50 A Review of Research into the Application of Acupuncture in Pregnancy Journal of Chinese Medicine Number 80 February 2006

A Review of Research into the

Application of Acupuncture in
Pregnancy
By: Debra Betts Abstract
This article examines research on the use of acupuncture during pregnancy, specifically for pelvic pain, nausea and
Keywords: vomiting, breech presentation, prebirth preparation and cervical ripening. The studies on pelvic pain, nausea and
acupuncture, vomiting and breech presentation have been selected because they have been published in medical and midwifery
pregnancy, journals which are readily accessible to medical professionals. The studies on prebirth preparation and cervical
pelvic pain, ripening have been selected due to their relevance to clinical practice.
nausea and
vomiting,
breech Introduction Three physiotherapists gave standard treatment, two

W
presentation, hile traditional Chinese acupuncture aims
prebirth to provide treatment specically tailored
preparation, to an individual, the aims of modern
cervical research are often different and frequently assess
ripening. acupuncture treatment formulas for a specic western
diagnosis. Despite this conict, western research into
acupuncture presents interesting opportunities for
practitioners. Research appearing in medical and
nursing journals can be used to initiate discussion with
western health professionals, to promote acupuncture
practice in the community and to evaluate personal
clinical practice. This is especially true in the eld of
obstetrics where safety and evidence based practice
are primary concerns.
medical acupuncturists delivered the acupuncture
treatment and two physiotherapists gave the
stabilising exercises.
Pain was measured by a visual analogue scale
and by an independent examiner before and after
treatment.
Conclusion
Acupuncture was superior to stabilising exercises in
the management of pelvic girdle pain in pregnancy,
with acupuncture the treatment of choice for patients
with one sided sacroiliac pain, one sided sacroiliac
pain combined with symphysis pubis pain and double
sided sacroiliac pain.

Research Acupuncture comments

Acupuncture and pelvic pain in pregnancy
Elden et al.1 2005 published a randomised single blind
controlled trial involving 386 pregnant women in the
British Medical Journal (BMJ).
Summary
The objective was to compare the efcacy of standard
treatment for pelvic pain (a pelvic belt, patient education
and home exercises for the abdominal and gluteal
muscles) to standard treatment plus acupuncture or
standard treatment plus physiotherapy stabilising
exercises (for the deep lumbopelvic muscles).
The study time frame consisted of one week
which was used to establish a baseline, followed
by six weeks of treatment. The acupuncture
treatment was given twice a week and the
stabilising exercise sessions one hour per week
(with patients then doing these exercises several
times a day on a daily basis). Follow up was carried
out one week after treatment nished.
Treatment method
The women received 17 needles at each visit. Seven
needles were used bilaterally at Baihui DU-20, Hegu
L.I.-4, Kunlun BL-60 and Zusanli ST-36 with ten
further acupuncture needles selected from a number
of local points which were tested for tenderness
on palpation: Guanyuanshu BL-26, Ciliao Bl-32,
Zhongliao BL-33, Zhibian BL-54, Henggu KID-11,
Huantiao GB-30, Chongmen SP-12 and the extra point
Yaoyan M-BW-24 (identied in the study as EX 21).
The points were used bilaterally with the needles
inserted to a depth of 15-70 mm. Once deqi was
achieved they were left in place for 30 minutes and
manually stimulated every 10 minutes.
Clinical perspectives
Although no serious complications were reported
during treatment, it is of concern that the acupuncture
points Hegu L.I.-4, Kunlun BL-60 and Ciliao Bl-32 are
listed with no mention of their function in traditional
Journal of Chinese Medicine Number 80 February 2006
Chinese medicine of inducing labour2,3. The women in this
study who received acupuncture were from 12 to 31 weeks
gestation. Traditionally these points would be regarded as
forbidden (or only to be used with great care) at this stage
of a pregnancy. To me this is especially true when they are
used in combination.
E-mail correspondence with the author Helen Elden
conrmed that Baihui DU-20, Hegu L.I.-4, Kunlun BL-60
and Zusanli ST-36 were used as routine points at each
acupuncture treatment. She commented that they did not
use TCM theory when choosing the points. The study
states that these distal points were chosen due to their
well known pain relieving effect.
