A Study to Assess the Effectiveness of Acupressure during Labour pain among Primigravida Mothers in Selected Hospitals, Puducherry

 

Dr. V. Indra

Department of Maternal, Child, and Community Health Nursing, University of Hail, Kingdom of Saudi Arabia.

 

ABSTRACT:

Acupressure has been used frequently to improve labour, manage labour pain, and shorten delivery time. However, there has been little research-based evidence to support the positive effects of acupressure in the obstetric area and obstetric nursing. The aim of this study was to evaluate the effects of SP6 acupressure on labour pain and delivery time in primigravida women in labour. The study was conducted at selected Hospitals in Puducherry. Its design was a randomized controlled clinical trial study using a single-blinded method. One hundred (100) primigravida women in labour were randomly assigned to either the SP6 acupressure (n = 50) or control group (n = 50). Acupressure was practiced 35 times in total on the SP6 point of both legs in the SP6 acupressure group; 15 times (during contraction) when cervical dilation was 2-3 cm, 10 times when cervical dilation was 5-6 cm and 10 times at 9-10 cm dilation, while the women in the control group received standard care. Labour pain was measured five times using a structured questionnaire of a subjective labour pain scale (visual analogue scale-VAS) when dilation was 2-3 cm (VAS 2), 5-6 cm (VAS 3) and 8-9 cm (VAS 4) before and after acupressure was applied to the SP6 point (VAS 1), and finally at the early postpartum period (VAS 5). The duration of labour in both groups was measured with a parto-graph and the length of delivery time was calculated in two stages: from 3 cm cervical dilation to full cervical dilation, and from full cervical dilation to delivery. There were significant differences between the groups in subjective labour pain scores (except VAS 4) (P < 0.001). The duration of the Phase one (3 cm dilatation to full dilatation) and Phase two (full dilatation to birth) in the acupressure group was shorter than the control group (Phase one, 225 min and 320 min, respectively; Phase two, 15 min and 20 min, respectively; both P < 0.001). It was determined that SP6 acupressure was effective in decreasing pain and duration of labour.

 

 

 

INTRODUCTION:

Labour pain is recognized as one of the most severe and acute human pain. However, modern obstetrical practice rejects the belief that labour pain is acceptable or even necessary [1].

 

The American Society of Anesthe­siologists and the American College of Obstetrics and Gynecology recognize labour pain as an indication for treatment [1] [2]. Although labour pain is an important bi­ological sign indicating that labour is starting, it should be terminated when its purpose has ended. Labour pain stimulates the sympathetic system by causing neuroen­docrine stress response, increased levels of ACTH, cor­tisol, epinephrine, norepinephrine and β-endorphine. It also reduces blood flow to the uterus, causing acido­sis and fetal hypoxia [1]. For these reasons, labour pain should be absolutely eliminated. There are two ways to eliminate labour pain. The first is through more com­monly used pharmacological methods, and the second is with non-pharmacological methods, which are used less frequently [3] Non-pharmacological methods, such as acupressure, offer sufficient pain control and are harmless for mother and fetus under proper medi­cal supervision. Moreover, these methods do not slow down labour and have no side effects or allergy-related risks [1] [4][5]. One of the non-pharmacological methods that are used to reduce labour pain and to shorten the duration of labour is acupressure [5][11]. Acupressure is a means of manipulating the same acupoints as used in acupuncture, but without the use of needles [12][13]. Acupressure used on the BL60, BL67, GB21, LI4, SP9 and SP6 sites affects uterine contractions or duration of labour by stimulating the secretion of oxytocin from the hypophysis [13][14][6].  The SP6 point is the junc­tion point of the liver, spleen, and kidney meridians. Based on principles of traditional Chinese medicine, this acupuncture point is used to strengthen the spleen restoring balance to the Yin and to the blood, liver and kidneys. This SP6 point is also commonly used in the treatment of reproductive conditions in women, such as labour induction and pain relief during labour [15][16][7]. In addition, acupressure prevents the increase of levels of catecholamine, beta endorphins, ACTH and cortisol in the pregnant woman by reducing the neuro­endocrine response to pain. Thus, maternal metabolic speed, oxygen consumption and risk of acidosis and cardiovascular side effects are prevented and the prog­ress of labour is facilitated [17]. Yet, the precise mechanism by which acupressure lessens pain is not clear [18]. More studies are needed to establish safe and effective pain-relieving strategies to increase the com­fort levels of pregnant women during labour, one of the most difficult experiences in a woman's life.

