressure may help relieve pain and reduce c-sections. When compared to sham acupressure, there was low certainty of the evidence for an effect on pain intensity and rate of assisted vaginal birth, and little to no effect found on the use of pharmacological analgesia. Researchers found moderate certainty that acupressure reduces c-section rates (4 trials with 313 women). When acupressure was compared to usual care, there was low certainty evidence of an effect on pain intensity or satisfaction with pain relief. There was also low certainty that there is little to no effect on c-section rates. More studies are needed comparing acupressure to usual care overall. When acupressure was compared to a combined control, moderate certainty evidence exists that acupressure slightly decreases pain intensity and low certainty evidence exists for any effect on pharmacological analgesia used, satisfaction with childbirth, assisted vaginal birth rates or c-section rates. We need more high quality studies that compare acupressure to sham or usual care in order to reach firm conclusions about whether or not acupressure during labor has an effect on any of these outcomes. The Cochrane Review authors also called for more studies which looked at outcomes on sense of control in labor, satisfaction with childbirth experience and with pain relief.

Notable findings from other studies:

One study published in 2016 by Kate Levett’s group (4) had a very interesting design and encouraging results. The well designed study was a randomized controlled trial with 176 low risk, nulliparous participants in Australia. Roughly half were assigned to attend a 2 day antenatal education course where they were taught 6 techniques for pain management during labor called The Complementary Therapies for Labor and Birth Protocol (CTLB). This included education in acupressure, visualization and relaxation, breathing, massage, yoga techniques and facilitated partner support. The other half, the control group, received standard care alone. The participants in the CTLB group had a statistically significant reduction in epidural use and cesarean section rate as well as a statistically significant reduction in rates of labor augmentation, length of the second stage of labor and reduced perineal trauma. Although this is just one study, it was well designed and demonstrates the potential impact of using a variety of noninvasive, non-pharmacological complementary techniques which are tailored to the individual in labor.

The acupressure points and their descriptions can be found in this simple guidebook created by one of my mentors, Debra Betts.

In addition to the desire for better outcomes and higher satisfaction with the labor and delivery process, practical measures such as cost-savings (both to payers and patients) are useful to explore. In conjunction with their 2016 study, Levett et al examined the cost savings associated with a reduction in cesarean sections for women who participated in a 2 day antenatal education course (9). The women and a support person were taught a variety of complementary support techniques. Although the exact cost savings will differ based on the country and the health insurance payer (this could be government funded or private insurance), this particular analysis which took place in Australia found significant savings when a cesarean section was avoided. While not all c-sections are preventable, when it is possible, there is obvious benefit both to the health of the birthing person as well as to the payer.

Resource Links

Evidence Based Birth: review on acupuncture and acupressure during labor. https://evidencebasedbirth.com/acupuncture-and-acupressure-for-pain-relief-during-labor/
Evidence Based Birth Pain Management Series https://evidencebasedbirth.com/category-pain-management-series/
Debra Betts’ Guidebook on acustimulation points for pain relief during labor: https://acupuncture.rhizome.net.nz/download-booklet/
BirthCourse Antenatal Education Course described in the acupressure research summary: https://www.birthcourse.com/
Working with pain in labour- Leap et al 2010

Sources

Smith CA, Collins CT, Levett KM, Armour M, Dahlen HG, Tan AL, Mesgarpour B. Acupuncture or acupressure for pain management during labour. Cochrane Database of Systematic Reviews 2020, Issue 2. Art. No.: CD009232.
Bergamo TR, Latorraca COC, Pachito DV, Martimbianco ALC, Riera R. Findings and methodological quality of systematic reviews focusing on acupuncture for pregnancy-related acute conditions. Acupunct Med. 2018 Jun;36(3):146-152. doi:10.1136/acupmed-2017-011436. Epub 2018 Mar 20. PMID: 29559431.
Citkovitz C, Klimenko E, Bolyai M, Applewhite L, Julliard K, Weiner Z. Effects of acupuncture during labor and delivery in a U.S. hospital setting: a case-control pilot study. J Altern Complement Med. 2009;15(5):501-505. doi:10.1089/acm.2008.0422

Levett KM, Smith CA, Bensoussan A, et alComplementary therapies for labour and birth study: a randomised controlled trial of antenatal integrative medicine for pain management in labourBMJ Open 2016;6:e010691. doi: 10.1136/bmjopen-2015-010691
Citkovitz, C. (2020). Acupressure and acupuncture during birth: An integrative guide for acupuncturists and birth professionals. London: Singing Dragon.
Chaillet N, Belaid L, Crochetière C, Roy L, Gagné GP, Moutquin JM, et al. Nonpharmacologic approaches for pain management during labor compared with usual care: a meta-analysis. Birth 2014;41(2):122-37.
Working with pain in labour- Leap et al 2010
Levett KM, Dahlen HG, Smith CA, et al. Cost analysis of the CTLB Study, a multitherapy antenatal education programme to reduce routine interventions in labour. BMJ Open 2018;8:e017333. doi:10.1136/bmjopen-2017-017333

Can acupressure or acupuncture help with pain management during labor?

Acupuncture Studies:

Acupressure Studies

Why do women want alternatives to pharmaceutical pain relief during labor?

How might acupuncture and acupressure work to relieve pain?

2020 Cochrane Review Findings:

Resource Links

Sources

Health Topics

Lower back pain or pelvic pain

Nausea/Vomiting and Hyperemesis Gravidarum

Prebirth and Labor Induction

Safety of Acupuncture During Pregnancy

Anxiety and Depression

Moxa for Breech Presentation

Threatened Miscarriage

Pre-Eclampsia

Insomnia