ORIGINAL ARTICLE

Effect of ear acupressure on acute postpartum perineal pain:
a randomised controlled study
Winny SC Kwan and William WH Li

Aims and objectives. To explore the effect of ear acupressure in relieving perineal pain in women during the first 48 hours
after delivery.
Background. Perineal pain is a common problem during postpartum, and different treatment modalities have been used for
relief. Ear acupressure has been reported to have possible benefit on relieving acute postpartum perineal pain.
Design. This study was designed as a prospective, randomised controlled trial.
Methods. Chinese women with a singleton vertex foetus at the gestation of 37 weeks or above were recruited. One hundred
and twenty six and 130 women were randomised into the intervention and control groups, respectively. Women in the intervention group received application of tapes and seeds on four designated acupressure points on both ears, while women in
the control group received tapes on four irrelevant points. Both groups were instructed to stimulate the points in a similar
fashion. Pain perception was assessed by the Verbal Descriptive Pain Scale and the Visual Analogue Scale, and the consumption of analgesics was also reviewed.
Results. No significant difference in perineal pain perception between the groups was observed in Verbal Descriptive Pain
Scale. Although the mean Visual Analogue Scale and the accumulative mean consumption of paracetamol were generally
lower in the intervention group, statistical significance was not reached.
Conclusions. There is no evidence so far to conclude that ear acupressure can effectively relieve perineal pain based on the
statistical results. Further research is suggested to explore whether the effectiveness of pain relief is affected by the frequency
and duration of acupressure point stimulation.
Relevance to clinical practice. Training of midwives to perform this intervention is easy to achieve, but further evidence is
required to prove its effectiveness.
Key words: Chinese, ear acupressure, pain relief, perineal pain, postpartum, pregnancy
Accepted for publication: 11 January 2013

During the first few days after even a normal vaginal delivery, many women find the perineal pain unbearable while,
at the same time, they have to take up the skill of baby
care. The prevalence of postpartum perineal pain varies
among countries and ethnic groups (Macarthur &

Macarthur 2004, Andrews et al. 2008, Leeman et al. 2009,
Amorim Francisco et al. 2010, East et al. 2011), and factors such as parity (Thompson et al. 2002), severity of the
trauma (Klein et al. 1994, Albers et al. 1999) and mode of
delivery (Glazener et al. 1995, Declercq et al. 2008) may
affect the rate of prevalence. Different pharmacologic and
nonpharmacologic means to reduce postpartum perineal

Authors: Winny SC Kwan, RCMP, FHKAN, Registered NurseMidwife, Department of Obstetrics & Gynecology, Queen Elizabeth
Hospital, Kowloon; William WH Li, MBBS, FRCOG, FHKAM
(O&G), Consultant Obstetrician, Department of Obstetrics &
Gynecology, Queen Elizabeth Hospital, Kowloon, Hong Kong

Correspondence: Winny SC Kwan, Registered Nurse-Midwife,
Department of Obstetrics & Gynecology, Queen Elizabeth Hospital, 30 Gascoigne Road, Kowloon, Hong Kong. Telephone: +852
2958 6151.
E-mail: bkscw01@ha.org.hk

Introduction

© 2013 John Wiley & Sons Ltd
Journal of Clinical Nursing, 23, 1153–1164, doi: 10.1111/jocn.12281

