Acta Obstetricia et Gynecologica.

2010; 89: 14531459

MAIN RESEARCH ARTICLE

Acupressure to reduce labor pain: a randomized controlled trial

ANNA HJELMSTEDT1, SHEELA T. SHENOY2, ELISABETH STENER-VICTORIN3,

MATS LEKANDER4, MAMTA BHAT2, LEENA BALAKUMARAN5 &
ULLA WALDENSTRM1
1

Department of Womens and Childrens Health, Division of Reproductive and Perinatal Health, Karolinska Institutet,
Stockholm, Sweden, 2Department of Obstetrics and Gynaecology, Medical College, Trivandrum, India, 3Institute of
Neuroscience and Physiology, Department of Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden,
4
Department of Clinical Neuroscience, Section of Psychology and Osher Center for Integrative Medicine, Karolinska
Institutet, Stockholm and Sweden Stress Research Institute, Stockholm University, Stockholm, Sweden, and 5Population
Health and Research Institute, Medical College, Trivandrum, India

Abstract
Objective. To evaluate the effect of acupressure administered during the active phase of labor on nulliparous womens ratings of
labor pain. Design. Randomized controlled trial. Setting. Public hospital in India. Sample. Seventy-one women randomized to
receive acupressure at acupuncture point spleen 6 (SP6) on both legs during contractions over a 30-minute period
(acupressure group), 71 women to receive light touch at SP6 on both legs during the same period of time (touch group)
and 70 women to receive standard care (standard care group). Methods. Experience of in-labor pain was assessed by visual
analog scale at baseline before treatment, immediately after treatment, and at 30, 60 and 120 minutes after treatment. Main
outcome measure. Labor pain intensity at different time intervals after treatment compared with before treatment. Results. A
reduction of in-labor pain was found in the acupressure group and was most noticeable immediately after treatment
(acupressure group vs. standard care group p < 0.001; acupressure group vs. touch group p < 0.001). Conclusion. Acupressure
seems to reduce pain during the active phase of labor in nulliparous women giving birth in a context in which social support and
epidural analgesia are not available. However, the treatment effect is small which suggests that acupressure may be most
effective during the initial phase of labor.

Key words: Acupressure, coping; labor, pain, randomized control trial

Introduction
Complementary and alternative methods to manage
labor pain have become increasingly popular in
high-income countries and they are often used as a
supplement to rather than a replacement for pharmacological methods such as epidural analgesia (1). In
low-income countries where pharmacological pain
relief may not be available, complementary methods
may be the only option to decrease pain in labor.
Complementary and alternative methods comprise a
wide range of heterogeneous and often sparsely evaluated methods, one of which is acupressure. This

method is built on the same principles as acupuncture, but the needles are replaced by pressure, with the
advantage that no equipment is required and that the
skin is not penetrated.
To our knowledge only two studies have been
published evaluating the effect of acupressure during
labor, one conducted in South Korea and one in
Taiwan (2,3). In the Korean study, it was found
that women who received acupressure at spleen
6 (SP6) which is an acupuncture point located on
the lower leg, rated the labor pain as being less than
the rating given by the women who only received
touch at the same point (2). The results of the

Correspondence: Anna Hjelmstedt, Division of Reproductive and Perinatal Health, Department of Womens and Childrens Health, Retzius vg 13 A, Karolinska
Institutet, 171 77 Stockholm, Sweden. E-mail: anna.hjelmstedt@ki.se.

(Received 7 November 2009; accepted 8 July 2010)

ISSN 0001-6349 print/ISSN 1600-0412 online  2010 Informa Healthcare
DOI: 10.3109/00016349.2010.514323

