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Acupuncture and Pregnancy
By Carmen Tamayo, MD
"Natures differ, and needs with them, hence the wise men of old did not lay down one measure for all."
— Chuang Tse, 4th century B.C.
Acupuncture is an ancient method of healing coming from traditional Chinese medicine (TCM). TCM theorizes that more than 2,000 acupuncture points on the human body connect with 12 main and eight secondary pathways, called meridians. Chinese medicine practitioners believe these meridians conduct energy, or qi, between the surface of the body and internal organs. Acupuncture stimulates and alters the flow of qi through these pathways.
Acupuncture is the insertion on the body’s surface of very fine needles, sometimes in conjunction with electrical stimulus, that influence physiological functioning of the body. An estimated 5,000 physicians and more than 7,000 Oriental medicine practitioners practice acupuncture in the United States.1
According to the NIH Consensus Statement on acupuncture, this treatment modality has been shown effective for adult postoperative and chemotherapy nausea and vomiting and for postoperative dental pain. Acupuncture may be useful as an adjunct treatment or an acceptable alternative to be included in a comprehensive management program for conditions such as addiction, stroke rehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia, myofascial pain, osteoarthritis, low back pain, carpal tunnel syndrome, and asthma.2
The use of acupuncture for gynecological conditions is well established among TCM practitioners. Research from China has found that acupuncture has a regulatory effect on the menstrual cycle, regulating the production of luteinizing hormone, follicle-stimulating hormone, and estradiol.3,4 In addition, acupuncture has been used effectively to prevent nausea and vomiting during pregnancy;5 to treat menorrhagia,6,7 dysmenorrhea,8 premenstrual syndrome, and infertility;9 to restore breech presentation;10 and to shorten labor time, relieve labor pain, and induce or stimulate labor by ripening the cervix.
The World Health Organization mentions acupuncture as a non-pharmacological method of pain relief that can be used during labor and emphasizes the need for critical review and adequate studies "to improve acceptability and extend the use."11
Patterns of Use
In a U.S. survey of 575 patients consulting acupuncturists, 17.4% received acupuncture for gynecological conditions; 92% of that group reported that their symptoms had either "disappeared" or "improved."12
Another U.S. survey evaluated the prevalence and type of complementary and alternative medicine (CAM) therapies used by certified nurse midwives in North Carolina. Acupressure was used by 52% of nurse midwives and almost 20% reported use of acupuncture during pregnancy, with 6% of responders specifically recommending its use to ripen the cervix and/or induce labor.13
Labor presents a physiological and psychological challenge for women. Pain associated with labor has been described as one of the most intense forms of pain that can be experienced. Labor pain is caused by uterine contractions, the dilatation of the cervix, and, in the late first stage and second stage, by stretching of the vagina and pelvic floor to accommodate the baby. Effective and satisfactory pain management needs to be individualized for each woman.
Acupuncture points used to reduce labor pain are located on the hands, feet, and ears. Few studies have evaluated the use of acupuncture to relieve pain during labor.
A Cochrane review examined the available evidence supporting the use of CAM therapies for pain management in labor on maternal and perinatal morbidity. The review included seven trials involving 366 women and reviewed the following modalities: acupuncture (n = 100), audio-analgesia (n = 25), aromatherapy (n = 22), music (n = 30), and hypnosis (n = 189). According to the findings, only acupuncture and hypnosis seem to have a positive effect in pain management during labor.14
In the acupuncture trial, the need for pain relief was reduced. In this parallel, single-blind, controlled trial, 100 women in the first and second stages of labor were randomized to receive acupuncture (n = 51) or no acupuncture (n = 49) during labor as a complement or alternative to conventional analgesia. All women in the trial received routine midwifery care. Randomization occurred in the delivery room; the midwives individualized and administered the acupuncture treatment. Needles were inserted at 45 or 90 degrees, stimulated manually until de qui (needling sensation) was obtained. Needles were left in situ and removed after 1-3 hours. Pain intensity and degree of relaxation were assessed once every hour and prior to and 15 minutes after administration of any analgesic. Only 90 women were included in the analysis because 10 women did not meet the inclusion criteria. The primary outcomes were maternal satisfaction and use of analgesia. Other outcomes included pain, relaxation, use of analgesics, augmentation of labor with oxytocin, duration of labor, outcome of birth, antepartum hemorrhage, Apgar scores, and infant birth weight.
