ORIGINAL ARTICLE

Effect of ear acupressure on acute postpartum perineal pain:

a randomised controlled study
Winny SC Kwan and William WH Li

Aims and objectives. To explore the effect of ear acupressure in relieving perineal pain in women during the first 48 hours
after delivery.
Background. Perineal pain is a common problem during postpartum, and different treatment modalities have been used for
relief. Ear acupressure has been reported to have possible benefit on relieving acute postpartum perineal pain.
Design. This study was designed as a prospective, randomised controlled trial.
Methods. Chinese women with a singleton vertex foetus at the gestation of 37 weeks or above were recruited. One hundred
and twenty six and 130 women were randomised into the intervention and control groups, respectively. Women in the inter-
vention group received application of tapes and seeds on four designated acupressure points on both ears, while women in
the control group received tapes on four irrelevant points. Both groups were instructed to stimulate the points in a similar
fashion. Pain perception was assessed by the Verbal Descriptive Pain Scale and the Visual Analogue Scale, and the consump-
tion of analgesics was also reviewed.
Results. No significant difference in perineal pain perception between the groups was observed in Verbal Descriptive Pain
Scale. Although the mean Visual Analogue Scale and the accumulative mean consumption of paracetamol were generally
lower in the intervention group, statistical significance was not reached.
Conclusions. There is no evidence so far to conclude that ear acupressure can effectively relieve perineal pain based on the
statistical results. Further research is suggested to explore whether the effectiveness of pain relief is affected by the frequency
and duration of acupressure point stimulation.
Relevance to clinical practice. Training of midwives to perform this intervention is easy to achieve, but further evidence is
required to prove its effectiveness.

Key words: Chinese, ear acupressure, pain relief, perineal pain, postpartum, pregnancy

Accepted for publication: 11 January 2013

Macarthur 2004, Andrews et al. 2008, Leeman et al. 2009,

Introduction
During the first few days after even a normal vaginal deliv-
ery, many women find the perineal pain unbearable while,
at the same time, they have to take up the skill of baby
care. The prevalence of postpartum perineal pain varies
among countries and ethnic groups (Macarthur &
Amorim Francisco et al. 2010, East et al. 2011), and fac-
tors such as parity (Thompson et al. 2002), severity of the
trauma (Klein et al. 1994, Albers et al. 1999) and mode of
delivery (Glazener et al. 1995, Declercq et al. 2008) may
affect the rate of prevalence. Different pharmacologic and
nonpharmacologic means to reduce postpartum perineal

Authors: Winny SC Kwan, RCMP, FHKAN, Registered Nurse-
Midwife, Department of Obstetrics & Gynecology, Queen Elizabeth
Hospital, Kowloon; William WH Li, MBBS, FRCOG, FHKAM
(O&G), Consultant Obstetrician, Department of Obstetrics &
Gynecology, Queen Elizabeth Hospital, Kowloon, Hong Kong
Correspondence: Winny SC Kwan, Registered Nurse-Midwife,
Department of Obstetrics & Gynecology, Queen Elizabeth Hospi-
tal, 30 Gascoigne Road, Kowloon, Hong Kong. Telephone: +852
2958 6151.
E-mail: bkscw01@ha.org.hk

© 2013 John Wiley & Sons Ltd

Journal of Clinical Nursing, 23, 1153–1164, doi: 10.1111/jocn.12281 1153
WSC Kwan and WWH Li
pain have been used. Nonpharmacologic pain relief meth-
ods such as ear acupressure or acupuncture have been prac-
tised, but researchers reported inconsistent findings. This
study discusses a clinical trial that aims to investigate the
effect of using ear acupressure to relieve immediate postpar-
tum perineal pain.
Background
The rate of perineal pain reported on the first day after
delivery could be as high as 92% (Macarthur & Macarthur
2004, Andrews et al. 2008). Multiparous women were less
likely than primiparous women to complain of perineal
pain after adjusting for the degree of perineal trauma
(Thompson et al. 2002). The severity of perineal trauma
had been found to be related to the prevalence of perineal
pain by Klein et al. (1994) and Albers et al. (1999). Klein
et al. (1994) also reported that spontaneous lacerations
were less painful than episiotomy. Women with assisted
vaginal birth were more likely to report a painful perineum
even at six months after childbirth as observed in a US
national survey (Declercq et al. 2008), a UK survey (Glaz-
ener et al. 1995) and an Australian cohort study (Thomp-
son et al. 2002). Parity, severity of trauma and the mode of
delivery are three major factors associated with the preva-
lence of perineal pain.
Adequate pain control is necessary for the postpartum
women to resume daily activities and to participate in
childcare. Oral analgesics such as paracetamol (Chou et al.
2010) and rectal analgesics such as diclofenac and indo-
methacin (Hedayati et al. 2005) had been widely researched
for its effectiveness on perineal pain relief, and the results
were significant. Many nonpharmacologic pain relief meth-
ods have been used by women, but not all modalities have
been evaluated by rigorous research. Better researched
modalities are cold therapy and therapeutic ultrasound.
East et al. (2007) found only limited evidence to support
the effectiveness of local cooling treatments, such as ice
packs, cold gel pads, cold or iced baths, in relieving peri-
neal pain following childbirth. Hay-Smith (1998) reported
that there is insufficient evidence to confirm the benefits or
harms of ultrasound for relieving perineal pain.
To have a better understanding of the effect of ear acu-
pressure on perineal pain, databases including the Cochrane
database, EMBASE, Medline, CINAHL and PubMed were
accessed. In addition, the China Journals Full-text Database
was searched as ear acupressure is a treatment modality
founded in Chinese medicine. The number of research on
the effect of ear acupressure or acupuncture on pain relief
is quite limited, and the majority is found in Chinese.
1154
Stimulation of the auricular points can be achieved by
taping ear ‘press studs’ or special Chinese ‘rape seeds’ on
the points accompanied by periodic massage (Anon 2002,
Yelland 2005). There is no standard recommendation on
the frequency and duration of stimulation. The ear auricle
contains specific acupuncture points related to each area of
the body, which, when stimulated, can provide rapid relief
from acute pain (Olesen et al. 1980). For lower back and
posterior pelvic pain associated with pregnancy, Wang
et al. (2009) reported that one week of continuous auricu-
lar acupuncture can decrease the pain and disability experi-
enced by women. Yelland (2005) has described the use of
ear acupuncture during labour, which enables women to
mobilise freely and assume natural birth positions with sat-
isfactory analgesic effects. Both Song (2002) and Wu et al.
(2003) reported significant effect of ear acupressure in
relieving labour pain, but both studies consisted of small
sample size. Kindberg et al. (2008) compared the effect of
ear acupuncture and local anaesthetics in relieving pain
during surgical repair of perineal lacerations. Although ear
acupuncture has been found to be less effective for pain
relief during the repair compared with local anaesthetics,
wound pain in 24–48 hours postpartum has been less com-
mon in women randomised to ear acupuncture, but this
finding is not statistically significant. Qu et al. (2000) have
indeed reported effectiveness of ear acupressure in relieving
episiotomy wound pain in 34 women. But due to a small
sample size and the lack of a scientific study design, further
research on this topic is warranted. It is hypothesised that
women who have received ear acupressure will report less
perineal pain during the first 48 hours after delivery, and
the amount of oral analgesics taken will be less compared
with the control group.
Methods
The aim of the study was to explore whether ear acupres-
sure could relieve the acute perineal pain during the first
48 hours after delivery. The first objective was to compare
the level of pain reported by women in the ear acupressure
group and in the control group. The second objective was
to evaluate the number of paracetamol tablets consumed by
women in these two groups.
Study design
This study was designed as a prospective, randomised
controlled clinical trial with an intervention group and a
control group. The trial was conducted from December
2010–July 2011 at an acute hospital in Hong Kong.
© 2013 John Wiley & Sons Ltd
Journal of Clinical Nursing, 23, 1153–1164
Original article Effect of ear acupressure on perineal pain