While the choice of Hegu L.I.-4 and Kunlun BL-60 as
distal points for pelvic pain is of concern from a traditional
Chinese medicine perspective, it is also surprising
considering that Hegu L.I.-4 was used in research as an
induction point for women at term (Rabl et al.l 20014).
They concluded that acupuncture was able to encourage
ripening of the cervix and reduce the time interval
between the expected date of delivery and the actual time
of delivery.
My own view is that despite the fact that 125 women
received acupuncture at Hegu L.I.-4 and Kunlun BL-60
with no serious side effects, this is not sufcient to modify
my clinical practice. From a traditional Chinese medicine
perspective there are a range of effective distal points to
use in the treatment of pelvic girdle pain without resorting
to the use of Hegu L.I.-4 and Kunlun BL-60, and this is
a small sample of women when compared to both the
historical data and the evidence of effective clinical use of
these points to induce labour.
This is an interesting study as, while it conrms
the benet of offering acupuncture for pelvic pain in
pregnancy, it also raises questions about the way point
prescription acupuncture can be used by physiotherapists
and medical acupuncturists.
Acupuncture and morning sickness
Smith et al. in 2002 published two articles from their
research on nausea and vomiting in pregnancy. The
rst looked at the effectiveness of acupuncture5 and the
second at the safety of acupuncture treatment in early
pregnancy.6
Summary
The objective was to compare i. traditional acupuncture
treatment, ii. acupuncture at Neiguan P-6 only, iii. sham
acupuncture and iv. no acupuncture treatment for nausea
and vomiting. 593 women who were less than 14 weeks
pregnant and were suffering nausea and vomiting of
pregnancy were randomised into 4 groups and received
treatment weekly. The acupuncture group, in which
points were chosen according to a traditional acupuncture
diagnosis, received two 20 minute acupuncture treatments
A Review of Research into the Application of Acupuncture in Pregnancy 51
in the rst week followed by one weekly treatment for
the next four weeks. The sham acupuncture group were
needled at points close to but not on acupuncture points
and both the sham and Neiguan P-6 acupuncture groups
were treated with the same frequency as the traditional
acupuncture group. All group received their treatment
from the same acupuncturist.
The outcomes of treatment were measured in terms of
nausea, dry retching, vomiting and health status.
When compared to the women who received no
treatment, the traditional acupuncture group reported
less nausea throughout the study and less dry retching
from the second week. The Neiguan P-6 acupuncture
group reported less nausea from the second week and less
dry retching from the third week. The sham acupuncture
group reported less nausea and dry retching from the
third week. So while all three acupuncture groups
reported improvement with nausea and dry retching, it
was the traditional acupuncture group that had the fastest
response.
Patients receiving traditional acupuncture also reported
improvement in ve aspects of general health status
(vitality, social function, physical function, mental health
and emotional role function) compared to improvement
in two aspects with both the Neiguan P-6 and sham
acupuncture groups. In the no treatment group there was
improvement in only one aspect.
Although there were no differences in vomiting found
in any of the treatment groups the authors speculated that
more frequent treatments might have produced greater
benets.
In assessing the safety of acupuncture in early pregnancy,
data was collected on perinatal outcome, congenital
abnormalities, pregnancy complications and problems of
the newborn. No differences were found between study
groups in the incidence of these outcomes suggesting
that there are no serious adverse effects from the use of
acupuncture treatment in early pregnancy.
Conclusion
Acupuncture is a safe and effective treatment for women
who experience nausea and dry retching in early
pregnancy.
Acupuncture comments
Treatment method
The traditional acupuncture treatment involved the
insertion of up to six needles per treatment. Deqi was
obtained in both the traditional acupuncture group and the
Neiguan P-6 needle group. No effort was made to obtain
deqi when needling the sham points which were inserted at
a minimal depth. In all three treatment groups the needles
were left in place for 20 minutes. The acupuncture points
for the traditional acupuncture treatment were selected
according to the following pattern differentiation.