1454

A. Hjelmstedt et al.

Taiwanese study showed a greater reduction of pain

during the active phase of the rst stage of labor in
women who received acupressure at the Large Intestinal 4 and Bladder 67 acupuncture points compared
with a non-treated control group. The Large Intestinal 4 is located on the dorsum of the hand and
Bladder 67 on the lateral foot. No statistical differences in pain assessments were found between the
acupressure group and women who received efeurage (light skin stroking), or between the efeurage
group and the control group (3). Differences between
the two studies regarding design and sample size make
it difcult to draw valid conclusions about the effect of
acupressure. Additional research has been requested
to elucidate the potential effects of acupressure on
labor pain (4).
The aim of the present study was to evaluate
the effect of acupressure on acupoint SP6 as in the
Korean study, and using a 3-arm design as in the
Taiwanese study. Pressure on SP6 causes afferent
activity in the tibial nerve which enters the spinal
cord at segmental level L4S1, corresponding to
the innervation of the uterus and cervix (5). The
primary outcome was the womens assessment of
in-labor pain at different time intervals after treatment
compared with before treatment. The secondary outcomes were retrospective ratings of labor pain, coping
with labor pain and experience of childbirth.
The study was conducted in a large public hospital
in India where epidural analgesia is not an option in
normal labor, and to which women cannot bring a
companion.

Material and methods

The recruitment of participants to the study
took place during the period September 1, 2007 to
April 31, 2008 at Sree Avittom Thirunal Hospital in
Trivandrum, India. Sree Avittom Thirunal Hospital
is a public hospital with approximately 13,000 deliveries per year. According to the hospital clinical
practices, the women rst came to an admission
room where the labor progress was assessed, and
where induction took place if deemed necessary. The
women in active labor, dened as cervical dilatation
3 cm and the presence of regular uterine contractions, were transferred to a labor room, and all these
women had spontaneously or articially ruptured
membranes. All women labored in the same room
and external companions were therefore not
allowed. The women were assisted by obstetricians
or medical students. During the study period, the
following forms of pain relief were available:
Tramadol (Tramadol, 100 mg i.m.); pentazocine/

promethazine (Fortwin/Phenergan, 3060 mg/25

50 mg i.m.) and morphine/promethazine (Morphine/
Phenergan, 3.57 mg i.m. or i.v./2550 mg i.m.).
The women were eligible for the study if they were
in active labor and had been transferred to the labor
room with a cervical dilatation between 3 and 7 cm.
They had to be healthy with an uncomplicated pregnancy, nulliparous, at term, and carrying a live fetus in
head presentation. Exclusion criteria were: hypertensive disorder, preeclampsia, diabetes, neuropathic
pain multiparity, intrauterine death, multiple fetuses,
breech presentation, gestation <38 or >42 weeks,
cervical dilatation <3 cm or >7 cm, elective cesarean
section, and the presence of pharmacological pain
relief. The most common exclusion criteria were
multiparity, followed by cervical dilatation >7 cm,
and a medical disorder such as hypertension and
diabetes.
The screening for eligibility took place between
8 am and 1 pm, Monday to Saturday except for
holidays, and was performed by two obstetricians.
The social worker who also collected the data, provided the eligible women with information about the
aim of the study, i.e. to evaluate the effect of acupressure on labor pain. If they agreed to participate they
were randomly assigned to receive either treatment
with acupressure or standard care without acupressure. The women who gave written consent were
randomly assigned to one of three groups as described
below.
The study was approved by the Human Ethical
Committee at the Medical College in Trivandrum
(reg. nr. C20/EC05/07/MCT) and the Regional Ethical Committee in Stockholm, Sweden (reg. nr. 2007/
1190). The study is registered in Karolinska Clinical
study registry (ID: CT20090020).
A computerized program was used to allocate the
participants to one of the treatment groups, i.e. acupressure group (APG), touch group (TG) or standard
care group (SCG) under investigation. A paper strip
with one of the letter combinations APG, TG or
SCG was put in consecutively numbered sealed opaque envelops. The women in the APG were treated
with acupressure at acupuncture point SP6 on both
legs simultaneously during each contraction over a
period of 30 minutes. This treatment was repeated
after 2 hours if the woman had not entered second
stage labor or been delivered. SP6 is located four
ngers width, measured with the womans own
ngers, above the tip of medial malleoulus at the
posterior border of tibia. The intensity of pressure
was adapted to reach each womans pain threshold.
Women in the TG received light touch, without any
pressure, at acupoint SP6 on both legs during contractions over a 30-minute period. The reason for