groups based on whether an episiotomy had been per-

Eligibility and recruitment
Chinese women admitted with a singleton vertex foetus at
the gestation of 37 weeks or above who intended to have a
normal vaginal delivery were eligible for recruitment into
the study. These women were approached at the antenatal
unit to facilitate a better understanding of the nature of the
study before they started to have labour pain. Written
informed consent was obtained from those women who
were willing to participate.
Only women with episiotomy or first or second degree of
perineal lacerations were included eventually. Exclusion cri-
teria included allergic history to adhesive tapes, mode of
delivery other than normal vaginal delivery, use of epidural
analgesia or any anaesthesia during labour, use of other
pharmacologic means for relief of pain other than perineal
pain after delivery, women with chronic pain, women with
diagnosed mental disorders, women with pre- or postnatal
depression and those with any medical indications that
required prolonged bed rest after delivery.
Allergic history was an absolute exclusion criterion as
application of adhesive tapes was required in this study.
Only normal vaginal deliveries were included to avoid the
confounding effect of other modes of delivery on perineal
pain. Participants opted for epidural analgesia and those
who had undergone anaesthesia for procedures like manual
removal of placenta, exploration of uterus and evacuation
of haematoma were excluded because of its possible impact
on pain perception after delivery. Women with chronic
pain, diagnosed mental disorders or depression related to
childbirth were excluded as these factors could possibly
distort the women’s perception of pain. Women with
conditions like primary postpartum haemorrhage and
hypertension or pre-eclampsia would not have the same
amount of activities as the rest of the participants at least
for the first 24 hours due to extended bed rest and were
therefore excluded from the study.
formed and whether the spontaneous laceration was first or
second degree if episiotomy had been avoided. The partici-
pants were randomly allocated to either one of the study
groups by drawing lots from one of the three envelops pre-
pared for first- and second-degree lacerations and episiot-
omy. If an episiotomy was clinically indicated, a
mediolateral episiotomy would be performed on the left
side of the perineum as a routine practice.
Blinding of intervention
The ear acupressure was achieved by taping seeds of Vac-
caria segetalis Garcke on various stimulation points on
both ears (Fig. 1). The apex of the auricle and the Shenmen
point were used to eliminate inflammation and relieve pain.
The point of external genital organs and the point of Anus
were selected for their correspondence to the anatomical
regions (Anon 2002). All women in the intervention group
had the same number of seeds placed on the same points.
Adhesive tapes of 6 mm 9 6 mm in size were used to
secure one seed to each stimulation point; thus, four pieces
of tapes with seeds were applied to each ear. The women
in the intervention group were instructed to press 30 sec-
onds onto each of the seeds every four hours while awake.
Apex of the
auricle Anus

Sample size and randomisation

External genital
organs
With an alpha value of 0
05 and power of 0
80, a total of
196 subjects for the two study groups would be needed if
the estimated effect size was 0
40 (Cohen 1988). Also with
an estimated dropout rate of 15%, an addition of 30
subjects would be recruited, for a total of 226.
Women who were deemed eligible and were still willing Shenmen

to participate were approached again prior to the suturing

of the perineal wound for randomisation. Stratified blocked
randomisation was used to assure that the number of Figure 1 Stimulation points for investigation of perineal wound
women would be equally distributed among the two study pain relief.