Acupuncture treatment during labor significantly reduced the need of epidural analgesia (12% vs. 22%, relative risk [RR] 0.52, 95% confidence interval [CI] 0.30 to 0.92) although the two groups assessed the same degree of pain intensity (mean difference -0.29, 95% CI -0.90 to 0.32). Patients who received acupuncture assessed a significantly better degree of relaxation compared with the control group (mean difference -0.93, 95% CI -1.66 to -0.20). No negative effects of acupuncture given during labor were found in relation to delivery outcome. There was no difference in maternal satisfaction of pain management between the acupuncture and control groups (RR 1.08, 95% CI 0.95 to 1.22). However, 54 women who received acupuncture required no additional analgesic compared with 12 women in the control group (P < 0.0001). Of the secondary outcomes, there was no difference in spontaneous vaginal delivery (RR 0.98, 95% CI 0.89 to 1.08), instrumental vaginal delivery (RR 1.91, 95% CI 0.18 to 20.36), caesarean section (RR 0.96, 95% CI 0.06 to 14.83), duration of labor (-0.25, 95% CI -1.75 to -1.26), or the need for augmentation with oxytocin (RR 1.02, 95% CI 0.58 to 1.80) between the acupuncture and control groups. No infants in either group had an Apgar score of > 7 at five minutes and there was no difference in infant birthweight. These results suggest that acupuncture could be a good alternative or complement to parturients who seek an alternative to pharmacological analgesia in childbirth. The authors conclude that further trials with a larger number of patients are required to clarify if the main effect of acupuncture during labor is analgesia or relaxation.15
In a controlled, single-blind study, 210 healthy parturients in spontaneous, active labor at term were randomly assigned to receive either real acupuncture (n = 106) or false acupuncture (n = 104). Visual analog scale (VAS) assessments were used to evaluate subjective effect on pain (0 = no pain, 10 = worst possible pain). Insertion of needles started at a pretreatment VAS pain score equivalent to 3 or higher. Subsequently, the degree of pain was recorded 30 min, 1 hour, and 2 hours after start of treatment. The objective outcome parameter was the need for analgesic medication in each group. There were significantly lower mean pain scores and significantly less need for pharmacological analgesia in the study group compared with the control group. Women given real acupuncture spent less time in active labor and needed less augmentation than the control group. Through its analgesic effect, real acupuncture reduced the requirement for analgesic medications that usually are accompanied by adverse side effects. The results indicate that acupuncture reduces the experience of pain in labor. A secondary outcome of acupuncture was a shorter delivery time. No adverse effects of the needle insertions were recorded during labor or stay in hospital, and none of the participants reported skin infections after arriving home.16
Other forms of acupuncture—such as electro-acupuncture, in which small amounts of current (1-3 mA) are applied to the acupuncture needles, and acupressure, a form of acupuncture that applies to stimulation of points by means of pressure applied by the practitioner’s hands, thumbs, fingers, elbows, and knees on the patient’s body—have been used to relieve pain in labor. In one study, electro-acupuncture administered repeatedly as needed at four sites for 20 minutes was shown to provide analgesia for a mean of six hours.17 Midwives commonly use acupressure to relieve labor pain and various points may be tried until one is located that feels good to the individual patient.18
In light of the limited data available to support the use of acupuncture to relieve pain in labor and birth, Eappen and Robbins conducted a review of acupuncture in labor trials. They concluded that: "Although there has been much evidence for the rational use of acupuncture for many pain states, labor analgesia is not one of them yet."19 These authors also point out that acupuncture rarely is associated with complications.
Acupuncture also has been used to achieve relaxation during labor but no randomized controlled trials have been conducted with relaxation as a primary outcome.
In parts of Europe and Asia, acupuncture has been used to stimulate the onset of labor. However, there is a dearth of scientific studies on the use of acupuncture to stimulate or induce labor. It has been suggested the mechanism may involve stimulation of the uterus by hormonal changes (increasing oxytocin levels) or stimulating the parasympathetic nervous system.20
Some observational studies conducted in the late 1970s suggest acupuncture for induction of labor appears safe, has no known teratogenic effects, and may be effective.21-23 The success rate ranged from 68% to 83% in the three studies and average induction to delivery time was 13 hours in one study.22
A case-control study of 120 women reported that acupuncture shortened the first stage of labor. Median duration of the first stage of labor was 196 min in the acupuncture group (Group A) compared with 321 min in the control group (Group B) (Wilcoxon 2-sample test, P < 0.0001). In addition, women in Group B received oxytocin significantly more often during the first stage of labor compared with Group A (85% and 15%, respectively, chi2 test, P = 0.01), as well as during the second stage of labor (72% and 28%, respectively, chi2 test, P = 0.03).24
Two non-randomized trials examined whether electro-acupuncture could initiate contractions in women at term.25,26 In both studies, an increase in the intensity of labor contraction frequency was observed and time to labor was reduced. However, randomized, placebo-controlled, or double-blind clinical trials have not been conducted to confirm these results.
