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General obstetrics

DOI: 10.1111/j.1471-0528.2010.02825.x

Acupuncture for pain relief during induced

labour in nulliparae: a randomised controlled
IZ MacKenzie,a J Xu,a C Cusick,b H Midwinter-Morten,b H Meacher,a J Mollison,c M Brockb
Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Oxford, UK b Maternity Department, John Radcliffe Hospital,
Oxford, UK c Department of Obstetrics and Gynaecology, University of Aberdeen, Aberdeen, UK
Correspondence: IZ MacKenzie, Nuffield Department of Obstetrics and Gynaecology, John Radcliffe Hospital, Oxford OX3 9DU, UK.
Email ian.mackenzie@obs-gyn.ox.ac.uk

Accepted 10 November 2010. Published Online 18 January 2011.

Objective To assess the role of acupuncture for analgesia during

Design Double-blind study of manual, electro and sham
acupuncture, and single-blind study comparing acupuncture with
a control group for analgesia for labour induction.

parenteral analgesia requirement, labour length, delivery mode,

neonatal condition and postpartum haemorrhage.

induction at term.

Results There was no difference in epidural analgesia between

acupuncture and sham acupuncture, relative risk 1.18 (95% CI
0.81.74), or between acupuncture and control, relative risk 0.88
(95% CI 0.661.19). There were no significant differences in the
secondary end points between the acupuncture groups and the
control group. Side effects or complications of acupuncture were
not identified.

Methods Twenty-three subjects needed to be randomised to each

Conclusions Using the protocols studied, there was no analgesic

group to have an 80% power of detecting a 50% relative

reduction in epidural rate with an alpha value of 0.05.

benefit with acupuncture for pain relief during induced labour in


Main outcome measures The primary end point was the rate of

Keywords Acupuncture, epidural, induced labour, labour out-

intrapartum epidural analgesia, and the secondary end points were

come, nulliparae.

Setting A major obstetric unit in the UK.

Population A cohort of 105 nulliparae undergoing labour

Please cite this paper as: MacKenzie I, Xu J, Cusick C, Midwinter-Morten H, Meacher H, Mollison J, Brock M. Acupuncture for pain relief during induced
labour in nulliparae: a randomised controlled study. BJOG 2011;118:440447.

The pain of labour caused by uterine contractions, cervical
dilatation, and vaginal and pelvic floor stretching has been
described as one of the most intense forms of pain.1
Acupuncture has been used for pain relief in labour for
centuries in China, and in recent decades has become popular and accepted in many Western countries. The mechanism by which it achieves analgesia remains uncertain.
Stimulation of acupuncture points is believed to involve
the spinal gate mechanism,2 although functional magnetic
resonance imaging and positron emission tomography in
humans and animals suggest acupuncture stimulates the
central nervous system and activates the descending antinociceptive pathway, releasing endogenous opioids that
deactivate the ascending nociceptive pain pathway.37


Clinical studies in Chinese literature report 6597%

efficacy for a range of traditional Chinese acupuncture
treatments, but such studies do not generally conform to
Western standards, and detailed data are often inaccessible: this makes it difficult to properly evaluate traditional
Chinese acupuncture.8 In Western literature, Ramnero
et al.9 in Sweden conducted a randomised trial of acupuncture during labour, and showed it significantly
reduced epidural analgesia requirement and increased
relaxation, compared with the control group. However,
systematic reviews of most studies of acupuncture during
labour found that data were not in a form that could be
included in meta-analyses, and recommend conducting
well-designed randomised controlled trials in this area.10,11
This prompted designing and executing a rigorously controlled double-blind and single-blind randomised study to

2011 The Authors Journal compilation RCOG 2011 BJOG An International Journal of Obstetrics and Gynaecology

Acupuncture for pain relief in labour

address the role of acupuncture as a method of analgesia

during labour.

