Beruflich Dokumente
Kultur Dokumente
Brooke Fortner
Abstract
Clinical Problem: Women who experience uncontrolled and severe pain in labor are at greater
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),
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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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
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
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-
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
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
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
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
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
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
References
http://americanpregnancy.org/labor-and-birth/epidural/
Dabiri, F., & Shahi, A. (2014). The effect of LI4 acupressure on labor pain intensity and duration
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
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
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 &
Hamlaci, Y., & Yazici, S. (2017). The effect of acupressure applied to point LI4 on perceived
doi:10.1097/HNP.0000000000000205
Jones, L., Othman, M., Dowswell, T., Alfirevic, Z., Gates, S., Newburn, M., . . . Neilson, J.
Schlaeger, J. M., Gabzdyl, E. M., Bussell, J. L., Takakura, N., Yajima, H., Takayama, M., &
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