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Running head: CONTROL OF PAIN IN LABOR 1

Non-pharmacological Pain Control for Laboring Women

Brooke Fortner

University of South Florida


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Abstract

Clinical Problem: Women who experience uncontrolled and severe pain in labor are at greater

risk of adverse consequences such as hyperventilation, increased blood pressure, ineffective

coping and delivery efforts, and increased use of delivery instruments. Epidural anesthesia and

opioids, which are the most commonly requested methods of pain control, have negative side

effects and outcomes for both the mother and fetus (APA, 2017; Jones et al., 2012).

Purpose: The purpose of this literature review was to discuss if a non-pharmacological pain

control intervention (PCI), specifically acupressure at acupuncture point Large Intestine 4 (LI4),

is effective in decreasing pain among laboring women.

PubMed and CINAHL were accessed to find randomized controlled trials (RCT) assessing the

use of acupressure for pain relief in labor. Key words used during this search were pain control

in labor, perceived labor pain, acupressure, Hegu point, point LI4, and acupressure and LI4

labor.

Results: The literature showed that perceived labor pain scores were significantly decreased

when acupressure was applied at point LI4, also known as the Hegu point, during the first stage

of labor (p<.05). Dabiri and Shahi (2014) demonstrated that decreased pain intensity was

reported among patients who received acupressure applied at the Hegu point for 30 minutes

during contractions (p<.001). Acupressure at the Hegu point decreased reported pain intensity at

30 minutes post-intervention (p<.05) (Hajiamini, Masoud, Ebadi, Mahboubh, & Matin, 2012).

According to Hamidzadeh, Shahpourian, Orak, Montazeri, and Khosravi (2012), labor pain

scores decreased at multiple time interval points following massage at LI4 point, when compared

to the control group (p<.001). Hamlaci and Yazici (2017) reported that subjective labor pain
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scores decreased when acupressure was applied at bilateral Hegu points during a contraction

(p<.0001).

Conclusion: Patients who received acupressure during the first stage of labor, at the LI4 point,

reported decreased pain levels. Further research is needed to evaluate during which phases of the

first stage of labor this PCI is most effective, and to evaluate the effectiveness of acupressure in

combination with other PCIs, when additional methods of pain control are required.
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Non-pharmacological Pain Control for Laboring Women

Pain is a common experience by women during labor and delivery, reported by more than

95% of mothers (Ebirim, Buowari, & Ghosh, 2012). Uncontrolled labor pain has negative

consequences including increased oxygen consumption, hyperventilation, increased blood

pressure, decreased uterine perfusion, and emotional distress (Ebirim et al., 2012). In labor and

delivery units throughout the United States, epidural anesthesia is the most requested form of

pain relief (American Pregnancy Association [APA], 2017). However, the use of medication in

labor has side effects for both the mother and the fetus, can be associated with negative

outcomes, and is not culturally acceptable by all women (APA, 2017; Jones et al., 2012). The use

of non-pharmacological pain control interventions (PCI) may be effective in decreasing pain

among laboring women, whether used alone or in combination with pharmacological

interventions.

A relevant evidence-based practice (EBP) question that will be discussed in this literature

review is: (P) Among women experiencing the first stage of labor, (I) do non-pharmacological

pain control interventions (PCI), (C) compared to no non-pharmacological PCIs, (O) affect self-

reported pain levels (T) over six months? The expected outcome measure is a decreased self-

reported pain level among laboring women.

Literature Search

PubMed and CINAHL databases were accessed to find randomized controlled trials

(RCT) assessing the use of acupressure for pain relief in labor. The years searched were 2012 to

2017. Key words used during this search were: pain control in labor, perceived labor pain,

acupressure, Hegu point, point LI4, and acupressure and LI4 labor.
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Literature Review

Clinical guidelines do not exist for the use of acupressure as a PCI during labor.

