Complementary Therapies in Clinical Practice 21 (2015) 257e261

Contents lists available at ScienceDirect

Complementary Therapies in Clinical Practice

journal homepage: www.elsevier.com/locate/ctcp

Acupressure for inducing labour for nulliparous women with

post-dates pregnancy
Sarah Gregson a, *, Denise Tiran b, Janine Absalom a, Lorraine Older a, Paul Bassett c
a

Maidstone and Tunbridge Wells NHS Trust, United Kingdom

Expectancy, United Kingdom
c
Statsconsultancy Ltd, United Kingdom
b

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 21 June 2015
Received in revised form
6 July 2015
Accepted 28 July 2015

Objective: To compare the efcacy of acupressure for induction of labour for nulliparous women with a
post-dates pregnancy.
Design: A single-blind randomised trial.
Setting: Antenatal and labour ward of a UK district general hospital.
Participants: One hundred and thirty two women requiring induction of labour with a post-dates
pregnancy (>41 weeks gestation) with no signicant medical, obstetric or fetal condition.
Method: Acupressure: 20 intermittent presses to stimulate each pair of acupressure points; (Large Intestine 4, followed by Spleen 6) or Sham treatment: 20 intermittent presses to the patella and then to
the olecranon.
Main outcome measures: Treatment-to-commencement of labour interval.
Secondary outcome measures: Requirements for oxytocin, mode of delivery, duration of labour,
requirement for pre-labour Caesarean section, presence of meconium, neonatal intensive care admission,
5 min Apgar scores, and evaluation of maternal satisfaction.
Results: There were no signicant differences between the two groups in treatment-to-commencement
of labour interval, requirements for oxytocin or mode of delivery. Fewer inductions of labour were
required in the sham treatment group (p 0.004 CI 1e35). The incidence of meconium-stained liquor,
and neonatal outcomes were similar for both groups.
Conclusions: Acupressure performed at 41 weeks gestation in nulliparous women does not appear to be
effective for inducing labour for post-dates pregnancy.
Crown Copyright 2015 Published by Elsevier Ltd. All rights reserved.

Keywords:
Acupressure
Acupuncture
Induction of labour
Post-dates pregnancy

1. Introduction
1.1. Background
Induction of labour is a common procedure that is performed in
around 20% of pregnancies in developed countries [1] It is indicated
when interrupting the pregnancy is thought to be advantageous for
the mother or baby and is often carried out for post-date pregnancies (>41 completed weeks of pregnancy), where it has been
shown to decrease perinatal mortality and morbidity [2]. Induction
of labour is not without risks and carries an increased prevalence of

* Corresponding author.
E-mail
addresses:
(S. Gregson).

segregson@btinternet.com,

sarah.gregson@nhs.net

http://dx.doi.org/10.1016/j.ctcp.2015.07.003
1744-3881/Crown Copyright 2015 Published by Elsevier Ltd. All rights reserved.

other interventions which impact upon both maternal and fetal

morbidity, such as an increased rate of Caesarean section, increased
incidence of operative delivery and increased use of epidural
analgesia [3]. It can also have a negative impact on the birth
experience of women, especially as a labour that is induced is
generally perceived as being more painful than spontaneous labour.
During the last decade, many women have resorted to using
natural methods such as complementary therapies and herbal
remedies in an effort to reduce medical intervention [4]. Unfortunately, most therapies have little robust evidence-base to prove
efcacy or safety, although this is slowly changing as the interest in
complementary medicine grows. However, acupressure and
acupuncture have been found to have some possible limited efcacy for managing pain in labour and birth [5,6] and some midwives and women believe it may also have some application for
inducing labour in post-term pregnancy [7], which could

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S. Gregson et al. / Complementary Therapies in Clinical Practice 21 (2015) 257e261

potentially avoid the use of pharmacological or mechanical means.