Nulliparae with a singleton pregnancy and fetal cephalic
presentation with intact membranes undergoing labour
induction using vaginal prostaglandins and low amniotomy
for prolonged gestation or mild hypertension in the John
Radcliffe Hospital were eligible for study; those with previous experience of acupuncture treatment were excluded.
An invitation to enrol in the study was publicised by mailing community midwives and obstetricians, and strategically placed posters in antenatal clinics. After the first
6 months of the study from February 2006, when few subjects had been recruited, potentially eligible subjects were
identified from the delivery suite Induction of Labour

Booking Register and contacted by one of us (HM) and

invited to participate. Voluntary participation was confirmed on admission for labour induction, and written
consent was obtained by the acupuncturist. The study was
approved by the Oxfordshire Research Ethics Committee
(C), reference number 05/Q1606/104.
Following recruitment, as illustrated in Figure 1, subjects
were randomised in the ratio 1:1:1:1, with variable block
sizes of four and eight to one of four therapeutic options:
electro-acupuncture; manual acupuncture; sham acupuncture, when acupuncture stimulation was not provided; or
a no-treatment control group not involving acupuncture.
Women randomised to sham acupuncture were further
randomised to sham-manual or sham-electro acupuncture in a ratio of 1:1, with variable block sizes of two and
four. Random numbers were generated using ralloc (Stata
Corporation, Singleton, TX, USA), and randomisation was

Nulliparae scheduled
for labour induction
at >38

Delivered before
induction date
753 (40%)

Eligible for
1144 (60%)

Not counselled
456 (40%)

117 (10%)

105 (9%)

Not suitable
298 (26%)

168 (15%)


acupuncture (26)

acupuncture (26)

manual (14)
electro (13)

Control group

Figure 1. Trial flow chart.

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MacKenzie et al.

stratified by the acupuncturist. Allocations were concealed

in numbered sealed opaque envelopes opened by the acupuncturist after written patient consent had been given,
immediately before treatment. Acupuncture treatment allocation was concealed from all except the acupuncturist,
who was not involved with intrapartum management (double blind). Subjects randomised to the no-treatment control group, as well as the acupuncturist, were alone in
being aware of their treatment group (single blind). Great
care was taken to conceal treatment allocation from those
providing intrapartum care or involved in data collection.
The randomisation code was only revealed after completion
of the clinical study.
Acupuncture was provided by qualified acupuncturists
registered either with the British Acupuncture Council or
the Association of Traditional Chinese Medicine (UK).
After labour induction had been initiated but before painful contractions had started, the randomised treatment
was given. Sterile disposable needles (Seirin DN04
0.20 300.30 50 mm; Scarboroughs Ltd, Crewkerne,
Somerset, UK) were inserted intramuscularly to a depth of
1520 mm until an unusual sensation developed (De-Qi),
usually described by subjects as tingling, heaviness
or numbness, and the needles remained inserted for
3060 minutes, during which time patient mobility was
restricted. The following bilateral acupoints on the hands
and feet, recognised to reduce labour pain,12,13 were used:
1 Hegu (LI 4), located at the midpoint of the first and second metacarpal bones.
2 Sanyinjiao (Sp 6), located on the inner aspect of the
lower leg, 3 cun* above the top of the ankle, just behind
the bone.
3 Kunlun (BL 60), located in the depressed area behind
the external malleolus.
4 Zhiyin (BL 67), located on the lower lateral side of the
little toe, 0.1 cun* lateral to the corner of the nail.
(*cun is a measurement for locating an acupoint in traditional Chinese medicine: 1 cun = 11.5 cm, depending
on the size of the patient.)
Following insertion, the needles were stimulated intermittently and irregularly by hand for 30 minutes for the manual acupuncture group, or were attached to an electrical
stimulator (Electronic Acupunctoscope AWQ-104L digital;
Scarboroughs Ltd., Crewkerne, UK) and stimulated with
2-Hz pulses of 0.5 millisecond duration for 30 minutes,
sufficient to cause non-painful muscle contractions for the
electro-acupuncture group. For sham acupuncture, the
needles were inserted adjacent to the specific acupuncture
sites to a depth of 11.5 mm only, and insufficient to
provoke an unusual sensation; those randomised to shammanual treatment received no stimulation, and those
randomised to sham-electro were connected to the


