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Meta-Analysis
. 2017 Oct 17;10(10):CD002962.
doi: 10.1002/14651858.CD002962.pub4.

Acupuncture or acupressure for induction of labour

Caroline A Smith  1 , Mike Armour, Hannah G Dahlen
Affiliations
Meta-Analysis

Acupuncture or acupressure for induction of labour

Caroline A Smith et al. Cochrane Database Syst Rev. .

Abstract

Background: This is one of a series of reviews of methods of cervical ripening and labour induction. The use of complementary therapies is increasing. Women may look to complementary therapies during pregnancy and childbirth to be used alongside conventional medical practice. Acupuncture involves the insertion of very fine needles into specific points of the body. Acupressure is using the thumbs or fingers to apply pressure to specific points. The limited observational studies to date suggest acupuncture for induction of labour has no known adverse effects to the fetus, and may be effective. However, the evidence regarding the clinical effectiveness of this technique is limited.

Objectives: To determine, from the best available evidence, the effectiveness and safety of acupuncture and acupressure for third trimester cervical ripening or induction of labour.

Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2016), PubMed (1966 to 25 November 2016), ProQuest Dissertations & Theses (25 November 2016), CINAHL (25 November 2016), Embase (25 November 2016), the WHO International Clinical Trials Registry Portal (ICTRP) (3 October 2016), and bibliographies of relevant papers.

Selection criteria: Randomised controlled trials comparing acupuncture or acupressure, used for third trimester cervical ripening or labour induction, with placebo/no treatment or other methods on a predefined list of labour induction methods.

Data collection and analysis: Two review authors independently assessed trials for inclusion and risk of bias, extracted data, and checked them for accuracy. The quality of the evidence was assessed using GRADE.

Main results: This updated review includes 22 trials, reporting on 3456 women. The trials using manual or electro-acupuncture were compared with usual care (eight trials, 760 women), sweeping of membranes (one trial, 207 women), or sham controls (seven trials, 729 women). Trials using acupressure were compared with usual care (two trials, 151 women) or sham controls (two trials, 239 women). Many studies had a moderate risk of bias.Overall, few trials reported on primary outcomes. No trial reported vaginal delivery not achieved within 24 hours and uterine hyperstimulation with fetal heart rate (FHR) changes. Serious maternal and neonatal death or morbidity were only reported under acupuncture versus sham control. Acupuncture versus sham control There was no clear difference in caesarean sections between groups (average risk ratio (RR) 0.80, 95% confidence interval (CI) 0.56 to 1.15, eight trials, 789 women; high-quality evidence). There were no reports of maternal death or perinatal death in the one trial that reported this outcome. There was evidence of a benefit from acupuncture in improving cervical readiness for labour (mean difference (MD) 0.40, 95% CI 0.11 to 0.69, one trial, 125 women), as measured by cervical maturity within 24 hours using Bishop's score. There was no evidence of a difference between groups for oxytocin augmentation, epidural analgesia, instrumental vaginal birth, meconium-stained liquor, Apgar score < 7 at five minutes, neonatal intensive care admission, maternal infection, postpartum bleeding greater than 500 mL, time from the trial to time of birth, use of induction methods, length of labour, and spontaneous vaginal birth. Acupuncture versus usual care There was no clear difference in caesarean sections between groups (average RR 0.77, 95% CI 0.51 to 1.17, eight trials, 760 women; low-quality evidence). There was an increase in cervical maturation for the acupuncture (electro) group compared with control (MD 1.30, 95% CI 0.11 to 2.49, one trial, 67 women) and a shorter length of labour (minutes) in the usual care group compared to electro-acupuncture (MD 124.00, 95% CI 37.39 to 210.61, one trial, 67 women).There appeared be a differential effect according to type of acupuncture based on subgroup analysis. Electro-acupuncture appeared to have more of an effect than manual acupuncture for the outcomes caesarean section (CS), and instrumental vaginal and spontaneous vaginal birth. It decreased the rate of CS (average RR 0.54, 95% CI 0.37 to 0.80, 3 trials, 327 women), increased the rate of instrumental vaginal birth (average RR 2.30, 95%CI 1.15 to 4.60, two trials, 271 women), and increased the rate of spontaneous vaginal birth (average RR 2.06, 95% CI 1.20 to 3.56, one trial, 72 women). However, subgroup analyses are observational in nature and so results should be interpreted with caution.There were no clear differences between groups for other outcomes: oxytocin augmentation, use of epidural analgesia, Apgar score < 7 at 5 minutes, neonatal intensive care admission, maternal infection, perineal tear, fetal infection, maternal satisfaction, use of other induction methods, and postpartum bleeding greater than 500 mL. Acupuncture versus sweeping if fetal membranes One trial of acupuncture versus sweeping of fetal membranes showed no clear differences between groups in caesarean sections (RR 0.64, 95% CI 0.34 to 1.22, one trial, 207 women, moderate-quality evidence), need for augmentation, epidural analgesia, instrumental vaginal birth, Apgar score < 7 at 5 minutes, neonatal intensive care admission, and postpartum bleeding greater than 500 mL. Acupressure versus sham control There was no evidence of benefit from acupressure in reducing caesarean sections compared to control (RR, 0.94, 95% CI 0.68 to 1.30, two trials, 239 women, moderate-quality evidence). There was no evidence of a clear benefit in reduced oxytocin augmentation, instrumental vaginal birth, meconium-stained liquor, time from trial intervention to birth of the baby, and spontaneous vaginal birth. Acupressure versus usual care There was no evidence of benefit from acupressure in reducing caesarean sections compared to usual care (RR 1.02, 95% CI 0.68 to 1.53, two trials, 151 women, moderate-quality evidence). There was no evidence of a clear benefit in reduced epidural analgesia, Apgar score < 7 at 5 minutes, admission to neonatal intensive care, time from trial intervention to birth of the baby, use of other induction methods, and spontaneous vaginal birth.