52 A Review of Research into the Application of Acupuncture in Pregnancy
Liver qi stagnation: Taichong LIV-3, Neiguan P-6,
Yanglingquan GB-34, Shangwan REN-13, Youmen KID-21,
Liangqiu ST-34, Zusanli ST-36.
Stomach or Spleen deciency: Zusanli ST-36, Neiguan P-6,
Zhongwan REN-12.
Stomach heat: Neiting ST-44, Jianli REN-11, Liangqiu
ST-34, Liangmen ST-21, Neiguan P-6, Quze P-3.
Phlegm: Fenglong ST-40, Yinlingquan SP-9, Burong
ST-19, Pishu BL-20, Youmen KID-21.
Heart qi deciency: Tongli HE-5, Neiguan P-6, Zusanli
ST-36, Juque REN-14.
Heart re: Neiguan P-6, Juque REN-14, Xinshu BL-15.
Local abdominal points were also used, selecting from:
Burong ST-19, Chengman ST-20, Liangmen ST-21, Youmen
KID-21, Futonggu KID-20, Juque REN-14, Shangwan
REN-13, Zhongwan REN-12, Jianli REN-11 and Xiawan
REN-10.
Clinical Perspective
This is a very interesting study, as it explores the use
of traditional pattern differentiation in both diagnosis
and treatment, compared to the use of a single point
formulated treatment. In doing so it provides information
both to acupuncturists and the western medical health
professions about the most effective use of acupuncture.
This research provides reassurance to the medical
profession that acupuncture is a safe and effective
treatment in early pregnancy as well as conrming the
effectiveness of traditional diagnosis over prescription
point acupuncture.
Moxibustion use for Breech Presentation
Cardini et al. in 19987 had the following randomised
controlled trial published in the Journal of the American
Medical Association (JAMA).
Summary
The objective was to evaluate the efcacy and safety
of moxibustion on Zhiyin BL-67 to correct breech
presentation.
130 women with a breech presentation and having their
rst baby (primigravidas), received moxibustion to Zhiyin
BL-67 at 33 weeks gestation while 130 women, also with
a breech presentation and who were also primigravidas,
received no intervention.
The moxibustion was administered for seven days.
Women were then assessed and a further seven days of
moxibustion treatment given if the babys position had
not changed.
Outcomes were measured in terms of foetal movements,
as counted by the mother for one hour each day for one
week, and the number of cephalic presentations both at 35
weeks gestation and at delivery.
At 35 weeks gestation 75.4% in the intervention group
had changed to cephalic (47.7% in the control). Women in
Journal of Chinese Medicine Number 80 February 2006
both groups then had the option of undergoing external
cephalic version (ECV). One woman took this option from
the intervention group and 24 from the control group.
At delivery the presentation of 75.4% of the intervention
group was cephalic compared to 62.3% in the control
group. The presentation did not change in any of the
groups after 35 weeks except in those undergoing ECV
(i.e. there were no spontaneous versions).
In terms of foetal movement the moxibustion group
experienced a greater number of movements (a mean of
48.45 compared to the control group with a mean of 35.35).
Conclusion
That in prigravidas at 33 weeks gestation with breech
presentation, moxibustion treatment for one to two
weeks at Zhiyin BL-67 increased foetal activity during the
treatment period and cephalic presentation at 35 weeks
and at delivery.
Acupuncture comments
Treatment method
The women and their partner (or a person to help with
the treatment) were given a treatment and taught how
to use the moxibustion in a hospital appointment within
24 hours of the scan conrming the breech position.
They then applied the treatment to Zhiyin BL-67 daily at
home. Moxa sticks were used with the women sitting or
in a semisupine position and the partner delivering the
treatment.
Clinical perspective
As part of this study, an attempt was made to assess if
there was a difference in applying moxibustion once or
twice a day.
87 women in the treatment group used moxibustion for
a total of 30 minutes (15 minutes to each point) once a day,
while 43 women used moxibustion in the same way but
received treatment twice a day.