electrical stimulator, but the current not activated.14,15 At

the end of the stimulatory period the needles were removed.
Intrapartum care was provided by the routine delivery
suite staff, who were not involved in the study and were
unaware of the randomisation allocation. Subsequent pain
management including aromatherapy, transcutaneous nerve
stimulation (TENS) and parenteral opioids, and regional
blockade was provided when requested or recommended by
the attending midwife or obstetrician.
Demographic details, labour management, duration and
outcome, especially analgesia requirement, delivery method,
including the indication for caesarean section, and neonatal
outcome assessed by Apgar scores and cord blood-gas
values were recorded for all subjects. Similar demographic
details and analgesic requirements for those eligible but not
recruited to the trial during the study period were recorded
to determine how representative the study participants were
of the population undergoing labour induction.
The primary outcome variable was the rate of intrapartum epidural analgesia requirement. In 2004 in the John
Radcliffe Hospital, 70% of 814 eligible nulliparae were
provided with an intrapartum epidural. At that time, the
solitary published randomised study examining the use of
acupuncture during labour observed a 50% reduction in the
use of epidural in women of mixed parity.9 To observe a
reduction from 70 to 35% in epidural rate requires 23 subjects in each of the four randomised groups to enable the
comparisons of acupuncture (manual and electro combined) versus sham acupuncture and acupuncture (manual
and electro combined) versus no treatment (control) to
have 80% power to detect a 50% relative reduction in
epidural rate, with an alpha value of 0.05; to accommodate
potential trial violations, we aimed to recruit 26 women to
each group. Categorical variables were analysed using
Pearsons chi-square test; when the assumptions for the chisquare test were violated, Fishers exact test was performed.
Non-normally distributed continuous outcomes were
analysed using the MannWhitney U-test. Epidural use was
compared using the chi-square test, and relative risks with
95% confidence intervals were calculated using cia
software.16 The analyses were based on intention to treat.

Rigorous attention to the inclusion criteria was maintained
throughout the 3.5 years of the study, when 9% of the eligible women who did not labour before their planned
induction date were recruited. There were two violations:
one subject was randomised to the control group and
received manual acupuncture, and a second subject was
randomised to electro-acupuncture but withdrew from the
study before the acupuncture was administered. All other
subjects were treated according to the randomisation

2011 The Authors Journal compilation RCOG 2011 BJOG An International Journal of Obstetrics and Gynaecology

Acupuncture for pain relief in labour

Table 1. Baseline characteristics of recruited and non-recruited women

Electro (n = 26)
40 weeks
41 weeks
42 weeks
Mean (SD) maternal age (years)
Mean (SD) infant birthweight (g)



Control (n = 26)

Manual (n = 26)



schedule. One acupuncturist treated 61 subjects, the second

treated 14 subjects and the third treated 28 subjects: there
was an equal distribution of treatment groups for each acupuncturist.
As shown in Table 1, maternal age, pregnancy gestation
and neonatal birthweight were similar for each of the randomised groups. The 1039 eligible non-recruited patients that
had their labour induced had a slightly earlier gestation,
with a resultant lower birthweight; 697 (67%) non-recruited
patients were given an epidural during labour.
The primary analyses compared the combined acupuncture group with sham acupuncture and control, respectively, as shown in Table 2. No significant difference in
epidural use was found for either comparison, 65 versus
56% and 65 versus 77% for the comparisons with sham
and control, respectively.
For vaginal deliveries, there were no significant differences
in the interval between the onset of labour and delivery or
the lengths of the first and second stages of labour between
the acupuncture and control groups or the sham-acupuncture and control groups (Table 2). Although not statistically
significant, there were more caesarean (35 versus 21%) and
fewer instrumental deliveries (35 versus 52%) in the control
group than in the acupuncture group (P = 0.15). There were
no differences in the indications for caesarean section, particularly for fetal distress or labour dystocia. Similarly, there
were no significant differences in neonatal outcome assessed
by Apgar scores and cord blood gases between the acupuncture and control groups or the sham-acupuncture and
control groups illustrated in Table 2. The marginal increase
in the frequency of blood loss 500 ml at vaginal delivery in
the control group (25%) was not significantly greater than
that observed in the acupuncture groups (1214%). Side
effects or complications from the acupuncture treatment
were not identified for any woman.
Table 3 lists the labour and neonatal outcomes for the
manual and electro-acupuncture treatment groups.
Although not significant, more women in the electro group
received an epidural, 73 versus 58% (RR = 1.27, 95% CI
0.851.90, P = 0.38).