1153

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

Apex of the auricle Anus External genital organs Shenmen Figure 1 Stimulation points for investigation of perineal wound pain relief. Blinding of intervention The ear acupressure was achieved by taping seeds of Vaccaria segetalis Garcke on various stimulation points on both ears (Fig. four pieces of tapes with seeds were applied to each ear. The point of external genital organs and the point of Anus were selected for their correspondence to the anatomical regions (Anon 2002). Adhesive tapes of 6 mm 9 6 mm in size were used to secure one seed to each stimulation point. Also with an estimated dropout rate of 15%. The women in the intervention group were instructed to press 30 seconds onto each of the seeds every four hours while awake. Stratified blocked randomisation was used to assure that the number of women would be equally distributed among the two study © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing. 1153–1164 Effect of ear acupressure on perineal pain groups based on whether an episiotomy had been performed and whether the spontaneous laceration was first or second degree if episiotomy had been avoided. women with diagnosed mental disorders. These women were approached at the antenatal unit to facilitate a better understanding of the nature of the study before they started to have labour pain. mode of delivery other than normal vaginal delivery. 23. Exclusion criteria included allergic history to adhesive tapes. The participants were randomly allocated to either one of the study groups by drawing lots from one of the three envelops prepared for first. use of epidural analgesia or any anaesthesia during labour. for a total of 226. 1155 .and second-degree lacerations and episiotomy. 1). women with chronic pain. thus. an addition of 30 subjects would be recruited. a total of 196 subjects for the two study groups would be needed if the estimated effect size was 040 (Cohen 1988). Only normal vaginal deliveries were included to avoid the confounding effect of other modes of delivery on perineal pain. All women in the intervention group had the same number of seeds placed on the same points. Only women with episiotomy or first or second degree of perineal lacerations were included eventually. Participants opted for epidural analgesia and those who had undergone anaesthesia for procedures like manual removal of placenta.or postnatal depression and those with any medical indications that required prolonged bed rest after delivery. The apex of the auricle and the Shenmen point were used to eliminate inflammation and relieve pain. Women who were deemed eligible and were still willing to participate were approached again prior to the suturing of the perineal wound for randomisation. Written informed consent was obtained from those women who were willing to participate. women with pre. If an episiotomy was clinically indicated. diagnosed mental disorders or depression related to childbirth were excluded as these factors could possibly distort the women’s perception of pain. use of other pharmacologic means for relief of pain other than perineal pain after delivery. Women with conditions like primary postpartum haemorrhage and hypertension or pre-eclampsia would not have the same amount of activities as the rest of the participants at least for the first 24 hours due to extended bed rest and were therefore excluded from the study. a mediolateral episiotomy would be performed on the left side of the perineum as a routine practice. exploration of uterus and evacuation of haematoma were excluded because of its possible impact on pain perception after delivery. Women with chronic pain.Original article Eligibility and recruitment Chinese women admitted with a singleton vertex foetus at the gestation of 37 weeks or above who intended to have a normal vaginal delivery were eligible for recruitment into the study. Allergic history was an absolute exclusion criterion as application of adhesive tapes was required in this study. Sample size and randomisation With an alpha value of 005 and power of 080.

Data collection A total of 573 Chinese women with a singleton vertex foetus at the gestation of 37 weeks or above intended to have a normal vaginal delivery were approached in the antenatal ward before they had any signs of labour onset. A credibility questionnaire was administered before discharge to assess any prior knowledge of ear acupressure and to obtain the women’s feedback on this treatment modality. four pieces of adhesive tapes of the same size were applied to four irrelevant points on both ears. The participants were told not to remove the adhesive tapes before discharge. One woman had late onset of hypertension and remained in bed rest for an extended period of time. Ten participants withdrew from the study after randomisation. The withdrawal rate was 38%. These midwives were not responsible for obtaining the pain score after the intervention. in Chinese medicine in general. Five women withdrew without stating any reasons.WSC Kwan and WWH Li The four-hour interval was designed to facilitate the women to remember stimulating the points as they were aware that oral analgesics could be offered every four hours if needed. with 126 and © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing. Application of the adhesives tapes was performed after the completion of perineal wound suturing. Therefore. Figure 2 shows the CONSORT flowchart of this study. All participants were also reminded that they could ask for oral analgesics whenever needed. 1153–1164 . Based on the exclusion criteria. Assessors of wound pain were midwives conducting the perineal suture and midwives working on the postnatal unit. Women in this group were instructed to rub over the tapes gently for 30 seconds every four hours while awake. Location of the adhesive tapes could give hints of whether stimulations points or irrelevant points were used if participants had prior knowledge of ear acupressure. Ten women were not eligible to join the study due to known allergy to adhesive tape. One woman was diagnosed with wound haematoma in the postnatal ward and required evacuation under anaesthesia. The standard prescription of oral analgesics in the current setting was 500-mg paracetamol tablet every four hours as needed. 23. Six women stated that they were sceptical about this treatment modality and did not have any interest 1156 Assessed for eligibility (n = 573) Nonparticipants (n = 24) Reasons: Adhesive tape allergy (n = 10) Skeptical about modality (n = 6) Demanding to perform task (n = 8) Enrollment with consent obtained (n = 549) Participants excluded (n = 283) Reasons: Epidural analgesia (n = 24) Cesarean section (n = 73) Vacuum extraction (n = 62) Forceps delivery (n = 2) Intact perineum (n = 22) Vaginal tear (n = 2) Postpartum hemorrhage (n = 10) Operation for incomplete placenta (n = 5) Wound complication (n = 3) Hypertension/pre-eclampsia (n = 6) Practitioner not available (n = 74) Spontaneous or induction of labour Randomisation (n = 266) Intervention group (n = 126) Analysis of VPDS Before LA Arrive PN 12 hours 18 hours 24 hours 30 hours 36 hours 42 hours 48 hours Withdrawal (n = 10) Reasons: Wound hematoma (n = 1) Late onset of hypertension (n = 1) Skin itchiness (n = 3) Unknown (n = 5) Control group (n = 130) Analysis of VAS Six hours 12 hours 18 hours 24 hours 36 hours 48 hours Analysis of paracetamol consumption 12 hours 24 hours 36 hours 48 hours Figure 2 CONSORT flowchart. Acupressure could be performed at the same time on both ears. The training session lasted for 30 minutes and consisted of demonstration and return demonstration to ensure uniform practice among all these midwives. consent was obtained from 549 women who eventually established the onset of labour either spontaneously or by induction. Credibility testing of assessors was unnecessary because the Verbal Descriptive Pain Scale (VDPS) would be obtained by different midwives on duty. Three women complained of itchiness over the ears. As a result. The refusal rate was 42%. data from 256 women were analysed. For the control group. There were eight other women who refused to join the study because they found it too demanding to have to massage the acupressure points on a regular basis and to complete the self-administered Visual Analogue Scale (VAS) score sheet. but no seeds were attached. the number of women who were eligible to remain in the study was further reduced to 266 as other intrapartum and postpartum confounding factors occurred. but no local allergic reaction was noted upon physical examination. Ten midwives working in the labour room received one individual training session by the author to apply the adhesive tapes with or without the seeds based on the randomised result from drawing lots by the subjects. The research assistant who performed the data entry was also blinded to the group assignment.