At the end of the rst week 79% of the cephalic versions
were obtained in the women using moxibustion twice
a day compared to 55.2 % in the once daily treatments.
But by the end of the second week 15 additional cephalic
versions were obtained in the group having moxibustion
treatment once a day. This meant that at 35 weeks the
results were termed as a nonsignicant difference (72.4%
in the once a day moxibustion group compared to 81% in
the twice a day group).
It may also be signicant to clinical practice that with
these primigravidas after assessment at 35 weeks there
was no spontaneous turning from a breech to cephalic
presentation for any of the women.
From a safety perspective it was reassuring that no adverse
events (such as intrauterine death or placental detachment)
were noted in the treatment group. It was also interesting
that while the number of premature rupture of membranes
Journal of Chinese Medicine Number 80 February 2006
was similar in both groups, the number of premature
births was lower in the intervention group and the use
of oxytocin, before or during labour, was also reduced
in the moxibustion group (8.6% compared to 31.3%).
Prebirth acupuncture
Prebirth acupuncture has an interesting history with
several studies examining the effect of acupuncture used
prior to labour.
Summary
Research on the use of acupuncture to prepare women for
labour rst appeared in 1974 with a study by Kubista and
Kucera8. Their research concluded that acupuncture once
a week from 37 weeks gestation using the acupuncture
points Zusanli ST-36, Yanglingquan GB-34, Jiaoxin KID-8
and Shenmai BL-62 was successful in reducing the mean
labour time of the women treated.
They calculated the labour time in two ways. The rst
was the mean time between a cervical dilation of 3-4 cm
and delivery. In the acupuncture group this was 4 hours
and 57 minutes compared to 5 hours and 54 minutes in the
control group. The second was the mean subjective time
of labour, taken from the onset of regular (10-15 minute)
contractions until delivery. The acupuncture group had
a labour time of 6 hours and 36 minutes compared to 8
hours and 2 minutes in the controls.
In 1987 Lyrendas et al.9, basing their study on the
work of Kubista and Kucera, contradicted their ndings,
concluding that acupuncture lengthened delivery time.
In their study the acupuncture group had a total mean
delivery time, calculated as time of admission to the
delivery ward until delivery, as 8 hours and 30 minutes
compared to 7 hours and 40 minutes in the control group.
In 1998 Zeisler et al.10 used the acupuncture points Baihui
DU-20, Shenmen HE-7 and Neiguan P-6, treating from 36
weeks gestation. This study concluded that acupuncture
treatment had a positive effect on the duration of labour
by shortening the rst stage of labour, dened as the time
between 3cm cervical dilation and complete dilation. The
acupuncture group had a median duration of 196 minutes
compared to the control group time of 321 minutes.
In comparing these studies the following points should
be noted.
Group numbers
In order to obtain accurate statistical comparisons it
is seen as ideal to have more or less the same numbers
of women in the treatment and control groups. While
this happened in the studies by Kubista and Kucera
(70 women in the acupuncture group and 70 women in
the control group) and Zeisler et al. (57 women in the
acupuncture group and 63 women in control group),
Lyrendas et al. had 56 woman in the acupuncture
group and 112 woman acting as controls.
A Review of Research into the Application of Acupuncture in Pregnancy 53
Measurement of labour time
It can be difcult to accurately dene the beginning of labour
as this is often a subjective measurement of the intensity
or timing of contractions which may vary according to
different womens perceptions of pain and expectations of
labour. Even if labour is medically dened by measuring
cervical dilation, women can vary considerably in their
presentation of early labour. For example in the study by
Zeisler et al., 27 women were excluded as they presented
for admission to the delivery unit with more than 3cm of
cervical dilation. Despite these difculties an attempt was
made in each study to measure the length of labour from
different starting points. It is worth noting that Lyrendas
et al. used the most subjective, and therefore the least
accurate method, by taking the beginning of labour as the
time that women presented in the delivery suite.