Acupuncture and acupressure are components of traditional
Chinese medicine, in which it is believed that the human body has a
complex series of channels (meridians) running throughout the
body. These channels carry the individual's energy or life force,
connecting one part to another to make the whole. When the
person is in optimum health, energy ows along the channels
without any impediment, but disease, disorder, stress or physiological changes (such as pregnancy and birth) may interfere with
the energy, causing blockages, deciencies or excesses at certain
points. Acupuncture (needling) or acupressure (thumb pressure)
are intended to apply the necessary stimulation or sedation to
correct these energy imbalances.
Certain specic acupressure points are considered to be contraindicated during pregnancy as they are known to trigger uterine
contractions when stimulated and should not be used prior to 37
weeks' gestation. Spleen 6 (Sp6) is a point located on the medial
aspect of the lower leg, approximately three nger-breadths above
the medial malleolus, in a depression just behind the tibia. Its
general function is to promote wellbeing of the stomach and
spleen, to regulate the uterus and to promote cervical ripening
towards the end of pregnancy. Spleen 6 stimulation can also be
used to aid progress in labour and for retained placenta. The Large
Intestine 4 (LI4) acupressure point is found on the dorsum of the
hand, between the rst and second metacarpal bones, at the midpoint of the second metacarpal bone, close to the border of the
radius. The function of LI4 is to aid circulation and the ow of the
energy along the channels, and to re-balance the energies
throughout the body. In Chinese medicine, Sp6 and LI4 are often
used to stimulate labour contractions, although several other points
may be added to the treatment, depending on the wellbeing of the
individual mother. The intention is to aid cervical ripening, ease
maternal anxiety and fear so that oxytocin levels can normalise and
some points are used to aid descent of the fetal head into the bony
pelvis. In the UK, many acupuncturists and midwife-acupuncturists
advocate an initial treatment by the practitioner, followed by selfadministration of acupressure stimulation to selected points by
the mother at home.
An extensive literature search found limited quality western
research in mainstream healthcare journals or databases relating to
acupuncture/acupressure stimulation for labour induction. It is
known that there are more papers available in acupuncture
research and Chinese medicine databases but it was not possible to
access these for the purpose of this review. There are anecdotal
reports of apparently successful acupuncture inductions, including
several in non-English language journals, and general papers on
post-dates pregnancy often cite acupuncture, acupressure or
shiatsu as effective means of triggering labour onset [8,9].
There is, however, little standardisation of methodology between the studies found. Papers from the 1970s are merely
extended case studies [10e12]. Most of the more recent studies are
randomised controlled trials but the nature of the control intervention varies from normal care to sham acupuncture [13e15]. This
may be either needling of false points [16] or, more commonly, false
needling of the appropriate points [17e19]. One study used
acupuncture in combination with oxytocin versus an oxytocin-only
control group [20] and another compared acupuncture with
misoprostol 21.
The gestation at which acupuncture point stimulation was
applied varied from 41 or more weeks [19], to 40 weeks [18,22] and
even 38 weeks [16,17], the earlier treatment intended as a means of
aiding cervical ripening. Others used acupuncture only in cases of
spontaneous membrane rupture with no contractions [23,24], or in
the event of a Bishops score of more than 7 [21].
Most formal studies have focused on stimulation by needling