 

METHODOLOGY:

A single-blind randomized clinical trial was conducted among primigravida women who had been admitted to the delivery ward. There were 50 people in each group in the post-hoc power anal­ysis (NQuery Advisor Statistical Power Analysis for Soft­ware) using the Man-Whitney U test. According to the vari­able VAS 2 during the latent phase at P < 0.05 significance level, and at 95% confidence interval, the power of the test study was determined as 0.99. This finding demonstrates sample adequacy [17][18][19][20]. After the participants were thor­oughly instructed in the aims and details of the study, an information sheet was provided and their informed con­sent was obtained. Participants signed the consent form knowing that they could withdraw from the study at any time.  Additional criteria for participation in the study re­quired women who would give birth at full term for the first time (between the 37th and 41st week of pregnancy), had one fetus with a weight of 2500-4000 gr according to ultrasound, had no pregnancy complications, were able to communicate effectively both orally and in written form, were primary school graduates or more, had no sys­temic or neurological disorder, had an intact membrane, were in the latent phase of labour (cervical opening 2-cm), had no damage, bruises or irritation at the SP6 acupoint, and had similar obstetric histories and socio-demograph­ic characteristics. Excluded from the study were women who took narcotics, analgesics or sedatives during labour, had any sign of fetal distress, had a previous hysterectomy or uterine scar had any medical or surgical complications of pregnancy, had a history of drug use outside of the usu­al supplements, exhibited high risk pregnancies, or had postnatal complications or cesarean delivery. Although 193 women initially agreed to participate, only 100 com­pleted the study. Ninety-three women were excluded from the study for the following reasons: 41 women gave birth by cesarean, 19 had a prolonged labour, nine devel­oped fetal distress, seven were taken to the obstetric table without 10 cm dilation or wanted to withdraw from the study, 13 women developed complications, and four were administered narcotic analgesics. When the women who had agreed to participate in the study experienced regu­lar uterine contractions, they were taken to the labour and delivery room. After examining them for parity, cervical dilation status, and status of the intact membrane the participants were randomly assigned to either the experi­mental (n = 50) or the control group (n = 50). Pregnant women were assessed in terms of study inclusion criteria and randomization was made after determining their ac­ceptance. The women were randomly divided into two groups (two parts, block random using sealed, sequen­tially) distributed envelopes to which the letters A and C had been allocated. The letter A was assigned to the acu­pressure group and the letter C to the control group. Each patient selected an envelope, which was then opened by the investigator. The groups were thus determined de­pending on which letter of envelope they chose. The preg­nant women not fitting the criteria were excluded from the study. The SP6 acupressure was applied 35 times dur­ing uterine contractions, 15 times at 2–3 cm of cervical di­lation, and 10 times each at 5–6 cm and 8–9 cm of cervical dilation. Before application of acupressure, the first SP6 point was anatomically located. The standard procedure in locating the correct point is to measure it with one’s own finger width. This measurement is depen­dent on the meridian theory in which the measurement is performed using the reference of one's own body. Here, the patient's own anatomical measurements provide the proportional reference. At the same time, the acupuncture point detector was used for each pregnant woman in order to detect the SP6 point correctly. After­wards, a green light and a special sound are emitted [21]. Acupressure was applied by placing thumbs on both legs at the same time from the beginning to the end of the contraction. The mean pressure applied was about 3 to 5 kg, and this amount was ascertained by the re­searcher. The thumbs of both hands (using not the edges but the round parts of the thumbs) were placed on the SP6 points. At the end of the contraction, pres­sure was gradually reduced and acupressure was stopped during the resting phase. The women were placed in a su­pine position with legs straight. During the acupressure procedure, uterine contractions and fetal heart rate were monitored with an electro-fetal monitor.  Apart from the acupressure practice, the women were encouraged to get out of bed, sit and/or walk around as a part of their rou­tine care. The researcher followed up on the women in both the acupressure and the control group during labour, answered their questions, and participated in their treat­ment and care. Except for the acupressure practice given to the acupressure group, the researcher gave the partici­pants of both groups equal care throughout the labour. No problems were seen in the women or fetuses during the acupressure application. Subjective pain was measured using the Visual Analogue Scale (VAS) with ratings from 0–10; a higher score indicated more pain. The VAS was administered to the women five times in both the experi­mental and control groups. The first VAS evaluation (VAS 1) was done before the acupressure practice; the second VAS evaluation (VAS 2) took place from the beginning to the end of a contraction at which time SP6 acupressure was applied 15 times with cervical dilation at 2-3 cm. The third VAS evaluation (VAS 3) was performed from the beginning to the end of a contraction when SP6 acupressure was ap­plied 10 times with cervical dilation at 5-6 cm; the fourth VAS evaluation (VAS 4) documented at the beginning to the end of a contraction in which SP6 acupressure was applied 10 times when cervical dilation was 8-9 cm; and the final VAS evaluation (VAS 5) was completed during the early postnatal period at the second hour after delivery, before the mothers were discharged from the hospital. In the control group, the first VAS evaluation (VAS 1) was done before the study, the second (VAS 2) was performed after 15 contractions (when cervical dilation was 2-3 cm ) in the la­tent phase, the third VAS evaluation (VAS 3) was done after 10 contractions (when cervical dilation was 5-6 cm) in the active phase, the fourth VAS evaluation (VAS 4) was per­formed after 10 contractions (when cervical dilation was 8-9 cm.) in the transition phase, and the final VAS evalua­tion (VAS 5) was completed in the early postpartum period (at the second hour, the end of the early postnatal period). The duration of labour to delivery was measured in two time periods from the participants’ charts: from the 3-cm cervical dilation to full cervical dilation; and from full cer­vical dilation to delivery. The dilation of the uterine cervix was measured by midwives or doctors. The newborns’ 1-minute and 5-minute APGAR scores and also mothers’ pulses and breathing rates were recorded so that poten­tial side effects of acupressure could be detected.