Therefore, four RCTs were used to evaluate the use of acupressure at point LI4 as an effective

non-pharmacological PCI. A single-blinded RCT by Dabiri and Shahi (2014) tested the

hypothesis that acupressure at LI4 point decreases reported pain in the first stage of labor. This

study utilized a sample size of 149 women presenting to the hospital in spontaneous labor.

Patients were excluded from the study if they chose to withdraw, if fetal distress or emergency

Cesarean section occurred, or if analgesic or augmentation medications were reported. After

criteria were met, participants were randomly assigned to an acupressure group (n=50), touch-

only group (n=50), or a control group (n=49). Women in the acupressure group received

rotational and vibrational pressure bilaterally at LI4 for one minute, followed by one minute of

rest before the pressure was reapplied, for a total of 30 minutes. Women in the touch group

received touch at the Hegu point, without pressure applied. No PCI was provided for women in

the control group. The visual analog scale (VAS) was used to measure pain intensity before the

intervention, then 30 minutes and one hour following intervention. The authors reported that pain

intensity in the acupressure group reduced pain intensity (p<.001), while pain intensity did not

decrease in the touch or control groups, but rather increased. This studys strengths included:

women were randomly assigned to groups, descriptions of reasons subjects did not complete the

study were provided, analysis occurred in respective intervention and control groups, and an

appropriately matched control group was chosen. Additional strengths were the use of the valid

and reliable VAS used to measure pain intensity, similar demographics and baseline variables

among subjects in all groups, and follow-up assessments conducted at necessary time-points to
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fully study the interventions effects. Weaknesses were that concealment of random assignment

during study enrollment was not described, and double blinding did not occur.

Hajiamini, Masoud, Ebadi, Mahboubh, and Matin (2012) tested the hypothesis that ice

massage, with or without acupressure, at the Hegu point can reduce intensity of labor pain. This

quasi-experimental RCT had a sample size of 30 women presenting to the hospital in the first

stage of labor. Patients were excluded from the study if there was underlying or pre-existing

disease, previous use of acupressure, analgesic use, or augmentation medications were reported.

After criteria were met, the patients were randomly assigned to an acupressure group (n=10), an

ice massage and acupressure group (n=10), or a control group (n=10). Women in the acupressure

group received rotational massage for ten minutes using a two-centimeter diameter glass marble

at LI4 on the hand. Women in the ice massage group received the same massage procedure as the

acupressure-only group, with the substitution of ice marbles in wet, thin gauze. Women in the

control group received ice balls at the Hegu point for ten minutes as well, but without pressure or

massage. The VAS was used to measure pain intensity before, and immediately after, the

intervention, then 30 minutes and one hour following intervention. The authors reported that at

30 minutes post-intervention, pain intensity reported via VAS decreased in both intervention

groups (p<.05). A Turkey test was then performed, which showed that ice massage use with

acupressure provided more pain relief than acupressure alone (p<.05). This studys strengths

included: women were randomly assigned to groups, descriptions of reasons for participant

withdrawal were provided, analysis occurred according to respective intervention and control

groups, and an appropriately matched control group was chosen, the instrument used to measure

pain severity (VAS) was valid and reliable, similar demographics and baseline variables among

subjects in all groups were demonstrated. Weaknesses were that concealment of random
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assignment from researchers enrolling mothers into the study was not described, double blinding

did not occur, adequate follow-up assessments were not conducted to fully study acupressure

effects, and a small sample size was used for the study.

Hamidzadeh, Shahpourian, Orak, Montazeri, and Khosravi (2012) tested the hypothesis

that women who receive LI4 acupressure during the active phase of labor experience less pain.

This was a single-blind RCT utilizing a sample size of 100 women presenting to the hospital in

the active phase of labor, with three to four centimeters dilatation, and regular uterine

contractions. Patients were excluded from the study if pharmacological intervention with

sedatives, analgesics, or oxytocin were provided. After criteria were met, random assignment to

an acupressure group (n=50) or a control group (n=50) occurred. Women assigned to the

acupressure group received LI4 acupressure during each contraction that occurred over a 20-

minute period. Women in the control group received touch, without massage, at the LI4 point.