© 2013 John Wiley & Sons Ltd

Journal of Clinical Nursing, 23, 1153–1164 1155
WSC Kwan and WWH Li

The four-hour interval was designed to facilitate the women Assessed for Nonparticipants (n = 24)
eligibility Reasons:
to remember stimulating the points as they were aware that (n = 573) Adhesive tape allergy (n = 10)
Skeptical about modality (n = 6)
oral analgesics could be offered every four hours if needed. Demanding to perform task (n = 8)
Acupressure could be performed at the same time on both Enrollment
ears. with consent obtained
(n = 549) Participants excluded (n = 283)
For the control group, four pieces of adhesive tapes of Reasons:
Epidural analgesia (n = 24)
the same size were applied to four irrelevant points on both Cesarean section (n = 73)
Spontaneous or Vacuum extraction (n = 62)
ears, but no seeds were attached. Women in this group induction of labour Forceps delivery (n = 2)
Intact perineum (n = 22)
were instructed to rub over the tapes gently for 30 seconds Vaginal tear (n = 2)
Postpartum hemorrhage (n = 10)
every four hours while awake. Randomisation Operation for incomplete placenta (n = 5)
(n = 266) Wound complication (n = 3)
Ten midwives working in the labour room received one Hypertension/pre-eclampsia (n = 6)
individual training session by the author to apply the adhe- Practitioner not available (n = 74)

sive tapes with or without the seeds based on the rando-

mised result from drawing lots by the subjects. The training
session lasted for 30 minutes and consisted of demonstra- Intervention Control Withdrawal (n = 10)
group group Reasons:
tion and return demonstration to ensure uniform practice (n = 126) (n = 130) Wound hematoma (n = 1)
Late onset of hypertension (n = 1)
among all these midwives. These midwives were not Skin itchiness (n = 3)
Unknown (n = 5)
responsible for obtaining the pain score after the interven-
tion.
Application of the adhesives tapes was performed after
Analysis of Analysis of Analysis of
the completion of perineal wound suturing. Location of the VPDS VAS paracetamol
Before LA Six hours consumption
adhesive tapes could give hints of whether stimulations Arrive PN 12 hours 12 hours
12 hours 18 hours 24 hours
points or irrelevant points were used if participants had 18 hours 24 hours 36 hours
24 hours 36 hours 48 hours
prior knowledge of ear acupressure. A credibility question- 30 hours 48 hours
36 hours
naire was administered before discharge to assess any prior 42 hours
knowledge of ear acupressure and to obtain the women’s 48 hours

feedback on this treatment modality. The participants were

told not to remove the adhesive tapes before discharge.
All participants were also reminded that they could ask
for oral analgesics whenever needed. The standard prescrip-
tion of oral analgesics in the current setting was 500-mg
paracetamol tablet every four hours as needed.
Assessors of wound pain were midwives conducting the
perineal suture and midwives working on the postnatal
unit. Credibility testing of assessors was unnecessary
because the Verbal Descriptive Pain Scale (VDPS) would be
obtained by different midwives on duty. The research assis-
tant who performed the data entry was also blinded to the
group assignment.
Data collection
A total of 573 Chinese women with a singleton vertex foe-
tus at the gestation of 37 weeks or above intended to have
a normal vaginal delivery were approached in the antenatal
ward before they had any signs of labour onset. Figure 2
shows the CONSORT flowchart of this study. Ten women
were not eligible to join the study due to known allergy to
adhesive tape. Six women stated that they were sceptical
about this treatment modality and did not have any interest
Figure 2 CONSORT flowchart.
in Chinese medicine in general. There were eight other
women who refused to join the study because they found it
too demanding to have to massage the acupressure points
on a regular basis and to complete the self-administered
Visual Analogue Scale (VAS) score sheet. The refusal rate
was 4
2%. Therefore, consent was obtained from 549
women who eventually established the onset of labour
either spontaneously or by induction.
Based on the exclusion criteria, the number of women
who were eligible to remain in the study was further
reduced to 266 as other intrapartum and postpartum con-
founding factors occurred. Ten participants withdrew from
the study after randomisation. One woman was diagnosed
with wound haematoma in the postnatal ward and required
evacuation under anaesthesia. One woman had late onset
of hypertension and remained in bed rest for an extended
period of time. Three women complained of itchiness over
the ears, but no local allergic reaction was noted upon
physical examination. Five women withdrew without stat-
ing any reasons. The withdrawal rate was 3
8%. As a
result, data from 256 women were analysed, with 126 and

© 2013 John Wiley & Sons Ltd

1156 Journal of Clinical Nursing, 23, 1153–1164
Original article
130 women randomised to the intervention and control
groups, respectively.
Perineal pain was assessed using a simple VDPS – no
pain, mild pain, moderate pain or severe pain. These four
descriptions of pain were phrased in the same Chinese
wordings and printed on the assessment form so that all
assessors used the same expressions to obtain the partici-
pants’ subjective description of perineal pain. A baseline
assessment of perineal pain intensity was performed before
the infiltration of local anaesthetics for wound suturing.
The subsequent pain assessments were carried out on the
postnatal unit. Perineal pain was assessed again when
the woman was first transferred onto the assigned bed in
the postnatal ward approximately two hours after delivery.
The woman was encouraged to rest in bed for a few hours
before she attempted ambulation. The intensity of perineal
pain was assessed again after her first ambulation. Pain
assessments were then performed every shift by the midwife
on duty, equivalent to three times per day, until 48 hours
after delivery.
The Visual Analogue Scale was also used for the evalua-
tion of perineal pain intensity. Six 10-cm horizontal lines
with one extreme marked ‘no pain at all’ and the other end
marked ‘worst pain imaginable’ in Chinese were printed on
a self-reporting form for the participants to express the
intensity of perineal pain during the first two days of their
hospital stay. The women were instructed to make a mark
perpendicularly on one line three times per day at a point
that represented the level of pain at that moment. The dis-
tance from the zero endpoint to the mark, measured to the
nearest 0
5 cm, was recorded as the pain score. The medi-
cation records of all participants were reviewed after
discharge to evaluate the number of 500-mg paracetamol
tablets consumed during the first 48 hours after delivery.
Data analyses
The independent samples t-test was used for analyses of
continuous data with normal distribution. Ordinal data
were analysed by the chi-square test. The chi-square test
and the independent samples t-test were used to analyse the
VDPS and VAS scores, respectively. The number of paracet-
amol tablets taken was categorised into ordinal data for
analysis by the Mann–Whitney U-test. Individual questions
on the credibility questionnaire were analysed by the Mann
–Whitney U-test except the last question that required the
chi-square test to examine the yes or no categorical vari-
ables. All statistical tests were two-tailed, and p <0
05 were
considered statistically significant. All data obtained from
the evaluation forms were entered into the Statistical
© 2013 John Wiley & Sons Ltd
Journal of Clinical Nursing, 23, 1153–1164
Effect of ear acupressure on perineal pain
Package for Social Sciences for Windows, version 13.0
(SPSS Inc., Chicago, IL, USA) for analysis.
Missing or indistinguishable items were labelled as miss-
ing values. Because there were many missing values in
VDPS and VAS at every time point, three time points (12,
24 and 36 hours) were selected for further analysis. Eighty-
six participants completed both VDPS and VAS at these
three time points. ANCOVA test and repeated measures with
adjustment of confounding factors, including parity, labour
onset, foetal position at birth, type of perineal trauma, birth
weight and paracetamol, were used to test for group effect,
time effect and group–time interaction effect.
Ethics consideration
The study was approved by the Research Ethics Committee
of the Kowloon Central and Kowloon East Clusters, Hospi-
tal Authority, Hong Kong (Ref: KC/KE-10-0189/ER-5).
The consent form was available in Chinese. Participants
were assured that participation in the study was voluntary
and withdrawal at any time would not affect their plan of
care. Indications for episiotomy were clearly explained to
assure the participants that episiotomy would not be made
for the sake of research. All participants and caregivers
were also reminded that other means of pain relief meth-
ods, be it pharmacologic or nonpharmacologic, should not
be withheld at anytime during the study if it was appropriate
to use such methods.
Results
Mothers’ demographic data
As shown in Table 1, demographic characteristics, such as
age, BMI, smoking status, education level of the two
groups of women, were comparable. There was no signifi-
cant difference between the groups in terms of parity, the
type of labour onset, the mean duration of the first and
second stages of labour.
Position of the foetal head at birth was not recorded on
the hospital notes in nine cases. No significant difference
was found between the intervention and control groups in
regard to the foetal position at birth. The mean birth
weight of the infant was 3304
92 g in the intervention
group compared with 3180
08 g in the control group
(p < 0
05).
When examining the perineal outcome, it was found that
172 women received an episiotomy, and for those without
an episiotomy, 58 had a first-degree laceration, and 26 had
a second-degree laceration. The distribution of the various
1157
WSC Kwan and WWH Li