(acupuncture). Only one study, undertaken by midwives, used

thumb pressure on the points, in the form of shiatsu (a modern
Japanese therapy similar to acupressure) [25]. Older studies added
extra stimulation in the form of electro-acupuncture [10e12], or
transcutaneous electrical nerve stimulation applied to the relevant
points [19].
The points stimulated also varied between studies, although this
may reect the formulaic approach of western acupuncture versus
the more individualised treatment advocated in traditional Chinese
medicine. Large Intestine (L14) and Spleen 6 (SP6) are the most
commonly-used points thought to trigger contractions, however
some studies have added other points, including Gall Bladder 21
[25], Bladder 67 a point intended to cause downwards movement
of the fetal head [12,16] additional Bladder channel points 31,32
and/or 56 [13,14] or Liver 3 [19] and Kidney 1, which may reduce
stress hormones to facilitate optimum oxytocin release.
Results have been generally disappointing. Excluding the pre2000s studies [19,10e12] in which the methodology was not as
robust as more recent investigations, only two studies showed
statistically signicant effectiveness for stimulation of acupuncture
points in initiating contractions [18,23], a fact supported by the
Cochrane systematic review of acupuncture for inducing labour7. It
is concluded that evidence at present is limited and that further
investigation is required to assess these techniques for clinical
meaningful outcomes.
2. Method
A single blinded randomised-controlled study was set up to test
the following null hypotheses:
(1) There is no signicant difference in efcacy of acupressure
for shortening treatment-to-commencement of labour interval (dened as the onset of regular painful contractions
increasing in strength) with a post-term pregnancy (41
completed weeks of pregnancy), compared to placebo
acupressure treatment.
(2) There is no signicant difference in clinical outcomes when
acupressure is used for shortening treatment-tocommencement of labour interval with a post-dates pregnancy compared to placebo acupressure treatment,
including incidence of operative delivery, meconium-stained
liquor, Apgar scores at 5 min and admission to the neonatal
unit.
Midwives were trained by a midwifery lecturer specialising in
complementary medicine to locate and correctly apply pressure
stimulation to the two designated acupressure points, Large Intestine 4 (LI4 on the hand) and Spleen 6 (SP6 on the inner lower
leg), Midwives delivering treatment were then assessed by the
lecturer for competence in locating and stimulating the points.
2.1. Sample size
The sample size was calculated based on showing a difference
between the two groups in terms of time to onset of labour from
the time of treatment. It is estimated that this outcome will have a
standard deviation of 1.75 days, and a difference between groups of
1 day would be of clinical importance. With a 5% signicance level
and 90% power it was calculated that 65 women per group would
be required for the study, a total of 130 women.
The study took place at Maidstone Birth Centre, Maidstone and
Tunbridge Wells NHS Trust between July 2012 and September 2014.
Approval for the study was obtained from the local Research Ethics
Committee.

S. Gregson et al. / Complementary Therapies in Clinical Practice 21 (2015) 257e261

Women were eligible to be included in the trial if they met the

following criteria: Singleton pregnancy at 41 completed weeks or
more of pregnancy, cephalic presentation, no signicant maternal,
fetal or medical condition. Women were excluded from the study if
they had any previous signicant cervical treatment such as cone
biopsy, signs that labour has started (including regular, painful
contractions, spontaneous rupture of the membranes) or had previously used a complementary therapy or natural remedy to start
labour in this pregnancy (eg raspberry leaf tea).
Those willing to participate in the trial were asked to give
written consent. The allocation of treatment was generated using a
computer random schedule at the start of the study and assignment
was concealed by placement in consecutively numbered, opaque,
sealed envelopes drawn in consecutive order by the midwife, who
was unaware which agent was allocated until the envelope was
opened. The investigators and participant were blind to allocation,
but blinding of the midwife administering the treatment was not
possible due to the differences in treatments used.
All participants (both groups) received a membrane sweep
(recommended routinely for post-dates pregnancy) prior to joining
the study. Following this, participants received either: acupressure,
20 intermittent presses to stimulate acupressure points Large Intestine 4 and Spleen 6 or sham treatment: 20 intermittent presses
to the patella and then olecranon. The sham points had been
determined following discussion with an acupuncturist who
conrmed that there were no other acupuncture points located
over these bony areas of the body.
Following treatment, both groups were asked to continue the
treatment at home by continuing to stimulate the points as above
four times a day. They were given a date to attend for induction of
labour at 40 weeks 13e14 days if labour had not begun spontaneously by then.
2.2. Outcome measures
The
primary
outcome
measure
was
treatment-tocommencement of labour interval.
Secondary outcomes were the requirement for induction of labour, need for oxytocin augmentation, mode of delivery, analgesia
use in labour, duration of labour, requirement for pre-labour
Caesarean section, presence of meconium, neonatal intensive care
admission, neonatal Apgar scores at ve minutes after birth and
maternal satisfaction with the intervention.
The experimental and control groups were compared for factors
that could potentially affect the induction process: age, parity,
height, weight, body mass index (BMI), ethnicity, gestational age,
birth weight, and Bishop score, (a measure of readiness for labour)
when membrane sweep was performed.
2.3. Data collection
Data was collected from the participants' hospital records and
entered onto a SPSS for Windows database. Immediately after
receiving the rst treatment from the midwife, participants were
asked to complete a short questionnaire about the treatment
experience and their thoughts on how likely it was to affect
commencement of labour. Following the birth, participants were
contacted by telephone and asked to complete a short questionnaire about the study.
2.4. Statistical analysis
All analyses were compared between the two study groups.
Categorical variables were compared between groups using the
Chi-square test. Continuous variables were compared between