It is also worth noting that different statistical methods
were used. Kubista and Kucera and Lyrendas et al. used
a mean labour time while Zeisler et al. used a median
labour time. The median labour time is considered to be
a more useful measurement for the length of time women
spend in labour, giving a more accurate value when used
for wide variations in data, whereas the mean is more
suitable for data that falls into a bell curve distribution
and can become extremely distorted by just one or two
extreme values.
Additional requirements for participating in the study
As a requirement for entry into the acupuncture group
in the Lyrendas et al. study, women were required to
consent to having two lumbar punctures, one at 38 weeks
gestation and another six months after delivery. Having
to consent to such an invasive medical procedure would
have certainly inuenced the range of women who agreed
to receive acupuncture. It is also notable that in this study
there was a control group of 16 women who received a
lumbar puncture (but did not receive acupuncture).
They had the longest mean labour time of 9 hours and 30
minutes (acupuncture group 8 hours and 30 minutes).
Conclusion
Although the research by Lyrendas et al. appears, at rst
glance, to contradict the ndings of both Kubista and
Kucera and Zeisler et al., the full paper casts doubt on
the validity of its conclusions. It used a control group
that was twice as large as the acupuncture group, used
the most subjective method for timing the onset of labour
(presentation to delivery suite) and used a recruiting
process that asked women in the acupuncture group to
have an invasive medical procedure (lumbar puncture).
Acupuncture comments
Treatment method
Kubista and Kucera
The acupuncture points Zusanli ST-36, Yanglingquan
54 A Review of Research into the Application of Acupuncture in Pregnancy
GB-34, Jiaoxin KID-8 and Shenmai BL-62 were used weekly
on primigravida women from 37 weeks until delivery. The
reasoning given for choosing these acupuncture points
was that as a group they would relax the women, tonify qi
and improve circulation of blood to the pelvis. The points
were needled bilaterally, with obtaining of deqi and an
even manipulation method, and retained for 20 minutes.
The women were treated in a sitting position and received
an average of three treatments.
Lyrendas et al.
Despite stating in their study that the acupuncture points
used were the same as those used in the Kubista and
Kucera study, Sanyinjiao SP-6 was substituted for Jiaoxin
KID-8, with no reason given. Zusanli ST-36 and Sanyinjiao
SP-6 were selected to improve the circulation of the pelvic
organs, Yanglingquan GB-34 was used as an inuential
(hui-meeting) point for the muscles and tendons, and
Shenmai BL-62 was used as a tranquillising point.
They also used a different acupuncture method from
the Kubista and Kucera study. While the women received
bilateral acupuncture with deqi and even manipulation,
the women were treated lying on their sides. As the total
treatment time was 30 minutes, each woman would
have only received acupuncture for 10 to 15 minutes at
each point. The prebirth acupuncture was commenced
at 36 weeks and the women received an average of ve
treatments.
Zeisler et al.
The acupuncture points Baihui DU-20, Shenmen HE-7 and
Neiguan P-6 were used, although no reason was given
for this choice. Bilateral needling with deqi was applied.
Treatment was given with the women in a resting position
with each session lasting 20 minutes. A minimum of four
sessions was recommended.
Clinical perspective
In terms of the number of prebirth treatments required,
Kubista and Kucera found no effect on the duration
of delivery time in woman who only received a single
acupuncture treatment, and Zeisler et al. ensured that
women received at least four treatments (twelve women
were excluded from the Zeisler et al. study because they
received less than four treatments).
In terms of possible side effects from receiving
acupuncture, Zeisler et al. found that there was an
increased frequency of premature rupture of membranes
in the acupuncture treatment group. This was not
considered a negative outcome as they associated it with
an acceleration of cervical maturation.
Overall there was no association with an elevated rate of
complications for the mother or the foetus in those women
receiving acupuncture in any of the studies.
Journal of Chinese Medicine Number 80 February 2006
Acupuncture for cervical ripening
A randomised controlled trial into the effects of
acupuncture on cervical ripening was published by Rabl
in 200111.
Summary
The objective was to evaluate whether acupuncture at
term can inuence cervical ripening and thus reduce the
need for postdates induction.
On their due dates 45 women were randomised into
either an acupuncture group (25) or a control group (20).