The mean birth weight of the infant was 330492 g in the intervention group compared with 318008 g in the control group (p < 005). There was no significant difference between the groups in terms of parity. 23. USA) for analysis. The distribution of the various 1157 . The intensity of perineal pain was assessed again after her first ambulation. No significant difference was found between the intervention and control groups in regard to the foetal position at birth. Perineal pain was assessed again when the woman was first transferred onto the assigned bed in the postnatal ward approximately two hours after delivery. demographic characteristics. 58 had a first-degree laceration.. Six 10-cm horizontal lines with one extreme marked ‘no pain at all’ and the other end marked ‘worst pain imaginable’ in Chinese were printed on a self-reporting form for the participants to express the intensity of perineal pain during the first two days of their hospital stay. When examining the perineal outcome. moderate pain or severe pain.Original article 130 women randomised to the intervention and control groups. The medication records of all participants were reviewed after discharge to evaluate the number of 500-mg paracetamol tablets consumed during the first 48 hours after delivery. were used to test for group effect. All statistical tests were two-tailed. including parity. A baseline assessment of perineal pain intensity was performed before the infiltration of local anaesthetics for wound suturing. and for those without an episiotomy. three time points (12. type of perineal trauma. the type of labour onset. Hospital Authority. respectively. until 48 hours after delivery. Missing or indistinguishable items were labelled as missing values. was recorded as the pain score. 1153–1164 Effect of ear acupressure on perineal pain Package for Social Sciences for Windows. smoking status. the mean duration of the first and second stages of labour. The subsequent pain assessments were carried out on the postnatal unit. The chi-square test and the independent samples t-test were used to analyse the VDPS and VAS scores. Hong Kong (Ref: KC/KE-10-0189/ER-5). The consent form was available in Chinese. were comparable. IL. Chicago. 24 and 36 hours) were selected for further analysis. be it pharmacologic or nonpharmacologic. birth weight and paracetamol. Data analyses The independent samples t-test was used for analyses of continuous data with normal distribution. and p <005 were considered statistically significant. All data obtained from the evaluation forms were entered into the Statistical © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing. ANCOVA test and repeated measures with adjustment of confounding factors. should not be withheld at anytime during the study if it was appropriate to use such methods. The distance from the zero endpoint to the mark. Ordinal data were analysed by the chi-square test. These four descriptions of pain were phrased in the same Chinese wordings and printed on the assessment form so that all assessors used the same expressions to obtain the participants’ subjective description of perineal pain. Because there were many missing values in VDPS and VAS at every time point. time effect and group–time interaction effect. Ethics consideration The study was approved by the Research Ethics Committee of the Kowloon Central and Kowloon East Clusters. equivalent to three times per day. The Visual Analogue Scale was also used for the evaluation of perineal pain intensity. Perineal pain was assessed using a simple VDPS – no pain. Results Mothers’ demographic data As shown in Table 1. labour onset. such as age. Individual questions on the credibility questionnaire were analysed by the Mann –Whitney U-test except the last question that required the chi-square test to examine the yes or no categorical variables. foetal position at birth. The women were instructed to make a mark perpendicularly on one line three times per day at a point that represented the level of pain at that moment. Indications for episiotomy were clearly explained to assure the participants that episiotomy would not be made for the sake of research. it was found that 172 women received an episiotomy. and 26 had a second-degree laceration. version 13. The woman was encouraged to rest in bed for a few hours before she attempted ambulation.0 (SPSS Inc. respectively. Eightysix participants completed both VDPS and VAS at these three time points. BMI. mild pain. measured to the nearest 05 cm. Participants were assured that participation in the study was voluntary and withdrawal at any time would not affect their plan of care. education level of the two groups of women. Position of the foetal head at birth was not recorded on the hospital notes in nine cases. All participants and caregivers were also reminded that other means of pain relief methods. Pain assessments were then performed every shift by the midwife on duty. The number of paracetamol tablets taken was categorised into ordinal data for analysis by the Mann–Whitney U-test.