Non-recruits (n = 1039)

Sham (n = 27)







There were no significant differences between the three
acupuncture groups in the use of epidural and parenteral
analgesia, or between the control group and the combined
acupuncture groups. The non-recruits had an epidural rate
of 69%, and 24% laboured without an epidural or parenteral analgesia, indicating that women recruited to the
study were seemingly representative of the background
population. It is notable that more than 60% of women
invited to participate in this study declined; we did not
record the reasons for their reluctance and are thus not
able to determine whether this might have had any bearing
on the outcome of the study.
By restricting recruitment to nulliparae undergoing
labour induction, with the acupuncture provided by
trained acupuncturists who were not involved in subsequent labour care, we have limited potential bias in the
outcomes and interpretation. We recognise that our study
was almost certainly underpowered to identify relevant differences in labour management or outcome beyond the
requirement for epidural analgesia, which was the primary
objective of our study. We also acknowledge that we could
not be confident that those randomised to the no-acupuncture control group might have declared this to the clinical
staff providing care during the subsequent labour and
delivery. It was therefore reassuring to note that the observations for this group did not show any significant differences between the three acupuncture groups.
Each of the small number of controlled studies reported
in recent years assessing the possible impact of acupuncture
on intrapartum analgesic requirement and labour outcome
have either been open-randomised or single-blind studies.9,1722 All have recruited women of mixed parity, apart
from in one study19 in established spontaneous labour
acupuncture was administered by the midwife who provided the subsequent intrapartum care, apart from one
study in which the acupuncturist was not recorded.19 There
is good evidence that multiparae compared with nulliparae
generally require less intrapartum analgesia, have shorter

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MacKenzie et al.

Table 2. Comparison of acupuncture versus sham acupuncture versus control: clinical and neonatal outcomes
(n = 52)
Primary endpoint
Parenteral (without epidural)
No epidural or parenteral
Spontaneous vaginal
Caesarean section
Indication for caesarean section
Fetal distress
Failure to progress in 1st stage
Failed advance in 2nd stage
Failed induction of labour
Length of labour (minutes) median (IQR)
1st stage
2nd stage
Arterial gases
pH <7.1
pH median (IQR)
BE; >)12.0 mmol/l
BE median (IQR)
Venous gases
pH median (IQR)
BE median (|IQR)
Apgar score 1
<4 n (%)
Median (IQR)
Apgar score 5
<8 n (%)
Median (IQR)
Blood loss > 500 ml (vaginal only)
n (%)
Days to discharge
Median (IQR)

(n = 27

vs sham

vs control

P = 0.54 RR: 1.18,

95% CI (0.801.74)

P = 0.44 RR: 0.88,

95% CI (0.661.19)

34 (65%)

15 (56%)

20 (77%)

34 (65%)
2 (4%)
16 (31%)

15 (56%)
4 (15%)
8 (30%)

20 (77%)
1 (4%)
5 (19%)

P = 0.27

P = 0.62

14 (27%)
27 (52%)
11 (21%)
n = 11
n = 42
332 (195,540)
108 (71,135)
n = 40
7.23 (7.17, 7.28)
3 (8%)
5.4 (3.7, 8.33)
n = 41
7.3 (7.25,7.36)
4.7 (3.5, 7.3)
n = 51
3 (6%)
10 (9,10)
n = 51
10 (10,10)
n = 41
5 (12%)
n = 52
2 (1,3)

13 (48%)
9 (33%)
5 (19%)
n = 23
240 (205,390)
110 (54,154)
n = 19
1 (5%)
7.21 (7.1, 7.29)
1 (5%)
6.4 (3.9, 9.1)
n = 20
7.33 (7.27,7.38)
5.3 (3.03,8.05)
n = 27
1 (4%)
9 (8,10)
n = 27
10 (10,10)
n = 22
3 (14%)
n = 27
1 (1,3)

8 (31%)
9 (35%)
9 (35%)
n = 19
270 (180,360)
124 (79,181)
n = 22
4 (20%)
7.24 (7.17, 7.28)
1 (5%)
5.15 (3.85, 7.23)
n = 22
7.33 (7.28,7.35)
4.9(2.8, 7.6)
n = 26
9 (8.75, 10)
n = 26
10 (10,10)
n = 16
4 (25%)
n = 22
2.5 (1.75,4)