Acupressure to reduce labor pain

including this group was to control for the possible
effects of the presence of a person paying particular
attention to the woman. The TG was identical to the
APG, except for the pressure. For the sake of brevity,
touch is referred to as treatment in the following text.
Women in the SCG received standard care with no
acupressure or touch. The acupressure and touch
were performed by one and the same person who
had undergone 3 days of training by a certicated
acupressure therapist. The training included theory
and practical training.
After obtaining written consent and before randomization, baseline information was collected by
interviewing the women. Questions about the
womens sociodemographic background were predened with given response alternatives. The womens
responses were entered into a questionnaire by a
social worker trained in data collection.
Women in the APG and the TG were asked to rate
pain intensity on a 100-mm visual analog scale (VAS)
anchored from no pain at all to much more pain
than I could imagine. Ratings were performed prior
to treatment, immediately after treatment, and 30,
60 and 120 minutes after treatment. Women in the
SCG rated their labor pain at the corresponding
points of time as in the APG and the TG.
After delivery (224 hours) on the postnatal ward,
VASs were used to rate memory of labor pain, ability
to cope with labor pain (not at all to very well), and
overall experience of childbirth (very bad to very
good). Women used a pencil to put a mark on the
respective line. Medical data from hospital records
were collected by two obstetricians.
The data collector was blinded to the patients
group allocation. However, in few cases there was
more than one woman in the study in the labor room
at the same time and the data collector could then
have noted that another woman was being treated.
She could not see a difference between the women
who were treated by acupressure (APG) and touch
(TG) since these treatments looked the same from an
observers point of view, but she could conclude that
this was not a woman in the SCG.

Statistical analyses
Power was estimated on the principal outcome, i.e.
the womens assessment of in-labor pain, and based
on the results from the acupressure study by Lee et al.
where the womens experience of pain had been
measured on a VAS (2). They compared the pain
scores of 36 women who received acupressure with
those of the 39 women who received touch at
60 minutes after the intervention and found a

1455

signicant difference (p < 0.01, power 80%) of

12 mm. We aimed at detecting a similar difference
but extended our sample to 70 women per group in
order to account for drop-outs caused by the longer
duration of the follow-up.
Data are presented as numbers or mean and standard deviation (SD). Groups were compared regarding differences in labor pain intensity at different time
intervals after treatment, compared with the baseline
assessment, by means of one-way analyses of variance
(ANOVA) followed by post hoc Bonferroni tests to
avoid Type 1 errors. Regarding the postnatal assessments, the differences between groups in VAS scores
of labor pain, coping ability and overall experience of
childbirth were analyzed by means of ANOVA followed by post hoc Bonferroni tests.
Statistical signicance was dened as p < 0.05.
Statistical analyses were carried out using the SPSS
version 15.0.

Results
The owchart of participants in the study is presented
in Figure 1. Out of 773 women assessed for eligibility,
227 met the inclusion criteria. Fourteen declined to
participate and those who remained were randomized
to APG (n = 71), TG (n = 71) and SCG (n = 71). One
woman in the SCG withdrew after randomization.
Table 1 shows that the women in each group had
similar sociodemographic and obstetric backgrounds.
On average, they were young and fairly well-educated.
Gestational age was, on average, 39 weeks in all three
groups. Induction rates were 32% in APG, 29% in
TG and 26% in SCG. Cervical dilatation before
randomization was around 3.5 cm in all groups. In
spite of pharmacological pain relief being an exclusion
criterion in the study, some women in each group
received either Tramadol, Fortwin/Phenergan or
Morphin/Phenergan before randomization. This
was a deviation from the trial protocol which will
be further discussed below.
The mean (SD) pain scores at baseline were:
62.6 (14.9) in APG, 57.5 (15.9) in TG and
56.7 (16.6) in SCG. Since the difference between
APG and SCG baseline scores was signicant
(p < 0.05), and the difference between APG and
TG was bordering on signicance (p = 0.05), we
chose to compare labor pain intensity at different
time intervals after treatment with the baseline assessment as previously described. Figure 2 shows changes
in pain scores expressed as the mean difference
between the baseline assessment and the followup assessments in respective groups. Some women
gave birth shortly after treatment (corresponding time

1456

A. Hjelmstedt et al.

Table 1. Sociodemographic and obstetric characteristics of the women in the randomized groups.