The mean total blood loss was not significantly different between the groups. 21-gauge needle was routinely used to apply the local anaesthetic directly into the wound. were grouped together according to the time indicated by the midwife. results obtained from the VAS were grouped together at their closest approximates to 6. Johnson & Johnson International) using the continuous method. 1153–1164 . No significant differences were found between the intervention and control groups in the VAS results obtained at any point in time. shown in Table 2. Differences in pain level measured by VDPS between the intervention and control groups Because the midwives would assess the pain level of the woman any time during the shift. The amount of local anaesthetic (2% lignocaine) given was based on the extent of the laceration or episiotomy wound. The compliance rate of the midwives to obtain the VDPS gradually declined from the highest 949% upon the transfer of the woman to the postnatal ward to the lowest 512% at 48 hours postdelivery. 18. 1158 upon transfer onto the postnatal bed. All perineal wounds were sutured by midwives with a rapidly absorbed suture with a tapercut needle (Vicryl Rapide gauge 2-0. results obtained by the VDPS. ‡ Chi-square test. Differences in pain level measured by VAS between the intervention and control groups Participants were informed to mark the VAS three times per day. 42 and 48 hours postdelivery. types of trauma among the women in both groups was found to be similar. No significant differences were found between the intervention and control groups in the VDPS results obtained at any point in time. Therefore. 12. but no more than 10 ml was allowed in the current setting. 24. 24. 18. 36 and 48 hours postdelivery for calculating the mean at each time point (Table 3). 36. but they could do so at any time. although the mean VAS scores were generally lower in the intervention group © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing. Ethicon.WSC Kwan and WWH Li Table 1 Demographic characteristics of the intervention and control groups Mean (SD) Total (n = 256) Intervention group (Ni = 126) Control group (Nc = 130) p-value* Age (years) BMI Duration of 1st stage (min) Duration of 2nd stage (min) Birth weight of baby (grams) Blood loss (ml) Frequency (%) Smoking status No Yes Education level Secondary Tertiary Parity Primigravida Multigravida Labour onset Spontaneous Induction Foetal position at birth Occipitoanterior Nonoccipitoanterior Type of perineal trauma First-degree laceration Second-degree laceration Episiotomy 3087 2089 17744 2811 324152 22988 3098 2112 18756 2826 330492 23056 3077 2068 16763 2797 318008 22923 (421) (258) (12046) (2333) (36295) (7491) 071† 021† 021† 092† 001† 089† 119 (915%) 11 (85%) 014‡ (451) (279) (12667) (2292) (37686) (7551) 240 (938%) 16 (63%) (481) (298) (13249) (2259) (38183) (7641) 121 (96%) 5 (4%) 139 (543%) 117 (457%) 76 (603%) 50 (397%) 63 (485%) 67 (515%) 006‡ 183 (715%) 73 (285%) 89 (706%) 37 (294%) 94 (723%) 36 (277%) 077‡ 147 (574%) 109 (426%) 78 (619%) 48 (381%) 69 (531%) 61 (469%) 015‡ 199 (777%) 48 (188%) 104 (839%) 20 (161%) 95 (772%) 28 (228%) 019‡ 58 (227%) 26 (102%) 172 (672%) 29 (23%) 11 (87%) 86 (683%) 29 (223%) 15 (115%) 86 (662%) 076‡ *p <005 is considered statistically significant. 23. and at 12. 30. † Independent samples t-test. Analysis was performed on the VDPS results obtained before the local anaesthetics were administered just prior to wound suturing.