P = 0.15

P = 0.30

P = 0.33
P = 0.78

P = 0.29
P = 0.34



labours and have higher vaginal delivery rates.2325 Studying women of mixed parity could conceal genuine differences in outcome between treatment methods, and
restricting recruitment to nulliparae undergoing labour
induction reduces the risk of bias associated with the stage
of labour at study entry. Many of these limitations have
been highlighted in the recent meta-analysis of studies
exploring the role of acupuncture for pain relief in
Sham acupuncture has been promoted in an attempt to
neutralise the potential placebo effect of acupuncture,11
but arguments have been advanced suggesting sham
treatment may stimulate opioid production,27 or diffuse


(n = 26)





P = 0.24
P = 0.99

P = 0.33
P = 0.95

P > 0.99
P = 0.34

P = 0.55
P = 0.22

P = 0.48

P = 0.96

P > 0.99

P = 0.25

P = 0.36

P = 0.13

noxious inhibitory control (DNIC),28,29 similar to that

following conventional acupuncture, and thereby influence
analgesic requirement. This could mitigate the impact of
such treatment as a control group.30 Acknowledging this,
we therefore also included a no-treatment control group
that was clearly revealed to the subject, but concealed as far
as possible from those providing clinical care during the
intrapartum period; it is not possible to design a doubleblind study involving a no-treatment control group.
Observing epidural use for women eligible for the trial but
not recruited for various reasons enabled us to confirm
that our study population appeared representative of the
population as a whole.

2011 The Authors Journal compilation RCOG 2011 BJOG An International Journal of Obstetrics and Gynaecology

Acupuncture for pain relief in labour

Table 3. Clinical and neonatal outcomes for the randomised acupuncture groups
Labour outcome

Analgesiareceived epidural

Parenteral excluding epidural
No analgesia
Delivery method
Spontaneous vaginal delivery
Caesarean section
Indication for caesarean section
Fetal distress
Failure to progress in first stage
Failed advance in second stage
Failed induction of labour
Length of labour (minutes)
First-stage labour median (IQR)
Second-stage labour median (IQR)
Arterial gases
pH < 7.1
pH median (IQR)
BE > )12.0 mmol/l
BE median (IQR)
Venous gases
pH median (IQR)
BE median (IQR)
Apgar score at 1 minute
<4 n (%)
Median (IQR)
Apgar score at 5 minutes
<8 n (%)
Median (IQR)
Blood loss > 500 ml (all randomised)
n (%)
Blood loss > 500 ml (vaginal only)
n (%)
Days to discharge
Median (IQR)

(n = 26)

(n = 26)

15 (58%)

19 (73%)

RR 1.27
95% CI (0.851.90)

15 (58%)
1 (4%)
10 (39%)

19 (73%)
1 (4%)
6 (23%)


6 (23%)
13 (50%)
7 (27%)
n = 20
297 (152, 755)
126 (96,165)
n = 20
1 (5%)
7.21 (7.17, 7.29)
2 (10%)
4.9 (3.7,8.6)
n = 21
7.28 (7.26, 7.35)
4.6 (3.3,6.9)
n = 25
2 (8%)
10 (9,10)
n = 25
10 (10,10)
n = 26
7 (27%)
n = 19
2 (11%)

8 (31%)
14 (54%)
4 (15%)
n = 22
333 (208, 468)
90 (68,126)
n = 20
4 (20%)
7.24 (7.13, 7.28)
1 (5%)
5.9 (3.6, 8.3)
n = 20
7.34 (7.24,7.36)
4.8 (3.7,8.9)
n = 26
1 (4%)
10 (9,10)
n = 26
10 (10,10)
n = 26
4 (15%)
n = 22
3 (14%)



2 (1,2.25)


Ramnero et al.s9 single-blind controlled study of

100 women, involving a majority of multiparae recruited
during spontaneous labour at up to 7 cm of cervical dilatation, reported a significant epidural reduction rate from 22
to 12% with acupuncture; the average total duration of
observed labour was just over 5 hours. The low rate of
epidurals in the control group in this study probably
reflects the impact of the large proportion of multiparae
studied and the advanced stage of labour at study entry.
A similar study of 212 mixed-parity women demonstrated
a reduction in parenteral analgesia requirement with



acupuncture, but without details of epidural administration.20 An open (unblinded) study of 128 mixed-parity
women in labour randomised to acupuncture or sterile
water injections found that the latter treatment reduced the
need for parenteral analgesia compared with acupuncture,
but found no difference in epidural requirement, although
precise numbers were not provided.18 A single-blind study
of 210 labouring women of mixed parity randomised to
manual or sham acupuncture reported a significant reduction in the use of epidural and parenteral analgesia with
acupuncture.21 Another open study involving 602 women