 

RESULTS:

Table 1 shows the demographic characteristics of the 100 women who completed the study. There were no significant differences between the two groups in the variables of maternal age, education, gestational age, fear of labour, prenatal care received, and mean APGAR score in the 1st and 5th minutes. The women in the control group perceived pain more se­verely at nearly each level of labour (except VAS 1 and VAS 4) when compared with the women in the acupressure group (VAS 1: A: 3.00, C:3.00; VAS 2: 3.00, C:4.00; VAS 3: A: 7.00, C:8.00; VAS 4:10.0, C:10.0; VAS 5: A:2.0, C:3.0). The statistical analysis showed that the difference between the groups was highly significant in terms of perceived pain severity as depicted in table 2. While first stage of labour was 225 min (3.75 hours) and the second stage was 15 min in pregnant women in the acupressure group, the I. stage lasted 320 minutes (5:33 hours), and the second stage lasted 20 min in the control group. The difference in duration of labour between the groups was found to be statistically significant in favor of the acupressure group (P < 0.001) as depicted in table 3.

 

DISCUSSION:

The purpose of this study was to evaluate the effects of acupressure on labour pain and duration of labour as per­ceived by pregnant women when acupressure was ap­plied to the SP6 acupoint. The results indicate that the women in the control group perceived pain more severely at nearly each level of labour (except VAS 1 and VAS 4) when compared with the women in the acupressure group. Fur­thermore, the women in the control group were in labour more than one hour longer than those in the acupressure group. As already noted, the expressed pain scores in the acupressure group were found to be significantly lower than those in the control group. This demonstrates that acupressure application is an effective method in reduc­ing the labour pain of pregnant women. In the evaluation of the initial pain (VAS 1) during the dilation of 2-3 cm (la­tent phase), the lack of difference between the two groups may be based on the fact that pregnant women were still in the early stages of labour, and it was administrated ret­rospectively before the application.

 

Table 1 Frequency and percentage distribution according to demographic variables (n = 100)

 

 

Table 2 Comparison of median pain intensity between acupressure and control group (n = 100)

 

 

Table 3 Comparison of median scores of duration of labour between acupressure and control group (n = 100)

 

 

The reason why there was no significant difference between the two groups in terms of the reduction of labour pain during the transi­tion phase (VAS 4) may be explained with the change in the type of labour pain. This is due to the pressure on the surrounding tissue and organs as the baby's head settles into the pelvis during the transition phase and the reduc­tion in the effect of acupressure during this period. In terms of the reduction of pain, acupressure might also be considered to be more effective for mild (latent phase) or moderate (active phase) pain.