259

groups, using the unpaired t-test if found to follow a normal distribution, and using the ManneWhitney test if not found to be
normally distributed.
All tests were 2-tailed and a signicance level of p < 0.05 was
accepted as statistically signicant. Ninety-ve percent condence
intervals (2-tailed) have been presented alongside summary measures (mean and percentage difference, medians) throughout.
3. Results
131 women were recruited of whom 70 received acupressure
and 60 received sham treatment. One participant went in to labour
before treatment was given, and was therefore excluded from the
analysis. Two women required a Caesarean section prior to labour
(either spontaneous or induced), however these were included in
the analysis as intention to treat.
Maternal demographic details were compared across experimental and control groups (Table 1). There were no signicant
differences except for a slight increase in BMI in the sham treatment group and a slightly lower Bishop's score prior to induction of
labour in the acupuncture group.
The results suggest there was no signicant difference in time
interval between treatment and start of labour (primary outcome)
Table 2.
Requirement for induction of labour was more common in the
acupressure group, with 14 more women having labour induced
than in the control group. The acupressure group also had a trend
towards requiring more use of oxytocin to augment labour,
although this result was not statistically signicant. No differences
between the groups were observed for mode of delivery, presence
of meconium or neonatal Apgar scores at 1 and 5 min. There were
no admissions to the Neonatal Unit in either group (Table 3).
Women found acupressure more uncomfortable than sham
treatment, although there was very little difference in the size of
the scores. It would appear that most women were motivated to
continue treatment whilst at home, with only 11% reporting that
they were too busy to do this (Table 4).
4. Discussion
This purpose of this study was to investigate the efcacy of
acupressure for reducing the need for induction of labour for
nulliparous women with a post-dates pregnancy. It was hypothesised that if effective, acupressure would be likely to be very
acceptable for women as a simple, non-invasive therapy with no
apparent side effects and also very cost effective for maternity
services to implement as 'routine' management for women with a
post-dates pregnancy. Unfortunately in this study, results did not
nd any evidence to support the use of acupressure for inducing
labour e and disappointingly found that sham treatment
Table 1
Maternal demographic details at onset of treatment.
Acupressure Sham treatment P Value
Age in years (16e40) Mean (SD)
28.6 (4.9)
27.9 (5.9)
Gestation in days (from EDD) (286e289) 287.2 (0.5) 287.1 (0.5)
BMI (18e37)
23.8 (3.7)
25.2 (3.7)
Birth weight of baby (gm) (2480e5230) 3737 (404) 3664 (480)
Bishop score at induction
3.4 (2.2)
4.3 (2.3)
Ethnicity
White
60 (86%)
53 (88%)
Black, Asian or Chinese
10 (14%)
7 (12%)

0.44
0.37
0.03
0.35
0.02
0.80

Values are given as a mean with standard deviation in brackets unless otherwise
indicated.
2 tailed t test used for all data except for Ethnicity (Fisher's Exact Test).

260

S. Gregson et al. / Complementary Therapies in Clinical Practice 21 (2015) 257e261

Table 2
Comparison of treatment-start of labour.

Median
SE
95% CI

Acupressure

Sham

P Value

103
(46.151)
17 (7.42)

72
(38, 110)
0

0.19

The results suggested that that there was no statistically signicant difference in the
time interval between delivering treatment between the two groups.

groups who continued the self-administered treatment at home

and who stated that they would try this strategy again in a future
post-dates pregnancy. It also implies that women felt empowered
by self-administering this treatment at home. This in turn may have
inuenced their willingness to wait for the full two weeks beyond
their due date (with less likelihood of an induction being necessary
for each day that passed), rather than requesting labour to be
induced at an earlier date.