Table 1 Demographic characteristics of the intervention and control groups

Mean (SD) Total (n = 256) Intervention group (Ni = 126) Control group (Nc = 130) p-value*

Age (years) 30
87 (4
51) 30
98 (4
81) 30
77 (4
21) 0
71†

BMI 20
89 (2
79) 21
12 (2
98) 20
68 (2
58) 0
21†
Duration of 1st stage (min) 177
44 (126
67) 187
56 (132
49) 167
63 (120
46) 0
21†
Duration of 2nd stage (min) 28
11 (22
92) 28
26 (22
59) 27
97 (23
33) 0
92†
Birth weight of baby (grams) 3241
52 (376
86) 3304
92 (381
83) 3180
08 (362
95) 0
01†
Blood loss (ml) 229
88 (75
51) 230
56 (76
41) 229
23 (74
91) 0
89†
Frequency (%)
Smoking status
No 240 (93
8%) 121 (96%) 119 (91
5%) 0
14‡
Yes 16 (6
3%) 5 (4%) 11 (8
5%)
Education level
Secondary 139 (54
3%) 76 (60
3%) 63 (48
5%) 0
06‡
Tertiary 117 (45
7%) 50 (39
7%) 67 (51
5%)
Parity
Primigravida 183 (71
5%) 89 (70
6%) 94 (72
3%) 0
77‡
Multigravida 73 (28
5%) 37 (29
4%) 36 (27
7%)
Labour onset
Spontaneous 147 (57
4%) 78 (61
9%) 69 (53
1%) 0
15‡
Induction 109 (42
6%) 48 (38
1%) 61 (46
9%)
Foetal position at birth
Occipitoanterior 199 (77
7%) 104 (83
9%) 95 (77
2%) 0
19‡
Nonoccipitoanterior 48 (18
8%) 20 (16
1%) 28 (22
8%)
Type of perineal trauma
First-degree laceration 58 (22
7%) 29 (23%) 29 (22
3%) 0
76‡
Second-degree laceration 26 (10
2%) 11 (8
7%) 15 (11
5%)
Episiotomy 172 (67
2%) 86 (68
3%) 86 (66
2%)

*p <0
05 is considered statistically significant.

†
Independent samples t-test.
‡
Chi-square test.

types of trauma among the women in both groups was
found to be similar. All perineal wounds were sutured by
midwives with a rapidly absorbed suture with a tapercut
needle (Vicryl Rapide gauge 2-0, Ethicon, Johnson & John-
son International) using the continuous method. The
amount of local anaesthetic (2% lignocaine) given was
based on the extent of the laceration or episiotomy wound,
but no more than 10 ml was allowed in the current setting;
21-gauge needle was routinely used to apply the local
anaesthetic directly into the wound. The mean total blood
loss was not significantly different between the groups.
upon transfer onto the postnatal bed, and at 12, 18, 24,
30, 36, 42 and 48 hours postdelivery. The compliance rate
of the midwives to obtain the VDPS gradually declined
from the highest 94
9% upon the transfer of the woman to
the postnatal ward to the lowest 51
2% at 48 hours postde-
livery. No significant differences were found between the
intervention and control groups in the VDPS results
obtained at any point in time.
Differences in pain level measured by VAS between the
intervention and control groups

Participants were informed to mark the VAS three times

Differences in pain level measured by VDPS between the
intervention and control groups
Because the midwives would assess the pain level of the
woman any time during the shift, results obtained by the
VDPS, shown in Table 2, were grouped together according
to the time indicated by the midwife. Analysis was
performed on the VDPS results obtained before the local
anaesthetics were administered just prior to wound suturing,
per day, but they could do so at any time. Therefore,
results obtained from the VAS were grouped together at
their closest approximates to 6, 12, 18, 24, 36 and
48 hours postdelivery for calculating the mean at each time
point (Table 3). No significant differences were found
between the intervention and control groups in the VAS
results obtained at any point in time, although the mean
VAS scores were generally lower in the intervention group