23. It was noted that the response rate from the women ranged from 82–938% at different time intervals. at all time points after the first six hours. and the results are shown in Table 8. Further analysis of a subgroup at three time points The subgroup of 86 participants. There was no significant difference between the groups in terms of having previous exposure to ear acupressure or ear acupuncture and their belief of ear acupressure in relieving perineal pain.Original article Effect of ear acupressure on perineal pain Table 2 Differences in pain level measured by VDPS between the intervention and control groups Perineal pain perceived by no. 36 and 48 hours postdelivery (Table 4). 1153–1164 graphic characteristics as the overall sample. It was found that the accumulative mean consumption of paracetamol tablets was greater in the control group at all times. Women from the intervention group tended to show more agreement with the following statements: 1159 . postnatal ward. Time and group effects were not observed (p > 005). with 41 in the intervention group and 45 in the control group. *p <005 is considered statistically significant (Chi-square test). but no statistical significance was observed. 24 and 36 hours. and there was no interaction effect between the two groups (p > 005). Responses from the credibility questionnaire Two hundred and thirty-six women returned the credibility questionnaire upon discharge. of women (collected by midwives) Intervention group (Ni = 126) Control group (Nc = 130) VDPS No Mild Mod Severe No Mild Mod Severe Compliance rate (%) p-value* Before LA Arrive PN 12 hours 18 hours 24 hours 30 hours 36 hours 42 hours 48 hours 7 32 11 4 6 6 9 7 3 64 77 85 84 73 87 79 69 56 38 12 17 12 11 7 7 6 2 12 2 2 0 1 0 0 1 0 4 38 14 10 8 7 11 7 5 61 77 89 88 93 75 75 66 61 48 13 15 12 6 9 7 4 4 9 1 0 1 0 1 0 0 0 949 984 910 824 773 750 734 625 512 048 086 047 038 027 060 087 074 068 LA. moderate. mod. local anaesthetic. Table 3 Differences in pain level measured by VAS between the intervention and control groups Mean VAS (self-recorded by participants) (No pain = 0. Most severe = 100) Time after delivery Intervention group (Ni = 126) Control group (Nc = 130) Response rate (%) (Intervention/Control) p-value* Six hours 12 hours 18 hours 24 hours 36 hours 48 hours 1890 2111 2129 1994 1790 1598 1703 2198 2226 2060 1845 1680 833% 833% 825% 905% 889% 698% 037 065 059 070 074 064 (0–60) (1–56) (0–55) (1–50) (0–52) (1–51) (0–53) (0–51) (0–51) (0–50) (0–50) (0–49) / / / / / / 808% 854% 869% 969% 962% 808% *p <005 is considered statistically significant (independent samples t-test). 24. Tables 5–7 show that there was no significant difference in the pain level by VDPS or VAS and the number of paracetamol consumed between the intervention and control groups after confounding factors were adjusted (p > 005) at 12. had similar demo© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing. Differences in paracetamol consumption between the intervention and control groups The accumulative mean consumption of paracetamol was compared at 12. PN.