Table 3
Secondary outcomes: labour and neonatal outcomes.

Requirement for induction of laboura

No requiring oxytocin augmentation
Presence of meconium
Mode of delivery
SVD
Instrumental
Caesarean section
Apgar Score at 1 min
Apgar Score at 5 min
a

Acupressure

Sham

P Value [1]

Percent diff.

Lower

Upper

28 (41%)
38 (54%)
22 (31%)

14 (24%)
23 (38%)
13 (22%)

0.04
0.07
0.21

17%
16%
10%

1%
1%
5%

33%
33%
25%

30
17
23
9
10

28
13
19
9
9

0.90

0
0

0
0

0
0

(43%)
(24%)
(33%)
(8, 9)
(9, 10)

(47%)
(22%)
(32%)
(8, 9)
(9, 10)

0.37
0.15

95% CI for percent diff.

Analysis omitting one patient in sham group and one patient in acupressure group who required pre labour caesarean section.

Table 4
Women's experience of treatment.

The treatment is likely to help my labour to start

The treatment was painful and uncomfortable
The treatment helped my labour to start
I continued treatment at home
How many times a day did you perform the treatment?
I would want to have this treatment again
if I was over due in another pregnancy.

Acupressure (Range 1e71 not

at all 7 extremely likely)

Sham (Range 1e7 1 not

at all 7 extremely likely)

Difference (95%CI)

P Value

4
2
3
49/52
3.3
6

4
1
4
40/51
3.1
6

0
1
0
16%
0.3
0

0.03
<0.001
0.40
0.02
0.22
0.67

(4.6)
(2.3)
(2.5)
(94%)
(1.1)
(5.7)

appeared to be more successful.

Acupressure was selected as a means of delivering the therapy,
rather than acupuncture (which requires needles to puncture the
skin) because of its non-invasive approach and the ease with which
midwives could be prepared to deliver the required therapy with
limited training and little nancial cost. It is possible that
acupuncture may have yielded different results.
The literature cites a number of acupuncture points that can
potentially be used for the purpose of inducing labour or causing
contractions, however the majority of studies examined by this
research team used LI4 and SP6. These points were therefore
selected for this study with the additional advantage of being
relatively easy to locate and subsequently deliver treatment in a
busy antenatal clinic setting. It is also possible that selection of
different or additional points may have altered the results, for
example, Gall Bladder 21 point which is known to encourage
downwards movement and which has been used in some studies.
Differences were found between the two groups in respect of
BMI and Bishop scores (the acupressure group had slightly lower
BMIs; the Sham treatment group had slightly more favourable
Bishop scores). However these differences were relatively small
and are therefore unlikely to have affected results in a major way.
Midwives who delivered the treatment package, reported that
women were pleased to have something positive to do that could
potentially bring the start of labour forward, thus possibly avoiding
the necessity for labour to be induced. This was reected in the high
number of participants in the acupressure and sham treatment

(4.6)
(1.2)
(2.6)
(78%)
(1.1)
(2.7)

(0.1)
(1.1)
(0.1)
(35, 29%)
(0.2,0.8)
(0.1)

There have been criticisms and debate in the literature around

using a reductionist framework to evaluate whole systems of
medicine, such as acupressure and other complementary therapies,
as this may obscure the real potential of the whole therapy under
investigation [6]. It is possible that using acupressure as part of a
package of additional therapies (such as aromatherapy, reexology
etc) may play a part in increasing effectiveness as has been suggested by an audit of a post-dates pregnancy clinic by Pauley and
Percival (2014).

5. Conclusion
In this study, stimulation of acupuncture points Large Intestine 4
and Spleen 6 to induce labour for nulliparous women with a postdates pregnancy does not appear to be effective. More research is
required to investigate whether other treatment regimens, adding
additional acupressure point stimulation or replacing acupressure
with acupuncture would be more likely to work.

Acknowledgements
The authors would like to thank the midwives working at
Maidstone Birth Centre and other staff at Maidstone and Tunbridge
Wells NHS Trust for their help and support with this research
project.

S. Gregson et al. / Complementary Therapies in Clinical Practice 21 (2015) 257e261

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