© 2013 John Wiley & Sons Ltd

1158 Journal of Clinical Nursing, 23, 1153–1164
Original article Effect of ear acupressure on perineal pain

Table 2 Differences in pain level measured by VDPS between the intervention and control groups

Perineal pain perceived by no. of women (collected by midwives)

Intervention group (Ni = 126) Control group (Nc = 130)

VDPS No Mild Mod Severe No Mild Mod Severe Compliance rate (%) p-value*

Before LA 7 64 38 12 4 61 48 9 94
9 0
48

Arrive PN 32 77 12 2 38 77 13 1 98
4 0
86
12 hours 11 85 17 2 14 89 15 0 91
0 0
47
18 hours 4 84 12 0 10 88 12 1 82
4 0
38
24 hours 6 73 11 1 8 93 6 0 77
3 0
27
30 hours 6 87 7 0 7 75 9 1 75
0 0
60
36 hours 9 79 7 0 11 75 7 0 73
4 0
87
42 hours 7 69 6 1 7 66 4 0 62
5 0
74
48 hours 3 56 2 0 5 61 4 0 51
2 0
68

LA, local anaesthetic; mod, moderate; PN, postnatal ward.

*p <0
05 is considered statistically significant (Chi-square test).

Table 3 Differences in pain level measured by VAS between the intervention and control groups

Mean VAS (self-recorded by participants) (No

pain = 0, Most severe = 100)

Intervention group Control group Response rate (%)

Time after delivery (Ni = 126) (Nc = 130) (Intervention/Control) p-value*

Six hours 18
90 (0–60) 17
03 (0–53) 83
3% / 80
8% 0
37

12 hours 21
11 (1–56) 21
98 (0–51) 83
3% / 85
4% 0
65
18 hours 21
29 (0–55) 22
26 (0–51) 82
5% / 86
9% 0
59
24 hours 19
94 (1–50) 20
60 (0–50) 90
5% / 96
9% 0
70
36 hours 17
90 (0–52) 18
45 (0–50) 88
9% / 96
2% 0
74
48 hours 15
98 (1–51) 16
80 (0–49) 69
8% / 80
8% 0
64

*p <0
05 is considered statistically significant (independent samples t-test).

at all time points after the first six hours. It was noted that
the response rate from the women ranged from 82–93
8%
at different time intervals.
Differences in paracetamol consumption between the
intervention and control groups
The accumulative mean consumption of paracetamol was
compared at 12, 24, 36 and 48 hours postdelivery
(Table 4). It was found that the accumulative mean
consumption of paracetamol tablets was greater in the con-
trol group at all times, but no statistical significance was
observed.
Further analysis of a subgroup at three time points
The subgroup of 86 participants, with 41 in the interven-
tion group and 45 in the control group, had similar demo-
graphic characteristics as the overall sample. Tables 5–7
show that there was no significant difference in the pain
level by VDPS or VAS and the number of paracetamol con-
sumed between the intervention and control groups after
confounding factors were adjusted (p > 0
05) at 12, 24 and
36 hours. Time and group effects were not observed
(p > 0
05), and there was no interaction effect between the
two groups (p > 0
05).
Responses from the credibility questionnaire
Two hundred and thirty-six women returned the credibility
questionnaire upon discharge, and the results are shown in
Table 8. There was no significant difference between the
groups in terms of having previous exposure to ear acupres-
sure or ear acupuncture and their belief of ear acupressure in
relieving perineal pain. Women from the intervention group
tended to show more agreement with the following statements:

© 2013 John Wiley & Sons Ltd

Journal of Clinical Nursing, 23, 1153–1164 1159
WSC Kwan and WWH Li

Table 4 Difference in paracetamol consumption between the intervention and control groups

Accumulative mean consumption of paracetamol (no. of 500-mg tablets)

Time after delivery Intervention group (Ni = 126) Control group (Nc = 130) p-value*

12 hours 0
33 (0–2) 0
42 (0–2) 0
39

24 hours 1
04 (0–5) 1
15 (0–4) 0
83
36 hours 1
54 (0–7) 1
73 (0–7) 0
71
48 hours 2
06 (0–10) 2
31 (0–9) 0
77

*p <0
05 is considered statistically significant (Mann–Whitney U-test).

Table 5 Subgroup analysis of VDPS at three time points (12, 24 and 36 hours)

Total Intervention group Control group

Time after delivery Mean (SD) n Mean (SD) Ni Mean (SD) Nc F (p-value)

12 hours 2
06 (0
66) 86 2
10 (0
70) 41 2
02 (0
62) 45 0
49 (0
48)†,§

24 hours 2
05 (0
43) 86 2
07 (0
47) 41 2
02 (0
40) 45 0
27 (0
60)†,§
36 hours 1
99 (0
42) 86 2
00 (0
39) 41 1
98 (0
45) 45 0
06 (0
81)†,§
Between groups [group]‡,§
F (p-value) 0
44 (0
51)
Within group [time]‡,§
F (p-value) [A, B] 0
26 (0
77) [0
48, 0
03 (0
97) [0
89, 0
52 (0
60) [0
31,
0
91] 0
86] 0
86]
Interaction effect [time 9 group]‡,§
F (p-value) [A, B] 0
13 (0
88) [0
70,
0
74]

A – 12 hours vs. 24 hours, B – 24 hours vs. 36 hours.

†
ANCOVA.
‡
Repeated measure.
§
Adjustment of factors including parity, labour onset, foetal position at birth, type of perinea trauma, birth weight and paracetamol.

Table 6 Subgroup analysis of VAS at 3 time points (12, 24 and 36 hours)

Total Intervention group Control group

Time after delivery Mean (SD) n Mean (SD) Ni Mean (SD) Nc F (p-value)

12 hours 22
02 (14
85) 86 21
98 (15
78) 41 22
07 (14
12) 45 0
11 (0
74)†,§

24 hours 20
35 (13
76) 86 19
20 (13
49) 41 21
40 (14
08) 45 0
30 (0
59)†,§
36 hours 17
17 (12
37) 86 16
76 (12
80) 41 17
56 (12
09) 45 0
02 (0
88)†,§
Between groups [group]‡,§
F (p-value) 0
00 (0
99)
Within group [time]‡,§
F (p-value) [A, B] 0
20 (0
82) [0
62, 0
67] 0
87 (0
43) [0
50, 0
38] 0
02 (0
98) [0
86, 0
91]
Interaction effect [time 9 group]‡, §
F (p-value) [A, B] 1
18 (0
31) [0
19, 0
39]

A – 12 hours vs. 24 hours, B – 24 hours vs. 36 hours.