Authors' conclusions: Overall, there was no clear benefit from acupuncture or acupressure in reducing caesarean section rate. The quality of the evidence varied between low to high. Few trials reported on neonatal morbidity or maternal mortality outcomes. Acupuncture showed some benefit in improving cervical maturity, however, more well-designed trials are needed. Future trials could include clinically relevant safety outcomes.

PubMed Disclaimer

Conflict of interest statement

Caroline Smith: is an author of one of the included trials (Smith 2008), and so a third independent person assessed and extracted data for this trial.

Mike Armour: is an acupuncturist recently involved in clinical practice and the director of an acupuncture clinic.

Hannah Dahlen: none known.

Figures

1
1
Study flow diagram.
2
2
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Acupuncture versus sham control, Outcome 1 Caesarean section.
1.2
1.2. Analysis
Comparison 1 Acupuncture versus sham control, Outcome 2 Neontal seizure.
1.3
1.3. Analysis
Comparison 1 Acupuncture versus sham control, Outcome 3 Cervical maturity within 24 hours (Bishop score).
1.4
1.4. Analysis
Comparison 1 Acupuncture versus sham control, Outcome 4 Oxytocin augmentation.
1.5
1.5. Analysis
Comparison 1 Acupuncture versus sham control, Outcome 5 Epidural analgesia.
1.6
1.6. Analysis
Comparison 1 Acupuncture versus sham control, Outcome 6 Instrumental vaginal birth.
1.7
1.7. Analysis
Comparison 1 Acupuncture versus sham control, Outcome 7 Meconium‐stained liquor.
1.8
1.8. Analysis
Comparison 1 Acupuncture versus sham control, Outcome 8 Apgar score less than seven at five minutes.
1.9
1.9. Analysis
Comparison 1 Acupuncture versus sham control, Outcome 9 Neonatal intensive care unit admission.
1.10
1.10. Analysis
Comparison 1 Acupuncture versus sham control, Outcome 10 Perinatal death.
1.11
1.11. Analysis
Comparison 1 Acupuncture versus sham control, Outcome 11 Maternal side effect ‐ Maternal infection.
1.12
1.12. Analysis
Comparison 1 Acupuncture versus sham control, Outcome 12 Postpartum bleeding > 500 mL.
1.13
1.13. Analysis
Comparison 1 Acupuncture versus sham control, Outcome 13 Maternal death.
1.14
1.14. Analysis
Comparison 1 Acupuncture versus sham control, Outcome 14 Time from trial intervention to birth of baby (days; hours).
1.15
1.15. Analysis
Comparison 1 Acupuncture versus sham control, Outcome 15 Use of other induction methods.
1.16
1.16. Analysis
Comparison 1 Acupuncture versus sham control, Outcome 16 Length of labour.
1.17
1.17. Analysis
Comparison 1 Acupuncture versus sham control, Outcome 17 Spontaneous vaginal delivery.
2.1
2.1. Analysis
Comparison 2 Acupuncture versus usual care, Outcome 1 Caesarean section.
2.2
2.2. Analysis
Comparison 2 Acupuncture versus usual care, Outcome 2 Cervical maturity within 24 hours (Bishop score).
2.3
2.3. Analysis
Comparison 2 Acupuncture versus usual care, Outcome 3 Oxytocin augmentation.
2.4
2.4. Analysis
Comparison 2 Acupuncture versus usual care, Outcome 4 Epidural analgesia.
2.5
2.5. Analysis
Comparison 2 Acupuncture versus usual care, Outcome 5 Instrumental vaginal birth.
2.6
2.6. Analysis
Comparison 2 Acupuncture versus usual care, Outcome 6 Apgar score less than seven at five minutes.
2.7
2.7. Analysis