birth weight and paracetamol. foetal position at birth. 24 and 36 hours) Total Intervention group Control group Time after delivery Mean (SD) n Mean (SD) Ni Mean (SD) Nc F (p-value) 12 hours 24 hours 36 hours Between groups [group]‡. B] 118 (031) [019.§ 027 (060)†. Table 6 Subgroup analysis of VAS at 3 time points (12. 039] Control group Mean (SD) Ni Mean (SD) Nc F (p-value) 2198 (1578) 1920 (1349) 1676 (1280) 41 41 41 2207 (1412) 2140 (1408) 1756 (1209) 45 45 45 011 (074)†. ‡ Repeated measure.§ F (p-value) [A. ‘I have manipulated the acupoints as instructed’ and ‘I would recommend this treatment to a friend who just delivered a baby’. ‡ Repeated measure.§ 006 (081)†. 1153–1164 . B – 24 hours vs. 074] 003 (097) [089.§ F (p-value) Within group [time]‡. † ANCOVA. type of perinea trauma.§ 002 (088)†. 086] A – 12 hours vs.§ 087 (043) [050. 24 and 36 hours) Total Time after delivery Mean (SD) Intervention group n 12 hours 2202 (1485) 86 24 hours 2035 (1376) 86 36 hours 1717 (1237) 86 Between groups [group]‡. of 500-mg tablets) Time after delivery Intervention group (Ni = 126) Control group (Nc = 130) p-value* 12 24 36 48 033 104 154 206 042 115 173 231 039 083 071 077 hours hours hours hours (0–2) (0–5) (0–7) (0–10) (0–2) (0–4) (0–7) (0–9) *p <005 is considered statistically significant (Mann–Whitney U-test).§ F (p-value) [A. 23.§ F (p-value) [A. 038] 002 (098) [086. B] 013 (088) [070. § F (p-value) [A. † ANCOVA. § Adjustment of factors including parity. 24 hours. 36 hours.WSC Kwan and WWH Li Table 4 Difference in paracetamol consumption between the intervention and control groups Accumulative mean consumption of paracetamol (no. labour onset. birth weight and paracetamol.§ F (p-value) 000 (099) Within group [time]‡. labour onset.§ 044 (051) 026 (077) [048. § Adjustment of factors including parity. © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing. 091] Interaction effect [time 9 group]‡. 36 hours. Table 5 Subgroup analysis of VDPS at three time points (12. 091] A – 12 hours vs. B] 206 (066) 205 (043) 199 (042) 86 86 86 210 (070) 207 (047) 200 (039) 41 41 41 202 (062) 202 (040) 198 (045) 45 45 45 049 (048)†. 24 hours. 086] 052 (060) [031. type of perinea trauma. B] 020 (082) [062.§ 030 (059)†. foetal position at birth. 067] Interaction effect [time 9 group]‡. Twenty-four women indicated that they were using 1160 another nonpharmacological method to relieve perineal pain at the same time. and this referred to the air ring available in the postnatal ward to promote comfort when sitting up. B – 24 hours vs.

Q7 is answered yes or no with space provided for elaboration.Original article Effect of ear acupressure on perineal pain Table 7 Subgroup analysis of paracetamol consumption at 3 time points (12. which was found to be higher than the episiotomy rate (53%) in the overall population of women who had a spontaneous vaginal delivery in this hospital during the same period. § Adjustment of factors including parity.§ F (p-value) Within group [time]‡. foetal position at birth. Table 8 Responses from the credibility questionnaire Ear acupressure Intervention group (Ni = 126) Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q1 Q2 Q3 Q4 Q5 Q6 Q7 Control group (Nc = 130) 216 (n = 117) 204 (n = 118) 282 (n = 117) 261 (n = 119) 339 (n = 116) 295 (n = 119) 283 (n = 115) 255 (n = 118) 308 (n = 116) 280 (n = 119) 300 (n = 116) 262 (n = 119) No = 88/Yes = 13 No = 96/Yes = 11 I have previous exposure of ear acupressure or ear acupuncture I believe ear acupressure can relieve perineal pain I have manipulated the acupoints as instructed I am having less perineal pain because of ear acupressure I will use this treatment again if I deliver another baby I would recommend this treatment to a friend who just delivered a baby I have used other nonpharmacologic methods to relieve perineal pain p-value* 057† 017† 001† 006† 008† 004† 056‡ *p <005 is considered statistically significant. This difference was probably due to the fact that the proportion of primiparous women was much greater in the study sample (71%) than that in the overall population (48%).§ 042 (052)†. 24 hours. 24 and 36 hours) Total Intervention group Control group Time after delivery Mean (SD) n Mean (SD) Ni Mean (SD) Nc F (p-value) 12 hours 24 hours 36 hours Between groups [group]‡. † Mann–Whitney U-test. 031] A – 12 hours vs. 009] Interaction effect [time 9 group]‡.§ F (p-value) [A. B] 003 (097) [081. ‡ Chi-square test. 072] 162 (021) [032. The loss of participants was mainly due to confounding factors that arose during the intrapartum period. 23. labour onset. 1153–1164 Sixty-seven per cent of the women received an episiotomy in this sample.§ F (p-value) [A. A greater proportion of primiparous women in this study sample may not affect the study result 1161 . ‡ Repeated measure. B – 24 hours vs. 36 hours. Remark: Q1–6 are rated on a 0 to 5 numeric scale with 0 indicating strongly disagree and 5 indicating strongly agree.§ 059 (044) 246 (009) [065. † ANCOVA. 090] 021 (081) [079. type of perinea trauma and birth weight. B] 035 (061) 064 (084) 058 (076) 86 86 86 032 (061) 056 (078) 054 (071) 41 41 41 038 (061) 071 (090) 062 (081) 45 45 45 013 (055)†. but only 266 (485%) were successfully enrolled in the study. Discussion Ear acupressure is observed to be a well-accepted modality among parturient women as evidenced by a low refusal rate (42%) and a low withdrawal rate (38%). © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing. Informed consent was obtained from 549 women.§ 037 (054)†.