 

LITERATURE REVIEW:

In a study by Lee [14] in which acupressure was performed on the SP6 point for 30 minutes after cervical dilation was 3 cm, it was found that pain in the experimental group decreased considerably compared to the control group. Another study’s results determined that acupressure per­formed on the LI4 and BL67 points produced a difference between the groups in pain scores measured during the active phase of the first stage of labour. The length of first stage of labour in the experimental group was shorter than that of the control group [6],[9],[22]. The randomized controlled study of Lee et al. [14] with 75 women reported that acu­pressure was applied to the SP6 point during each con­traction, when cervical dilation was at least 2-3 cm and uterus contractions were regular for 30 minutes. Results showed a significant difference between the groups in the VAS scores following the acupressure intervention af­ter 30 and 60 minutes. The same study also indicated that duration of labour in the SP6 group decreased significant­ly compared to the control group. Similarly, Kashanian and Shahali’s [19][26] research, which investigated the effect of acupressure on the Sanyinjiao point on the duration of labour and labour pain, found that the severity of pain in the women in the study group was lower than those in the control group. They also reported that the dura­tion of the active phase was shorter in the study group. Another study by Ozgoli et al. [25] found a significant difference in the pain scores of the experimental group as compared with the control group, when acupressure was performed on the LI4 point of the right hand during six uterus contractions with the cervix dilated at 4-5 cm, 6-7 cm and 8-10 cm Similar findings were also reported in systematic screenings and studies related to acupunc­ture and acupressure practice used for labour pain man­agement [7][10][26][27]. In contrast to our study, Mucuk et al. [28] and Ozturk et al. [23] reported no differences between pregnant women in the acupressure group and the control group. It is thus understood that the effects of acupressure on the duration of labour and labour pain dif­fer in some studies, yet none of the studies mention any side effects of acupressure applied to specific sites. We be­lieve that the different sample sizes and the use of differ­ent research methods may account for conflicting study results. When the APGAR scores of the newborn were analyzed to explore whether our non-pharmacological practices had any effect upon fetal health, no significant difference was noted between the first and fifth APGAR scores of the groups. Furthermore, other studies on the use of non-pharmacological methods do not reveal any significant differences in APGAR scores, and these results are consistent with those of our study [8][19][23][24].

 

CONCLUSION:

Findings of this study indicate that the application of SP6 acupres­sure is an effective means in relieving pain during labour, and it also can shorten the duration of labour without causing harm to the mother and baby. Thus, acupressure can be readily implemented in clinical practice to im­prove the quality of care in labour and delivery. This pres­ent study has limitations in that only one acupuncture point was researched per group and the sample size was small. These points may prevent a generalization of our findings to different populations. In this study, potential confounding factors such as the parity, cervical dilation status, status of the amniotic membranes, and childbirth readiness were taken into account via randomization; hence these variables did not differ between groups, nor were there any differences in newborn weights. Various factors such as individual differences in pain limits and cultural, social, psychological, and mental factors could influence pain measurement.

 

REFERENCES:

1.        Komurcu N, Berkiten AE. Labour Pain and Management. Stanbul: Be­dray Publishing Company; 2008.

2.        Owen MD. Regional Analgesia in Labour In: Sahin S, Owen MD, eds. Painless Labour and anesthesia in cesarean section. Stanbul, MA: Gunes Medicine Publishing; 2006.

3.        Cook A, Wilcox G. Pressuring pain. Alternative therapies for labour pain management. AWHONN Lifelines. 1997; 1(2):36–41.

4.        Tournaire M, Theau-Yonneau A. Complementary and alternative approaches to pain relief during labour. Evid Based Complement Alternat Med. 2007; 4(4):409–17.

5.         Beal MW. Acupuncture and acupressure. Applications to wom­en's reproductive health care. J Nurse Midwifery. 1999; 44(3): 217–30.

6.        Chung UL, Hung LC, Kuo SC, Huang CL. Effects of LI4 and BL 67 acupressure on labour pain and uterine contractions in the first stage of labour. J Nurs Res. 2003; 11(4):251–60.