Sociodemographic data
Age, years, mean (SD)
Education, years, mean (SD)
Obstetric data
Induction, n
Prostaglandin
Oxytocin
Gestational age, weeks, mean (SD)
Cervical dilatation before randomization, cm, mean (SD)
Pharmacological pain relief before randomizationa, n

APG (n = 71)

TG (n = 71)

SCG (n = 70)

22.4 (2.7)
12.4 (2.4)

22.7 (2.9)
12.0 (2.6)

22.9 (3.4)
11.6 (2.8)

32
31
1
38.7 (1.3)
3.6 (0.9)
9

29
28
1
38.7 (0.8)
3.5 (1.0)
8

26
26
0
38.6 (0.8)
3.4 (0.7)
11

Tramadol, Fortwin/Phenergan or Morphine/Phenergan.

Note: APG, acupressure group; TG, touch group; SCG, standard care group.

in SCG) or before the end of the last pain assessment

scheduled at 120 minutes after treatment. As a consequence the number of women differed in these
analyses. During the observation period, which lasted
for 2.5 hours (30 minutes treatment + 120 minutes
follow-up), contractions became more intense, and
without any pain relief one would therefore expect the
womens pain scores to increase accordingly. This
was also the case in the SCG in which the difference
from the baseline assessment increased continuously.
This was also found in the TG. By contrast, a reduction of pain was observed in the APG and was most
apparent when comparing baseline with immediately
after treatment measures. There were signicant differences between the APG and the SCG as well as
between the APG and the TG with respect to difference in pain scores between the baseline assessment
and the follow-up assessments (immediately, 30,

Enrollment

60 and 120 minutes after treatment) but no such

differences were found between the TG and the
SCG (Figure 2). When the women who had received
pharmacological pain relief prior to treatment (APG:
9; TG: 8; SCG: 11) were excluded from the analyses,
the overall results did not change.
Even though the APG had higher pain scores at
baseline, the mean (SD) pain scores in the SCG were
signicantly higher in comparison to the APG at all
follow-up assessments (30, 60 and 120 minutes after
treatment, p < 0.05) except immediately after treatment. At all follow-up assessments, there were nonsignicantly higher mean pain ratings in the TG in
comparison to the APG, and in the SCG in comparison to the TG.
Only 22 women in the APG, 26 in the TG and
23 in the SCG were in labor long enough after
the second treatment to be able to complete all

Assessed for eligility (n = 773)

Excluded (n = 560)
Not meeting inclusion
criteria (n = 546)
Declined participation (n = 14)
Randomized (n = 213)

Allocation
Allocated to APG (n = 71)
Received APG (n = 71)

Allocated to TG (n = 71)
Received TG (n = 71)

Allocated to SCG (n = 71)

Received SCG (n = 70)
Withdraw (n = 1)

Follow-Up

Lost to follow-up (n = 0)

Lost to follow-up (n = 0)

Lost to follow-up (n = 0)

Analysis

Analyzed (n = 71)

Analyzed (n = 71)

Analyzed (n = 70)

Figure 1. Flow chart of participants in trial.

Note: APG, acupressure group; TG, touch group; SCG, standard care group.