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

Cochrane Database of Systematic Reviews.: CD006304. 16–24. No. Andrews V. 152–156. Cochrane Database of Systematic Reviews. Amorim Francisco A. Templeton A & Russell IT (1995) Postnatal maternal morbidity: extent. Hillsdale. Said J & Forster D (2011) Perineal pain following childbirth: Prevalence. Cohen J (1988) Statistical Power Analysis for the Behavioral Sciences. Birth 35. with an average of 855% response rate. Standardisation of the intervention from application of seeds and tapes to stimulation of the points should be vigilantly controlled in future. Stroud P. the response rate from the women ranged from 82–938% at different time intervals. Such discrepancy in the pain assessment by healthcare professionals and the self-reporting pain perception by the women raised a concern of whether the issue of perineal pain was overlooked by the midwives. Thakar R. Issue 1. Gynecologic. but further evidence to prove its effectiveness would first of all be required. Marchant P & Wallace K (2007) Local cooling for relieving pain from perineal trauma sustained during childbirth. Hyslop T. Contributions Study design: WSCK. 1153–1164 acetaminophen (single administration) for perineal pain in the early postpartum period. References Albers L. Gyte GML & G€ ulmezoglu AM (2010) Paracetamol/ © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing. Art. Garcia J. Hong Kong. compliance to follow the guidelines on reporting pain scores and indications for taking analgesics should be monitored more closely to avoid missing or mistaken values. it can never be assumed that they are all pain free. Journal of Obstetric. Abdalla M. woman to the postnatal ward to the lowest 512% at 48 hours postdelivery. McCandlish R & Elbourne D (1999) Distribution of genital tract trauma in childbirth and related postnatal pain. WHL and manuscript preparation: WSCK. 282–287. East CE. e254–e259. Future research could evaluate the frequency and duration of point stimulation on the effectiveness of pain relief. Dahlen H & Homer C (2008) Perineal trauma and postpartum perineal morbidity in Asian and Non-Asian primiparous women giving birth in Australia. Sultan AH & Jones PW (2008) Evaluation of postpartum perineal pain and dyspareunia – a prospective study. 23. Medicine & Health Publishing Company. with an average of 764% compliance rate. Renfrew M. Chou D. American Journal of Obstetrics and Gynecology 188. European Journal of Obstetrics & Gynecology and Reproductive Biology 137. Familiarity with the application process and training of additional midwives in performing this task would probably facilitate the implementation of this intervention. A study sample with women of different parity and ethnic groups would probably make the results more generalisable. Issue 3. Johnson C & Sakala C (2008) Mothers’ reports of postpartum pain associated with vaginal and cesarean deliveries: results of a national survey. 455–463. Henshall NE. However. Sherburn M. 93–97. 11–15. Bick D & Gonzalez Riesco ML (2010) Women’s experiences of perineal pain during the immediate postnatal period: A cross-sectional study in Brazil. Lawrence Erlbaum Associates. Cunningham DK. data collection and analysis. We are indebted to all the women for their participation in this study and to the midwives for their interventions and data collection. 2nd edn. Naji S. Acknowledgements Relevance to clinical practice It was noted that 74 participants were lost due to the unavailability of practitioner on site. effects on postnatal recovery and analgesia usage. VAS and the mean accumulative consumption of paracetamol. Abalos E. WHL. 1063–1067. data collection and analysis: WSCK. and Neonatal Nursing 37. Midwifery 27. We are also grateful for the support of our research and statistical assistants in subject recruitment. British Journal of Obstetrics and Gynaecology 102. Art. NJ. Begg L. East CE. No. Vasconcellos de Oliveira SMJ. prevention and treatment. Even though most women seem to be able to take up the activities of self-care and baby care in the first two days after delivery. Tolosa JE & Sultana C (2003) Racial differences in severe perineal lacerations after vaginal delivery. Declercq E. and this raised the question of practicality of using ear acupressure in a busy clinical setting. Hay-Smith J (1998) Therapeutic ultrasound for postpartum perineal pain and 1163 . Anon (2002) Practical Ear-Needling Therapy. Goldberg J. For the self-administered VAS scores. Glazener CMA. Birth 26. Another interesting point to note is that the compliance rate of the midwives to obtain the VDPS score gradually declined from the highest 984% upon the transfer of the This project was funded by the Hong Kong Obstetrics and Gynecological Trust Fund.: CD008407. Barbosa da Silva FM. Nagle C.Original article Effect of ear acupressure on perineal pain statistical significance was observed between the intervention and control groups in terms of pain perception measured by the VDPS. causes. Midwifery 28.