The Cochrane Pregnancy and Childbirth Group attempted to do a systematic review of clinical trials evaluating the efficacy of acupuncture for third trimester cervical ripening or labor induction, but only two studies were found and neither evaluated labor induction.27 The first study compared electrical acupuncture stimulation or placebo acupuncture on the onset of uterine contractions in 20 post-date pregnant women.28 There was evidence of strong contractions in the treatment group; however, the trial did not report on whether women proceeded to spontaneous labor. The other study recruited 98 women and compared acupuncture with placebo acupuncture or a no acupuncture control group. Women were recruited to the trial at 37-38 weeks’ gestation and the effect of acupuncture in ripening the cervix was evaluated. The authors did not report whether labor was induced.29
A non-blinded, randomized study was designed to evaluate whether acupuncture at term can influence cervical ripening, induce labor, and, thus, reduce the need for postdate induction. Data for 45 women were evaluated. The cervical length in the acupuncture group (n = 25) was shorter than in the control group (n = 20) on day 6 and day 8 after estimated date of confinement (P = 0.04 for both). Labor was induced in 20% of women in the acupuncture group (n = 5) and in 35% in the control group (n = 7) (P = 0.3). Acupuncture at points Hegu (Large Intestine 4) and Sanyinjiao (Spleen 6) supports cervical ripening at term and shortens the time interval between the estimated date of confinement and the actual time of delivery.30
A randomized clinical trial to evaluate the influence of acupuncture stimulation on the induction of labor was begun in 1998 at the Department of Obstetrics and Gynaecology, Adelaide University, in Australia. The results have not been published.27
Breech presentation is common in the mid trimester of pregnancy, with the incidence of breech decreasing as the pregnancy approaches term. The incidence of breech presentation at term is reported to be 4%.31 Current management options to correct breech presentation include external cephalic version and postural management. A third treatment, moxibustion, utilizes heat generated by burning herbal preparations containing the plant Artemisia vulgaris to stimulate acupuncture points.32 This technique involves holding moxa sticks (1.5 cm in diameter and 20 cm in length) or burning moxa cones on or over the acupuncture point Zhiyin (Bladder 67) located at the tip of the fifth toe. The heat should be warm but not uncomfortable. Treatment is administered for 15 minutes, once or twice a day for a specified number of treatments. Anecdotal evidence suggests that moxibustion may correct breech presentation and no side effects have been reported.10 It has been proposed that this technique stimulates the production of maternal hormones (placental estrogens and prostaglandin), thus encouraging the uterine lining to contract, which in turn stimulates fetal activity. 32,33
Women with a breech presentation may seek treatment with moxibustion from 32 to 38 weeks since it seems to be a cheap, safe, simple, self-administered, non-invasive, painless, and generally well-tolerated technique. There are very few scientific or controlled clinical studies of this method of treatment but a Cochrane review has been proposed to evaluate the available evidence. 34
A recent study reported that breech presentation was corrected successfully by stimulating acupuncture points with moxibustion or low-frequency electrical current. The authors conclude that acupuncture stimulation, especially with moxibustion, is expected to serve as a safe and effective modality in the management of breech presentation in a clinical setting.35
Acupuncture is a very safe intervention in the hands of competent practitioners and rarely is associated with complications.36 The most common include minor bruising and dizziness. As required by the United States Food and Drug Administration, sterile or disposable needles should be used to avoid any infectious risks.
Acupuncture does have an effect in the gynecological system due to the central effect of neuropeptides on the hypothalamic-pituitary-ovarian axis and peripherally on the uterus. Various clinical studies show that acupuncture is effective in relieving acute or sudden pain, but the effect in labor pain has not been thoroughly evaluated. Acupuncture can induce uterine activity in pregnant women and seems to reduce the intensity of labor pain. Although acupuncture appears helpful in reducing labor pain, only two randomized, single-blind studies were found in the literature. Therefore, randomized controlled studies are needed to evaluate the efficacy of acupuncture in the induction of labor and to confirm its effect in diminishing labor pain, reducing the need for analgesics, and achieving relaxation during labor.
In addition, treatment protocols can differ widely in acupuncture studies, depending on the type of acupuncture used, the selection of points, skill of the acupuncturist, and the needling techniques used (duration and depth of needling, type of needle, number of needle insertions, number of points used, type of stimulation, and point selection). It is important that any future clinical trials of acupuncture report the treatment regimen (number of sessions and frequency of treatment) and needling described in the STRICTA (STandards for Reporting Intervention in Clinical Trials of Acupuncture) guideline.37
Dr. Tamayo is Director, Division of Complementary and Alternative Medicine, Foresight Links Corp., London and Dundas, Ontario, Canada.
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