Acupressure to reduce labor pain

APG

TG

1457

SCG

16
14
12
VAS score difference, mean (SD)

13.4 (14.7)
n = 40

11.9 (11.5)
n = 50

9.4 (13.1)
n = 39

8.6 (11.6)
n = 55

8.3 (9.6)
n = 60

10
8
4.7 (10.8)
n = 69

6
4
2

4.0 (10.8)
n = 62

2.0 (8.5)
n = 68

1.1 (14.0)
n = 52

0
0.2 (15.4)
n = 39

2
4
6

4.4 (8.1)
n = 69
Immediately

2.8 (11.6)
n = 56
30 minutes

60 minutes

120 minutes

Time after first treatment

Figure 2. Assessment of in-labor pain at different time intervals after treatment compared with before treatment.
Note: APG, acupressure group; TG, touch group; SCG, standard care group.

pain-ratings. This reduced sample was not large

enough to allow for the assessment of the effect of
the second treatment.
Table 2 shows that labor outcomes were similar in
each study group. About half of the women received
oxytocin for augmentation and pharmacological pain
relief (either after or before inclusion into the study).
The proportions of women who had received pharmacological pain relief during labor were equally
distributed between the groups (APG 49%, TG
48%, SCG 57%). More women in the APG had a
spontaneous vaginal delivery compared with the other
two groups, but this difference was not signicant.

The majority had an episiotomy (89% in APG; 75%

in TG; 85% in SCG), reecting clinical practices in
the hospital. Infant birth weight and length was similar
in each group. Mean Apgar score at 5 minutes was
9.6. One infant in the APG had an Apgar score of 6 at
5 minutes but recovered from the respiratory distress
soon after birth.
Retrospectively (224 hours after birth), the women
in the APG remembered having had less pain during
labor and said they coped better with their labor pain
compared with the SCG (Table 3). Compared to the
women in the TG, those in the APG remembered
having coped better with the pain. There were no

Table 2. Labor data in the randomized groups.

Oxytocin for augmentation, n

Pharmacological pain relief during labora, n
Spontaneous vaginal delivery, n
Emergency cesarean delivery, n
Forceps, n
Vacuum extraction, n
Episiotomy, n
Infant birth weight, mean (SD)
Infant birth length, mean (SD)
Apgar 5 minutes, mean (SD)

APG (n = 71)

TG (n = 71)

SCG (n = 70)

38
35
55
7
1
8
63
2,981.1 (340.0)
50.1 (0.4)
9.6 (0.6)

37
34
43
17
3
8
53
2,931.8 (379.9)
50.2 (0.7)
9.6 (0.5)

38
40
47
12
4
7
59
2,941.5 (387.8)
50.2 (0.6)
9.7 (0.5)

Tramadol, Fortwin/Phenergan or Morphine/Phenergan.

Note: APG, acupressure group; TG, touch group; SCG, standard care group.

1458

A. Hjelmstedt et al.

Table 3. Postnatal assessments of labor pain, ability to cope with labor pain and overall experience expressed as mean values on visual analog
scale (VAS).
TG
(n = 71)

VAS score (0100 mm)

APG
(n = 71)
Mean (SD)

SCG
(n = 70)
Mean (SD)

pa

APG vs. SCG

pb

APG vs. TG
pb

TG vs. SCG
pb

Labor pain
Coping with labor pain
Experience of childbirth

74.0 (18.2)
90.1 (15.9)
85.0 (25.0)

78.9 (19.9)
82.3 (19.7)
84.3 (22.8)

84.3 (15.8)
79.2 (20.2)
76.2 (25.2)

0.004
0.002
0.06

0.003
0.002
0.1

0.34
0.04
1.0

0.23
1.0
0.15

Labor pain: 0, no pain at all; 100, much more pain than I could think of. Ability to cope with labor pain: 0, not at all; 100, very well. Experience
of labor: 0, very poor; 100, very good.
a
ANOVA.
b
Bonferroni test.
Note: APG, acupressure group; TG, touch group; SCG, standard care group.

statistical differences between the groups regarding

the overall experience of childbirth.