Subjective pain scores were measured using the VAS before the intervention, immediately after

the intervention, 20 minutes after, and then every 60 minutes following intervention until the first

stage of labor ended. The authors reported that subjective labor pain scores decreased in the

intervention group immediately, and 20, 60, and 120 minutes following acupressure (p<.001).

Additionally, pain intensity perception 24 hours following labor was significantly lower in the

intervention group (p=.0001). Strengths of this study were: random assignment of women to the

control and intervention groups, attrition rationale was provided, follow-up assessments were

conducted 24 hours after labor to further assess the pain experience, mothers in the acupressure

and control groups were analyzed in their respective groups, an appropriately matched control

group, the use of the valid and reliable VAS, similar demographics and baseline variables among

women in all groups were demonstrated, a large sample size was used, and the trained midwife
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obtaining all measurements was blind to the intervention. Weaknesses were that concealment of

random assignment from researchers enrolling mothers into the study was not described and

double blinding did not occur.

Hamlaci and Yazici (2017) tested the hypothesis that acupressure on point LI4 would

decrease perceived labor pain. This was a single-blind RCT, with a sample size of 88 women

presenting to the hospital in the active phase of labor. After criteria were met, random

assignment to an acupressure group (n=44) or a control group (n=44) occurred. The trained

researchers thumbs were used to apply acupressure bilaterally to LI4 points, from the beginning

to the end of the contraction, for 16 total contractions: eight times during four- to five-centimeter

dilatation, and eight times during seven- to eight-centimeter dilatation. During periods without

acupressure, standard care was provided. Women in the control group received the same routine,

without acupressure. Subjective labor pain scores were measured using the VAS at hospital

admission, before and after both rounds of acupressure application, and two hours following

labor. The authors reported that subjective labor pain scores decreased in the intervention group

(p<.0001). Strengths of this study were: random assignment of women to the control and

intervention groups, attrition rationale was provided, concealment of random assignment from

individuals enrolling subjects occurred, adequate follow-up assessments were conducted to fully

study acupressure effects, analysis occurred according to respective intervention and control

groups, an appropriately matched control group was used, the VAS was valid and reliable, and

women in both groups were similar in regards to baseline clinical variables and demographics. A

weakness was the lack of double blinding as the researcher performing acupressure was not blind

to the study group.


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Synthesis

Dabiri and Shahi (2014) reported that pain intensity in the acupressure group reduced

pain intensity (p<.001) at 30 minutes, and one hour following application of pressure and

massage at the LI4 acupuncture point. Hajiamini et al. (2012) demonstrated that at 30 minutes

post-intervention, pain intensity reported via visual analog scale (VAS) decreased when

acupressure was applied at LI4, with even more decreased pain when the acupressure was

applied in combination with ice. Hamidzadeh et al. (2012) reported that subjective labor pain

scores decreased up to 120 minutes following acupressure at the Hegu point (p<.001).

Additionally, pain intensity perception 24 hours following labor was significantly lower in

women who received acupressure (p=.0001). Hamlaci and Yazici (2017) demonstrated that

subjective labor pain scores decreased after both rounds of acupressure application, and two

hours following labor (p<.0001).

These research findings demonstrated that the application of acupressure during the first

stage of labor, through massage and pressure, at the acupuncture point LI4 decreased the pain

intensity reported immediately to 24 hours following intervention. All of these studies

demonstrated that the reduction in pain intensity was statistically significant when used for low-

risk, single fetus, mothers presenting to the hospital in spontaneous labor, during the first stage.

Therefore, acupressure may be used as a PCI, implemented during the first stage of labor, to

decrease pain levels and decrease the incidence of epidural and narcotic use. Except for the

Hamidzadeh et al. (2012) study, the researchers collecting data on pain scores were not blind to

the intervention group assignments, so the need for more double-blind studies are required.