7.        Gentz BA. Alternative therapies for the management of pain in labour and delivery. Clin Obstet Gynecol. 2001; 44(4):704–32.

8.        Hamidzadeh A, Shahpourian F, Orak RJ, Montazeri AS, Khosravi A. Effects of LI4 acupressure on labour pain in the first stage of labour. J Midwifery Womens Health. 2012; 57(2):133–8.

9.        Hjelmstedt A, Shenoy ST, Stener-Victorin E, Lekander M, Bhat M, Balakumaran L, et al. Acupressure to reduce labour pain: a randomized controlled trial. Acta Obstet Gynecol Scand. 2010; 89(11):1453–9.

10.     Kim YR, Chag SB, Lee M K, Maeng WJ. Effects on labour pain and length of delivery time for primipara women treated by san-yin-jian (SP-6) acupressure and hob-gog (LI-4) acupressure. Korean J Women Health Nurs. 2002; 8(2):244–56.

11.     Ma W, Bai W, Lin C, Zhou P, Xia L, Zhao C, et al. Effects of Sanyinjiao (SP6) with electro acupuncture on labour pain in women during labour. Complement There Med. 2011; 19 Suppl 1:S13–8.

12.     Hakverdioglu G, Turk G. Acupressure. Hacettepe Nurs School J. 2006; 13.

13.     Yesilcicek CK, Komurcu N. Acupressure. 2ed Stanbul, MA: Nobel Medical Publishing; 2013.

14.     Lee MK, Chang SB, Lee H. S., Kim HS. Effects of treatment with sanyin-jian (sp-6) acupressure for labour women on labour pain, length time for delivery and anxiety: A clinical trial pilot study. Korean J Women Health Nurs. 2002; 8(4):559–69.

15.     Betts D. Inducing labour with acupuncture-crucial consider­ations. J Chinese Med. 2009; 90(1):20–5.

16.     Yıldırım, G., Somek, A. A., Kayır, H. Establishment of the correla­tion between weight of the newborn and labour pain [Turkey]. Is­tanbul Uni Florence Nightingale Health School J. 2006; 15(57):99–107.

17.     Dixon WJ, Massey FJ. Introduction to statistical analysis. 4ed USA: McGraw-Hill; 1983.

18.     Lee MK, Chang SB, Kang DH. Effects of SP6 acupressure on labour pain and length of delivery time in women during labour. J Altern Complement Med. 2004; 10(6):959–65.

19.     Kashanian M, Shahali S. Effects of acupressure at the Sanyinjiao point (SP6) on the process of active phase of labour in nulliparas women. J Matern Fetal Neonatal Med. 2009:1–4.

20.     O'Brien RG, Muller KE. Applied analysis of variance in behavioral sci­ence marcel dekker. New York; 1983.

21.     Osmaniye F, Çobançeşme, S., Şahin Ap . Diagnostics and ear acu­puncture point detector. 2011.

22.     Modares M, Mirmolaee ST, Mirmohammadalie M, et all. The Ef­fect of Education on the Use of Partogram to Control the Quality of Care Offered by Midwives. Res J Biol Sci. 2009; 4(2):152–6.

23.     Ozturk CH, Saruhan A. Studyıng the effect of ıce-massage ap­plied to hands of pregnant women to reduce the perceived labour pains [Turkey]. J Nurs Res Develop. 2008; 1(1):18–37.

24.     Waters BL, Raisler J. Ice massage for the reduction of labour pain. J Midwifery Womens Health. 2003; 48(5):317–21.

25.     Ozgoli G, Sedigh S, Heshmat R, Alavi MH. Effect of right hand hegu acupressure on pain intensity of active phase of labour pain in primiparous women. Kowsar Medic J. 2010; 14(4):229–34.

26.     Haris PE. Acupressure: A review of the literature. Complementary Therapies in Medicine. 1997;3(5):156–61.

27.     Huntley AL, Coon JT, Ernst E. Complementary and alternative medicine for labour pain: a systematic review. Am J Obstet Gynecol. 2004; 191(1):36–44.

28.     Mucuk S, Baser M. Effects of noninvasive electro acupuncture on labour pain and duration. J Clin Nurs. 2014; 23(11-12):1603–10.

 

 

 

Received on 23.11.2016          Modified on 21.12.2016

Accepted on 30.01.2017          © A&V Publications all right reserved