Discussion
We found that acupressure on acupoint SP6 during
contractions reduced the experience of pain intensity
in nulliparous women during the active phase of
labor, whereas pain intensity increased in women
who received light touch or standard care. The effect
of acupressure was most apparent immediately after
treatment but the difference in pain scores compared
with the group receiving only touch and the group
receiving no form of treatment lasted for at least
2 hours. At this point in time the womens pain scores
reached about the same level as before treatment, in
spite of the progression of labor over a period of
2.5 hours. Considering that there was an imbalance
in pain intensity pain scores at baseline between the
groups we chose to calculate mean differences in labor
pain intensity between the baseline assessment and
the follow-up assessments. Despite this initial difference, signicantly higher mean pain ratings were
observed in the SCG in comparison to the APG at
all follow-up assessments except immediately after
the treatment. Similarly, the TG showed numerically
higher pain ratings as compared to the APG at followup assessments, but these differences were not statistically different. Thus, a positive treatment effect of
acupressure in the active phase of labor in nulliparous
women was indicated. Furthermore, this study indicates that acupressure may affect womens retrospective assessment of labor pain, since the women in the
APG remembered having had less pain than the
women in the SCG, and were better able to cope
with the pain than the women in the SCG and the TG,
when asked after the birth. Since the proportions of
women who had received pharmacological pain relief
during labor were equally distributed between the
groups it is not probable that this could have affected

the results (APG 49%, TG 48%, SCG 57%). Our

ndings support the conclusion of previous studies
that acupressure is effective in reducing labor
pain (2,3).
The effect of acupressure remains unclear on a
mechanistic level. One explanation is based on the
gate-control theory (6). According to this theory
acupressure activates mechanoreceptors that innervate sensory nerve bers, A-beta and/or A-delta
depending on the pressure intensity, which leads to
the inhibition of pain transmission at the spinal level.
It is also possible that acupressure activates central
pain inhibitory centers, leading to an activation of the
descending pain inhibitory pathways (7). However, it
cannot be ruled out that the positive effect that
we found in the APG could be due to expectations
of pain relief, thus driving a placebo elicited inhibition
of pain.
The reason for including a group of women who
received touch without pressure was to control for the
possible effects of the presence of a person paying
particular attention to the woman. A Cochrane review
has shown that continuous support during labor may
reduce the use of obstetric pain relief and increase
satisfaction with childbirth (8). Although Figure 2
suggests that the women in the TG experienced
less pain than the women in the SCG, this difference
was not statistically signicant. Neither did we nd
any difference in the postnatal assessment of childbirth between these two groups.
A strength of our study was that the risk of selection
bias was limited. All the women who had been transferred to the labor room with a cervical dilatation
between 3 and 7 cm during the data collection period
were screened for eligibility and only one woman
chose to withdraw after randomization. A limitation
of the study was that blinding to the respective
group was not possible. The women who received
neither acupressure nor touch could conclude that
they had received no treatment. However, the difference between acupressure and touch was less

Acupressure to reduce labor pain

obvious, and we believe that most of the women were
not aware of the difference. They had been informed
that the aim of the study was to evaluate the effect of
acupressure on labor pain, but no details were given
about the procedures. From the clinicians and the
data collectors perspective the two treatments looked
the same.
In conclusion, our study shows that acupressure
seems to reduce pain during the active phase of labor
in nulliparous women giving birth in a context where
social support and epidural analgesia are not available.
However, the treatment effect is small which suggests
that acupressure may be most effective during the
initial phase of labor. In contexts where more effective
methods of pain relief are available, such as epidural
analgesia, acupressure may be an alternative predominantly in early labor. In contexts where resources are
limited acupressure could be an important option for
women with painful labor pain. Acupressure is not
associated with risks of infections since the skin is
not penetrated by needles, and there are no costs for
equipment. In addition, acupressure is easy to
administer and extensive training of the person who
administers the treatment is not necessary. However,
further studies of efcacy as well as effectiveness are
needed to determine the clinical applicability of
acupressure in labor pain.

Acknowledgements
We are grateful to Manju Chandrika Soman for
acupressure and touch treatments, Aseena

1459

Naseemabeevi and Vrinda Menon for data collection and K.T. Shenoy for advice on study design
and analysis of data. The study was funded by the
Osher Center for Integrative Medicine, Karolinska
Institutet and the Center for Health Care Science,
Karolinska Institutet.
Declaration of interest: The authors report no
conicts of interest. The authors alone are responsible
for the content and writing of the paper.

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