Comparison 2 Acupuncture versus usual care, Outcome 7 Neonatal intensive care unit admission.
2.8
2.8. Analysis
Comparison 2 Acupuncture versus usual care, Outcome 8 Maternal side effect ‐ maternal infection.
2.9
2.9. Analysis
Comparison 2 Acupuncture versus usual care, Outcome 9 Maternal side effect ‐ perineal tear.
2.10
2.10. Analysis
Comparison 2 Acupuncture versus usual care, Outcome 10 Maternal side effect ‐ fetal infection.
2.11
2.11. Analysis
Comparison 2 Acupuncture versus usual care, Outcome 11 Postpartum bleeding > 500 mL.
2.12
2.12. Analysis
Comparison 2 Acupuncture versus usual care, Outcome 12 Time from trial intervention to birth of baby (days; hours).
2.13
2.13. Analysis
Comparison 2 Acupuncture versus usual care, Outcome 13 Maternal satisfaction.
2.14
2.14. Analysis
Comparison 2 Acupuncture versus usual care, Outcome 14 Use of other induction methods.
2.15
2.15. Analysis
Comparison 2 Acupuncture versus usual care, Outcome 15 Length of labour.
2.16
2.16. Analysis
Comparison 2 Acupuncture versus usual care, Outcome 16 Spontaneous vaginal delivery.
3.1
3.1. Analysis
Comparison 3 Acupuncture versus sweeping of fetal membranes, Outcome 1 Caesarean section.
3.2
3.2. Analysis
Comparison 3 Acupuncture versus sweeping of fetal membranes, Outcome 2 Oxytocin augmentation.
3.3
3.3. Analysis
Comparison 3 Acupuncture versus sweeping of fetal membranes, Outcome 3 Epidural analgesia.
3.4
3.4. Analysis
Comparison 3 Acupuncture versus sweeping of fetal membranes, Outcome 4 Instrumental vaginal birth.
3.5
3.5. Analysis
Comparison 3 Acupuncture versus sweeping of fetal membranes, Outcome 5 Apgar score less than seven at five minutes.
3.6
3.6. Analysis
Comparison 3 Acupuncture versus sweeping of fetal membranes, Outcome 6 Neonatal intensive care unit admission.
3.7
3.7. Analysis
Comparison 3 Acupuncture versus sweeping of fetal membranes, Outcome 7 Postpartum bleeding > 500 mL.
4.1
4.1. Analysis
Comparison 4 Acupressure versus sham control, Outcome 1 Caesarean section.
4.2
4.2. Analysis
Comparison 4 Acupressure versus sham control, Outcome 2 Oxytocin augmentation.
4.3
4.3. Analysis
Comparison 4 Acupressure versus sham control, Outcome 3 Instrumental vaginal birth.
4.4
4.4. Analysis
Comparison 4 Acupressure versus sham control, Outcome 4 Meconium‐stained liquor.
4.5
4.5. Analysis
Comparison 4 Acupressure versus sham control, Outcome 5 Time from trial intervention to birth of baby (hours).
4.6
4.6. Analysis
Comparison 4 Acupressure versus sham control, Outcome 6 Spontaneous vaginal delivery.
5.1
5.1. Analysis
Comparison 5 Acupressure versus usual care, Outcome 1 Caesarean section.
5.2
5.2. Analysis
Comparison 5 Acupressure versus usual care, Outcome 2 Epidural analgesia.
5.3
5.3. Analysis
Comparison 5 Acupressure versus usual care, Outcome 3 Apgar score less than seven at five minutes.
5.4
5.4. Analysis
Comparison 5 Acupressure versus usual care, Outcome 4 Neonatal intensive care unit admission.
5.5
5.5. Analysis
Comparison 5 Acupressure versus usual care, Outcome 5 Time from trial intervention to birth of baby (hours).
5.6
5.6. Analysis
Comparison 5 Acupressure versus usual care, Outcome 6 Use of other induction methods.
5.7
5.7. Analysis
Comparison 5 Acupressure versus usual care, Outcome 7 Spontaneous vaginal birth.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