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MacKenzie et al.

of mixed parity in spontaneous labour randomised to

manual acupuncture, TENS or traditional analgesia
reported no differences in overall analgesic requirements
between the three groups.17 In all of these randomised
studies, the acupuncture or control treatments were
administered or overseen by midwives who also provided
continuing intrapartum care, and consequently there was a
possibility of bias in the provision of analgesia during
labour in those studies.
We found no significant difference in the total length of
labour between any of the acupuncture groups or the control group in our study, but acknowledge the study might
be underpowered to identify such differences. Similarly
there were no differences between the duration of the first
and second stages of labour. Of the four randomised studies reporting duration of labour, three observed no difference between acupuncture and the control groups used,
whereas one study observed a significantly shorter duration
of labour with acupuncture compared with sham acupuncture.18 Definitions for duration of labour varied in each
study, suggesting there was a degree of heterogeneity, and
in the circumstances it is difficult to reach firm conclusions
on this issue, although the predominant view is that acupuncture as provided in these studies, including our own,
does not significantly shorten the length of labour. We
were not able to address the issue of the need for labour
augmentation with an oxytocic, as this was a fundamental
part of the labour induction process.
There were no differences in the mode of delivery
between the acupuncture groups or between the control
group and the combined acupuncture groups. Each of the
six randomised studies reported in the literature discussing
caesarean section similarly reported no difference between
caesarean section rates for those given acupuncture or the
control group used, including sham acupuncture, an alternative analgesia or no specific treatment. The one study
limited to nulliparae unfortunately removed cases delivered
by caesarean section from the analysis.19 We did not
observe any significant differences for the indications for
caesarean section between the groups, a detail that was not
discussed in any of the other studies.
With all acupuncture studies there is the potential for
a lack of precision with placement of the needles at the
specified acupoints, which relies upon the subjective sensation of De-Qi: the inclusion of a sham acupuncture group
provides some protection for this variability. There does
not appear to be universal agreement from the published
studies on which acupoints should be used to provide intrapartum analgesia, nor how long the needles should
remain in place, with studies reporting a range from a
minimum of 10 minutes to the total duration of labour.
Similarly, there appears to be no agreement on how often
needle stimulation should be performed. It is also acknowl-


edged that it is not possible to devise a double-blind study

that includes a no-treatment control group. We recognise
the disparity in the numbers of cases treated by the three
acupuncturists, but were reassured by the lack of difference
in outcome between acupuncturists. By ensuring those who
gave acupuncture did not provide subsequent clinical care
we have reduced the risk of clinician bias, as well as the
variability resulting from parity and stage of labour when
enrolled, and thus potential duration of labour.

Neither manual nor electro-acupuncture reduced the need
for epidural anaesthesia compared with sham acupuncture,
and none of these techniques gave improved results compared with the control group. Although there was a trend
towards lower analgesic requirement and caesarean section
with acupuncture, the differences did not reach statistical
significance, although the study was not sufficiently
powered to identify such differences. This method of intrapartum analgesia cannot be recommended using the methodology employed here. It was, however, reassuring to
report an absence of side effects and no detrimental impact
on outcome attributable to acupuncture.

Disclosure of interests
None. IM provides legal opinion in litigation cases at the
request of claimants and defendants.

Contribution to authorship
JX and IZM had the original idea for the study, and IZM
is the guarantor. JX, CC, MB, JM and IZM were involved
in designing the study; HM was responsible for recruitment; JX, CC and HMM provided the acupuncture; JM
and IZM analysed the data. All authors were involved in
writing the article.

Details of ethics approval

Ethical approval was given by the Oxfordshire Research
Ethics Committee (C) on 5 August 2005, reference number

This study was supported by a grant from the Oxfordshire
Health Services Research Committee and The Uterine Contractility Trust Fund, held by the Oxford Radcliffe NHS

The authors acknowledge the assistance given by the
Oxford Centre for Medical Statistics performing the study
randomisation, and retaining the randomisation code until
recruitment to the study had been completed. j

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Acupuncture for pain relief in labour

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