†
ANCOVA.
‡
Repeated measure.
§
Adjustment of factors including parity, labour onset, foetal position at birth, type of perinea trauma, birth weight and paracetamol.

‘I have manipulated the acupoints as instructed’ and ‘I would another nonpharmacological method to relieve perineal pain at
recommend this treatment to a friend who just delivered a the same time, and this referred to the air ring available in the
baby’. Twenty-four women indicated that they were using postnatal ward to promote comfort when sitting up.

© 2013 John Wiley & Sons Ltd

1160 Journal of Clinical Nursing, 23, 1153–1164
Original article Effect of ear acupressure on perineal pain

Table 7 Subgroup analysis of paracetamol consumption at 3 time points (12, 24 and 36 hours)

Total Intervention group Control group

Time after delivery Mean (SD) n Mean (SD) Ni Mean (SD) Nc F (p-value)

12 hours 0
35 (0
61) 86 0
32 (0
61) 41 0
38 (0
61) 45 0
13 (0
55)†,§

24 hours 0
64 (0
84) 86 0
56 (0
78) 41 0
71 (0
90) 45 0
42 (0
52)†,§
36 hours 0
58 (0
76) 86 0
54 (0
71) 41 0
62 (0
81) 45 0
37 (0
54)†,§
Between groups [group]‡,§
F (p-value) 0
59 (0
44)
Within group [time]‡,§
F (p-value) [A, B] 2
46 (0
09) [0
65, 0
21 (0
81) [0
79, 1
62 (0
21) [0
32,
0
09] 0
72] 0
31]
Interaction effect [time 9 group]‡,§
F (p-value) [A, B] 0
03 (0
97) [0
81,
0
90]

A – 12 hours vs. 24 hours, B – 24 hours vs. 36 hours.

†
ANCOVA.
‡
Repeated measure.
§
Adjustment of factors including parity, labour onset, foetal position at birth, type of perinea trauma and birth weight.

Table 8 Responses from the credibility questionnaire

Ear acupressure

Intervention group (Ni = 126) Control group (Nc = 130) p-value*

Q1 2
16 (n = 117) 2
04 (n = 118) 0
57†

Q2 2
82 (n = 117) 2
61 (n = 119) 0
17†
Q3 3
39 (n = 116) 2
95 (n = 119) 0
01†
Q4 2
83 (n = 115) 2
55 (n = 118) 0
06†
Q5 3
08 (n = 116) 2
80 (n = 119) 0
08†
Q6 3
00 (n = 116) 2
62 (n = 119) 0
04†
Q7 No = 88/Yes = 13 No = 96/Yes = 11 0
56‡
Q1 I have previous exposure of ear acupressure or ear acupuncture
Q2 I believe ear acupressure can relieve perineal pain
Q3 I have manipulated the acupoints as instructed
Q4 I am having less perineal pain because of ear acupressure
Q5 I will use this treatment again if I deliver another baby
Q6 I would recommend this treatment to a friend who just delivered a baby
Q7 I have used other nonpharmacologic methods to relieve perineal pain

*p <0
05 is considered statistically significant.

†
Mann–Whitney U-test.
‡
Chi-square test.
Remark: Q1–6 are rated on a 0 to 5 numeric scale with 0 indicating strongly disagree and 5 indicating strongly agree. Q7 is answered yes
or no with space provided for elaboration.

Sixty-seven per cent of the women received an episiotomy

Discussion
Ear acupressure is observed to be a well-accepted modality
among parturient women as evidenced by a low refusal rate
(4
2%) and a low withdrawal rate (3
8%). Informed con-
sent was obtained from 549 women, but only 266 (48
5%)
were successfully enrolled in the study. The loss of partici-
pants was mainly due to confounding factors that arose
during the intrapartum period.
in this sample, which was found to be higher than the episi-
otomy rate (53%) in the overall population of women who
had a spontaneous vaginal delivery in this hospital during
the same period. This difference was probably due to the
fact that the proportion of primiparous women was much
greater in the study sample (71%) than that in the overall
population (48%). A greater proportion of primiparous
women in this study sample may not affect the study result