British Journal of Obstetrics and Gynaecology 116.WSC Kwan and WWH Li dyspareunia. Kaczorowski J. Robbins JM. Kindberg S. Edinburgh. Hopkins LM. Fast and easy online submission: online submission at http://mc. Chinese Acupuncture & Moxibustion 22. Gauthier RJ. severity. Albers LL & Rogers RG (2009) Postpartum perineal pain in a low episiotomy setting: association with severity of genital trauma. 2nd edn. Cao W & Wang C (2000) Effect of ear acupressure on relieving mediolateral episiotomy wound pain – a report of 34 cases. Fullilove AM. Guralnick MS. Klunder L. 1164 © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing. Olesen TD. please visit JCN on the Wiley Online Library website: http:// wileyonlinelibrary. as well as the option to deposit the article in your preferred archive. The Journal of Clinical Nursing (JCN) is an international. Johnson B.manuscriptcentral. Chinese Acupuncture & Moxibustion 3.: CD000495. 569 –576. Cochrane Database of Systematic Reviews. and determinants of perineal pain after vaginal delivery: a prospective cohort study. Berman MR. Pain 8. Macarthur AJ & Macarthur C (2004) Incidence. Manocchio R. Luskey GW & Joshi AK (1994) Relationship of episiot- omy to perineal trauma and morbidity. Parsons J & Crowther CA (2005) Topically applied anaesthetics for treating perineal pain after childbirth. 83– 94. Waghorn K. Zheng Y & Zhang X (2003) Use of ear point stimulation and Ciliao injection for inhibiting pain in parturition. sexual dysfunction. 23. Yue JJ. Franco ED. DeZinno P. Hedayati H. Kroening RJ & Bresler DE (1980) An experimental evaluation of auricular diagnosis: the somatotopic mapping of musculoskeletal pain at ear acupuncture points. Birth 36. Leeman L.e1–271. Positive publishing experience: rapid double-blind peer review with constructive feedback. American Journal of Obstetrics and Gynecology 201. 140. Glidden DV & Laros RK (2005) Racial/ethnic differences in perineal. 1153–1164 .: CD004223.com/jcnur. and birth variables. Jorgensen SH. Early View: fully citable online publication ahead of inclusion in an issue. 271. Thompson JF. Qu A. Cochrane Database of Systematic Reviews. No.e9. 283–288. Roberts CL. Art. 1392–1393. Wu J. Elsevier. One of the most read nursing journals in the world: over 19 million full text accesses in 2011 and accessible in over 8000 libraries worldwide (including over 3500 in developing countries with free or low cost access). Wang S. Song C (2002) Application of auricular point taping and pressing therapy in doula type labor. No. labor care. 455–459. Lin H.com/journal/jocn Reasons to submit your paper to JCN: High-impact forum: one of the world’s most cited nursing journals. with an impact factor of 1316 – ranked 21/101 (Nursing (Social Science)) and 25/103 Nursing (Science) in the 2012 Journal Citation Reportsâ (Thomson Reuters. Borders N. 2012). Gelfand MM. American Journal of Obstetrics and Gynecology 193. Strom J & Henriksen TB (2008) Ear acupuncture or local anaesthetics as pain relief during postpartum surgical repair: a randomized controlled trial. Issue 3. Yelland S (2005) Acupuncture in Midwifery. For further information and full author guidelines. 521–522. 217–229. Art. Issue 2. Caughey AB. Birth 29. Currie M & Ellwood DA (2002) Prevalence and persistence of health problems after childbirth: associations with parity and method of birth. and pelvic floor relaxation. American Journal of Obstetrics and Gynecology 191. Journal of Medical Theory & Practice 16. Braveman F & Kain ZN (2009) Auricular acupuncture as a treatment for pregnant women who have low back and posterior pelvic pain: a pilot study. 591–598. Lin EC. Online Open: the option to make your article freely and openly accessible to non-subscribers upon publication in Wiley Online Library. 1199–1204. American Journal of Obstetrics and Gynecology 171. vaginal and cervical lacerations. Klein MC. peer reviewed journal that aims to promote a high standard of clinically related scholarship which supports the practice and discipline of nursing.

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