While all four studies reported at what time points the pain scores were reported to be lower by

the patient, more studies are required to determine the average time that acupressure decreases
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the experience of pain, based on how long the pressure and massage were applied. This

correlation between the lengths of time acupressure is applied and how long the pain control lasts

would be important in establishing clinical guidelines for this PCI. The studies utilized different

methods of applying pressure. For example, one study used a marble to apply acupressure, while

others used the researchers thumbs to apply the massage. A standardized protocol is needed for

the use of acupressure after more studies are completed that use the same method of applying

acupressure, using the same measurement to ensure a consistent amount of pressure that is

applied (Schlaeger et al., 2016). Further research should include studies that retain participants

regardless of the use of pharmacologic PCIs in order to study the effectiveness of acupressure for

pain, to assess the effectiveness in combination with other PCIs. A clinical guideline for the use

of acupressure is required.

Clinical Recommendations

Research findings demonstrate that acupressure provides pain relief among women in the

first stage of labor, when applied to the LI4 acupuncture point of the hand. Acupressure can be

successful in decreasing reported pain levels when used alone, but also may be successful when

used in combination with other PCIs. Additional research should be implemented to determine if

the use of LI4 acupressure reduces the costs of labor and delivery, decreases the rates of epidural

and narcotic analgesic use, and correlates with a decrease in complications such as emergency

Cesarean sections and fetal distress. A standard protocol and clinical guideline should be created

to guide the use of acupressure as a method of pain control. It could be beneficial to begin

teaching patients about acupressure prior to hospitalization, through information provided during

birthing classes and online forums. Certification programs may be created to provide adequate

training in this intervention. The use of acupressure, which requires minimal resources and has
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minimal side effects, offers a promising method of pain relief among laboring women, when

compared to no use of non-pharmacological PCIs.


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References

American Pregnancy Association. (2017). Epidural anesthesia. Retrieved from

http://americanpregnancy.org/labor-and-birth/epidural/

Dabiri, F., & Shahi, A. (2014). The effect of LI4 acupressure on labor pain intensity and duration

of labor: A randomized controlled trial. Oman Medical Journal, 29(6), 425429.

http://doi.org.ezproxy.hsc.usf.edu/10.5001/omj.2014.113

Ebirim, L. N., Buowari, O. Y., & Ghosh, S. (2012). Physical and psychological aspects of pain in

obstetrics. In Pain in Perspective (9). Retrieved from

https://www.intechopen.com/books/pain-in-perspective/physical-and-psychological-

aspects-of-pain-in-obstetrics

Hajiamini, Z., Masoud, S. N., Ebadi, A., Mahboubh, A., & Matin, A. A. (2012). Comparing the

effects of ice massage and acupressure on labor pain reduction. Complementary

Therapies in Clinical Practice, 18(3), 169-172. doi:10.1016/j.ctcp.2012.05.003

Hamidzadeh, A., Shahpourian, F., Orak, R. J., Montazeri, A. S., & Khosravi, A. (2012). Effects

of LI4 acupressure on labor pain in the first stage of labor. Journal of Midwifery &

Women's Health, 57(2), 133-138. doi:10.1111/j.1542-2011.2011.00138.x

Hamlaci, Y., & Yazici, S. (2017). The effect of acupressure applied to point LI4 on perceived

labor pains. Holistic Nursing Practice, 31(3), 167-176.

doi:10.1097/HNP.0000000000000205

Jones, L., Othman, M., Dowswell, T., Alfirevic, Z., Gates, S., Newburn, M., . . . Neilson, J.

(2012). Pain management for women in labour: An overview of systematic reviews.

Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD009234.pub2

Schlaeger, J. M., Gabzdyl, E. M., Bussell, J. L., Takakura, N., Yajima, H., Takayama, M., &
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Wilkie, D. J. (2017). Acupuncture and acupressure in labor. Journal of Midwifery &

Women's Health, 62(1), 12-28. doi:10.1111/jmwh.12545

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