© 2013 John Wiley & Sons Ltd

Journal of Clinical Nursing, 23, 1153–1164 1161
WSC Kwan and WWH Li
as long as they are evenly distributed between the interven-
tion and control groups. Stratified blocked randomisation
had achieved a fairly even distribution of the various types
of perineal trauma between the study groups while main-
taining the purpose of randomisation.
The VDPS score was not significantly different between
the study groups before suturing. This was to ensure that
the baseline VDPS score was similar between the groups
before any intervention was carried out. However, there
were no differences observed in the VDPS results during the
first two days of hospitalisation. The majority of women
rated the perineal pain as being mild in both intervention
and control groups, and this contrasted with the findings of
Dahlen and Homer (2008) who reported that Asian women
were more likely to rate their perineal pain as being moder-
ate to severe on day 1 following the birth. The highest
levels of pain by VAS were noted during the first
12–18 hours in both intervention and control groups with
a gradual decline observed as time passed. The mean VAS
scores were generally lower in the intervention group after
the first six hours, but no statistical significance was
reached at any point in time. The accumulative mean con-
sumption of paracetamol was generally lesser in the inter-
vention group, although not statistically significant. These
results basically echo with the finding of Kindberg et al.
(2008) that perineal pain in 24–48 hours postpartum was
less common in women randomised to ear acupuncture
even though statistical significance was not reached.
Many missing values were noted in both VDPS and VAS
at every time point, and this reflected that both the
midwives and mothers did not follow the instructions
closely. A subgroup analysis of 86 participants at three
time points was made to reduce the effect of missing
values on the results. However, this selected sample was
much smaller than the intended sample size, and no signif-
icant difference between the intervention and control
groups was observed.
The response rate ranged from 81–92% for individual
questions with an average response rate of 90% obtained for
the overall questionnaire. Based on the questionnaire, there
was no significant difference between the groups in terms of
having previous exposure to ear acupressure or ear acupunc-
ture and their belief of ear acupressure in relieving perineal
pain. However, it could not be ensured that the mothers did
not communicate with each other about the different treat-
ment they received; therefore, blinding of the participants
could not be guaranteed. Women in the intervention group
reported to have higher compliance to the instruction on
manipulation of the acupressure points compared with those
in the control group; however, full compliance was not
1162
observed in either group. Although not statistically signifi-
cant, more women in the intervention group agreed that they
had less perineal pain because of the ear acupressure. They
were also more likely to use ear acupressure again in subse-
quent delivery and to recommend ear acupressure to others.
Study limitation
This study had certain limitations that needed to be
addressed. First, selection bias could occur because not all
eligible women admitted to this hospital were approached
due to manpower constraints. The sample of participants
recruited had comprised of more primiparous women than
usual, and generalisation of the study results could be ques-
tioned if the sample was not representative of the larger
population.
Second, this study only explored the effect of ear acupres-
sure in relieving perineal pain among Chinese women thus
limiting the generalisability of study results to women of
other ethnic origins. Because racial differences in perineal
trauma have been reported by several authors (Goldberg
et al. 2003, Hopkins et al. 2005, Dahlen & Homer 2008)
with Asian, particularly Chinese, women at higher risk of
severe trauma, this study was purposely designed to look at
one particular racial group alone.
Third, the standardisation of intervention performed by
the trained midwives could never be guaranteed even when
uniform training had been provided with all the trainees
assessed by return demonstration. What was even more dif-
ficult to control in terms of standardisation of intervention
was to ensure that all participants would follow the instruc-
tion on manipulating the acupressure points. Responses for
the credibility questionnaire showed that full compliance to
the instruction was not achieved. Further survey would be
recommended to evaluate the relationship between
frequency of acupressure point stimulation and its effect on
pain relief. There was no standard recommendation on the
frequency and duration of point stimulation.
Fourth, paracetamol was also offered in the current set-
ting for relief of breast engorgement pain. Thus, the con-
sumption of paracetamol might not have truly reflected the
women’s need to relieve perineal pain. Further study should
consider this confounding variable and should specify the
indication for taking other pain relief measures.
Conclusion
This study discussed the results of a clinical study that
explored the effect of ear acupressure in relieving perineal
pain during the immediate postpartum period. No
© 2013 John Wiley & Sons Ltd
Journal of Clinical Nursing, 23, 1153–1164
Original article Effect of ear acupressure on perineal pain

statistical significance was observed between the interven-
tion and control groups in terms of pain perception mea-
sured by the VDPS, VAS and the mean accumulative
consumption of paracetamol. However, compliance to fol-
low the guidelines on reporting pain scores and indica-
tions for taking analgesics should be monitored more
closely to avoid missing or mistaken values. Standardisa-
tion of the intervention from application of seeds and
tapes to stimulation of the points should be vigilantly
controlled in future. Future research could evaluate the
frequency and duration of point stimulation on the effec-
tiveness of pain relief. A study sample with women of
different parity and ethnic groups would probably make
the results more generalisable.
woman to the postnatal ward to the lowest 51
2% at
48 hours postdelivery, with an average of 76
4% compli-
ance rate. For the self-administered VAS scores, the
response rate from the women ranged from 82–93
8% at
different time intervals, with an average of 85
5%
response rate. Such discrepancy in the pain assessment by
healthcare professionals and the self-reporting pain per-
ception by the women raised a concern of whether the
issue of perineal pain was overlooked by the midwives.
Even though most women seem to be able to take up the
activities of self-care and baby care in the first two days
after delivery, it can never be assumed that they are all
pain free.

Relevance to clinical practice
It was noted that 74 participants were lost due to the
unavailability of practitioner on site, and this raised the
question of practicality of using ear acupressure in a busy
clinical setting. Familiarity with the application process and
training of additional midwives in performing this task
would probably facilitate the implementation of this inter-
vention, but further evidence to prove its effectiveness
would first of all be required.
Another interesting point to note is that the compliance
rate of the midwives to obtain the VDPS score gradually
declined from the highest 98
4% upon the transfer of the
Acknowledgements
This project was funded by the Hong Kong Obstetrics and
Gynecological Trust Fund. We are indebted to all the
women for their participation in this study and to the mid-
wives for their interventions and data collection. We are
also grateful for the support of our research and statistical
assistants in subject recruitment, data collection and analy-
sis.
Contributions
Study design: WSCK, WHL; data collection and analysis:
WSCK, WHL and manuscript preparation: WSCK.