Ajori 2013 {published data only}
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Alsharnoubi 2015 {published data only}
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Andersen 2013 {published data only}
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Asher 2009 {published data only}
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Gaudernack 2006 {published data only}
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Gaudet 2008 {published data only}
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Gregson 2015 {published data only}
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Gribel 2011 {published data only}
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Harper 2006 {published data only}
    1. Harper TC, Coeytaux RR, Chen W, Campbell K, Kaufman JS, Moise KJ, et al. A randomized controlled trial of acupuncture for initiation of labor in nulliparous women. Journal of Maternal‐Fetal and Neonatal Medicine 2006;19(8):465‐70. - PubMed
    1. Harper TC, Coeytaux RR, Chen W, Campbell K, Kaufman JS, Thorp J, et al. A randomized controlled trial of acupuncture for initiation of labor in nulliparous women [abstract]. American Journal of Obstetrics and Gynecology 2005;193(6 Suppl):S43. - PubMed
Long 1994 {published data only}
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    1. Long ZG. 200 cases of ear acupoint press therapy for induced labor by rivanol at middle and late stage. Chinese Acupuncture and Moxibustion 1994;14(5):26.
Mackenzie 2011 {published data only}
    1. Mackenzie I, Xu J, Cusick C, Midwinter‐Morten H, Meacher H, Mollison J, et al. Acupuncture for pain relief during induced labour in nulliparae: a randomised controlled study. British Journal of Obstetrics and Gynaecology 2011;118(4):440‐7. - PubMed
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Martinez 2004 {published data only}
    1. Martinez AC, Rivera LN, Arangel CR. Acupuncture as an alternative technique for uterine contraction in term pregnant patients. 5th World Congress on Controversies in Obstetrics and Gynecology; 2004 June 3‐6; Las Vegas, USA. 2004.
Modlock 2010 {published data only}
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Mollart 2016 {published data only}
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Neri 2014 {published data only}
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Rabl 2001 {published data only}
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Romer 2000 {published data only}
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Selmer‐Olsen 2007 {published data only}
    1. Selmer‐Olsen T, Lydersen S, Morkved S. Does acupuncture used in nulliparous women reduce time from prelabour rupture of membranes at term to active phase of labour? A randomised controlled trial. Acta Obstetricia et Gynecologica Scandinavica 2007;86(12):1447‐52. - PubMed
Smith 2008 {published data only}
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Torkzahrani 2015 {published data only}
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Torkzahrani 2016 {published data only}
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Tremeau 1992 {published data only}
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References to studies excluded from this review

Aghamohammadi 2011 {published data only}
    1. Aghamohammadi A, Behmanesh F, Zafari M, Tofighi M. Effect of using Transcutaneous Electrical Nerve Stimulation (TENS) in acupuncture points [Hegu (Li4) and Sanyinjiao (Sp6)] on duration of the first stage of labor. Journal of Babol University of Medical Sciences 2011;13(2):19‐24.
Bo 2006 {published data only}
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Dorr 1990 {published data only}
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Dunn 1989 {published data only}
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Li 2007 {published data only}
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Liu 2012 {published data only}
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Lyngso 2010 {published data only}
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References to ongoing studies

NCT00379327 {published data only}
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NCT01052857 {published data only}
    1. NCT01052857. Efficacy of acupuncture on induction of labour. clinicaltrials.gov/show/NCT01052857 (first received 11 December 2007).
NCT02392988 {published data only}
    1. NCT02392988. Does acupuncture therapy reduce the need for labor induction after postdate (week 41). clinicaltrials.gov/show/NCT02392988 (first received 2 March 2015).
NCT02394041 {published data only}
    1. NCT02394041. Randomised controlled trial of the efficacy of acupuncture versus placebo on the caesarean section rate in case of cervical dystocia in full‐term pregnancy (ACUCESAR). clinicaltrials.gov/show/NCT02394041 (first received 16 March 2015).

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