References
Albers L, Garcia J, Renfrew M, McCandlish
R & Elbourne D (1999) Distribution of
genital tract trauma in childbirth and
related postnatal pain. Birth 26, 11–15.
Amorim Francisco A, Vasconcellos de
Oliveira SMJ, Barbosa da Silva FM,
Bick D & Gonzalez Riesco ML (2010)
Women’s experiences of perineal pain
during the immediate postnatal period:
A cross-sectional study in Brazil.
Midwifery 27, e254–e259.
Andrews V, Thakar R, Sultan AH & Jones
PW (2008) Evaluation of postpartum
perineal pain and dyspareunia – a pro-
spective study. European Journal of
Obstetrics & Gynecology and Repro-
ductive Biology 137, 152–156.
Anon (2002) Practical Ear-Needling Ther-
apy. Medicine & Health Publishing
Company, Hong Kong.
Chou D, Abalos E, Gyte GML &
G€ulmezoglu AM (2010) Paracetamol/
acetaminophen (single administration)
for perineal pain in the early postpar-
tum period. Cochrane Database of
Systematic Reviews, Issue 3, Art. No.:
CD008407.
Cohen J (1988) Statistical Power Analysis
for the Behavioral Sciences, 2nd edn.
Lawrence Erlbaum Associates, Hills-
dale, NJ.
Dahlen H & Homer C (2008) Perineal
trauma and postpartum perineal mor-
bidity in Asian and Non-Asian primip-
arous women giving birth in Australia.
Journal of Obstetric, Gynecologic,
and Neonatal Nursing 37, 455–463.
Declercq E, Cunningham DK, Johnson C
& Sakala C (2008) Mothers’ reports
of postpartum pain associated with
vaginal and cesarean deliveries: results
of a national survey. Birth 35, 16–24.
East CE, Begg L, Henshall NE, Marchant P
& Wallace K (2007) Local cooling for
relieving pain from perineal trauma
sustained during childbirth. Cochrane
Database of Systematic Reviews, Issue
1, Art. No.: CD006304.
East CE, Sherburn M, Nagle C, Said J &
Forster D (2011) Perineal pain follow-
ing childbirth: Prevalence, effects on
postnatal recovery and analgesia
usage. Midwifery 28, 93–97.
Glazener CMA, Abdalla M, Stroud P, Naji
S, Templeton A & Russell IT (1995)
Postnatal maternal morbidity: extent,
causes, prevention and treatment. Brit-
ish Journal of Obstetrics and Gynae-
cology 102, 282–287.
Goldberg J, Hyslop T, Tolosa JE & Sultana
C (2003) Racial differences in severe
perineal lacerations after vaginal deliv-
ery. American Journal of Obstetrics
and Gynecology 188, 1063–1067.
Hay-Smith J (1998) Therapeutic ultrasound
for postpartum perineal pain and

© 2013 John Wiley & Sons Ltd

Journal of Clinical Nursing, 23, 1153–1164 1163
WSC Kwan and WWH Li

dyspareunia. Cochrane Database of
Systematic Reviews, Issue 3, Art. No.:
CD000495.
Hedayati H, Parsons J & Crowther CA
(2005) Topically applied anaesthetics
for treating perineal pain after child-
birth. Cochrane Database of Systematic
Reviews, Issue 2, Art. No.: CD004223.
Hopkins LM, Caughey AB, Glidden DV &
Laros RK (2005) Racial/ethnic
differences in perineal, vaginal and
cervical lacerations. American Journal
of Obstetrics and Gynecology 193,
455–459.
Kindberg S, Klunder L, Strom J & Henrik-
sen TB (2008) Ear acupuncture or
local anaesthetics as pain relief during
postpartum surgical repair: a random-
ized controlled trial. British Journal of
Obstetrics and Gynaecology 116, 569
–576.
Klein MC, Gauthier RJ, Robbins JM, Ka-
czorowski J, Jorgensen SH, Franco
ED, Johnson B, Waghorn K, Gelfand
MM, Guralnick MS, Luskey GW &
Joshi AK (1994) Relationship of episiot-
omy to perineal trauma and morbidity,
sexual dysfunction, and pelvic floor
relaxation. American Journal of Obstet-
rics and Gynecology 171, 591–598.
Leeman L, Fullilove AM, Borders N, Manoc-
chio R, Albers LL & Rogers RG (2009)
Postpartum perineal pain in a low episi-
otomy setting: association with severity
of genital trauma, labor care, and birth
variables. Birth 36, 283–288.
Macarthur AJ & Macarthur C (2004) Inci-
dence, severity, and determinants of
perineal pain after vaginal delivery: a
prospective cohort study. American
Journal of Obstetrics and Gynecology
191, 1199–1204.
Olesen TD, Kroening RJ & Bresler DE
(1980) An experimental evaluation of
auricular diagnosis: the somatotopic
mapping of musculoskeletal pain at ear
acupuncture points. Pain 8, 217–229.
Qu A, Cao W & Wang C (2000) Effect of
ear acupressure on relieving mediolat-
eral episiotomy wound pain – a report
of 34 cases. Chinese Acupuncture &
Moxibustion 3, 140.
Song C (2002) Application of auricular
point taping and pressing therapy in
doula type labor. Chinese Acupunc-
ture & Moxibustion 22, 521–522.
Thompson JF, Roberts CL, Currie M &
Ellwood DA (2002) Prevalence and
persistence of health problems after
childbirth: associations with parity
and method of birth. Birth 29, 83–
94.
Wang S, DeZinno P, Lin EC, Lin H, Yue
JJ, Berman MR, Braveman F & Kain
ZN (2009) Auricular acupuncture as a
treatment for pregnant women who
have low back and posterior pelvic
pain: a pilot study. American Journal
of Obstetrics and Gynecology 201,
271.e1–271.e9.
Wu J, Zheng Y & Zhang X (2003) Use of
ear point stimulation and Ciliao injec-
tion for inhibiting pain in parturition.
Journal of Medical Theory & Practice
16, 1392–1393.
Yelland S (2005) Acupuncture in
Midwifery, 2nd edn. Elsevier, Edin-
burgh.

The Journal of Clinical Nursing (JCN) is an international, peer reviewed journal that aims to promote a high standard of
clinically related scholarship which supports the practice and discipline of nursing.

For further information and full author guidelines, please visit JCN on the Wiley Online Library website: http://
wileyonlinelibrary.com/journal/jocn

Reasons to submit your paper to JCN:

High-impact forum: one of the world’s most cited nursing journals, with an impact factor of 1
316 – ranked 21/101
(Nursing (Social Science)) and 25/103 Nursing (Science) in the 2012 Journal Citation Reportsâ (Thomson Reuters,
2012).
One of the most read nursing journals in the world: over 1
9 million full text accesses in 2011 and accessible in over
8000 libraries worldwide (including over 3500 in developing countries with free or low cost access).
Early View: fully citable online publication ahead of inclusion in an issue.
Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jcnur.
Positive publishing experience: rapid double-blind peer review with constructive feedback.
Online Open: the option to make your article freely and openly accessible to non-subscribers upon publication in Wiley
Online Library, as well as the option to deposit the article in your preferred archive.

© 2013 John Wiley & Sons Ltd

1164 Journal of Clinical Nursing, 23, 1153–1164