The acupuncture group received acupuncture every two
days at the acupuncture points Hegu L.I.-4 and Sanyinjiao
SP-6. The women in both groups were examined every
other day for cervical length (measured by vaginal
trasonography, cervical mucus and cervical stasis
according to Bishops score). If women had not delivered
after 10 days labour was induced by administering vaginal
prostaglandin tablets.
The time from the womans due date to delivery was an
average of 5 days in the acupuncture group compared to
7.9 days in the control group, and labour was medically
induced in 20% of women in the acupuncture group
compared to 35% in the control group. There were no
differences between overall duration of labour or of the
rst and second stages of labour.
Conclusion
Acupuncture at the points Hegu L.I.-4 and Sanyinjiao
SP-6 supports cervical ripening and can shorten the time
interval between the womans expected date of delivery
and the actual time of delivery.
Acupuncture comments
Treatment method
Hegu L.I.-4 and Sanyinjiao SP-6 were needled bilaterally.
Deqi was obtained and the needles were retained for 20
minutes with no further stimulation.
Clinical perspective
It was interesting that four women were delivered within
24 hours of having their rst acupuncture treatment while
no women in the control group delivered within 24 hours
of their rst examination.
It is also interesting to note that none of the women from
the acupuncture group went into labour during treatment
or within one hour following treatment, reecting that it
is a practical option for women to receive acupuncture for
clinical ripening in a private clinical setting.
From a safety perspective there was no difference in
the number of women experiencing difculties during
delivery, with three women requiring a vacuum extraction
and two women requiring a caesarean section from each
group.
Journal of Chinese Medicine Number 80 February 2006 A Review of Research into the Application of Acupuncture in Pregnancy 55

Conclusion
While research does not always reect the reality of clinical
practice, it can be an important tool to promote acupuncture.
All these studies illustrate the potential of research to promote
the safety and effectiveness of acupuncture in pregnancy.
They also answer interesting questions for acupuncturists,
for example:
An individualised diagnosis is more effective than a single
point treatment for nausea in pregnancy.
Moxa for breech presentation is effective administered at
33 weeks gestation, with a treatment once or twice a day both
producing similar effects over a two week period.
That points traditionally listed as needing to be used with
caution in pregnancy do have observable effects on cervical
ripening. Also as none of the women went into labour within
an hour of receiving treatment, this indicates that promoting
treatment to induce labour at a private clinic is a practical
option .
The research on pelvic pain in pregnancy also raises
concerns that traditional acupuncture theory can be so lightly
disregarded by medical acupuncturists.
As the interest by women and the medical profession in
using acupuncture during pregnancy grows, it is important
that acupuncturists trained in a holistic approach promote
themselves as practitioners to treat these conditions.

Debra Betts practises in New Zealand and teaches at the New

Zealand School of Acupuncture in Wellington. She is the author
of The Essential Guide to Acupuncture in Pregnancy and Childbirth to
be published by The Journal of Chinese Medicine in spring 2006.
Her booklet on using acupressure for pain relief in labour can be
downloaded at acupressure.rhrizome.net.nz She can be contacted at
debra.betts@rhizome.net.nz

Notes 6 Smith C, Crowther C, Beilby J.

Pregnancy outcome following
1 Elden H, Ladfors l, Fagevik
womens participation in a
Olsen M, Ostaard H, Hagberg
randomised controlled trial of
H. Effects of acupuncture
acupuncture to treat nausea and
and stabilising exercises as
vomiting in early pregnancy.
adjunct to standard treatment
Complement Ther Med. 2002 Jun;
in pregnant women with
10(2):78-83.
pelvic girdle pain: randomised
singleblind controlled trail. BMJ 7 C a r d i n i F, We i x i n H .
2005;330:761. Moxibustion for correction of
breech presentation. JAMA 1998;
2 Deadman P, Al-Khafaji M, Baker
280:1580-1584.
K. A Manual of Acupuncture.
Journal of Chinese Medicine 8 Kubista E Kucera H, Geburtshilfe
Publications; 2001 p 103 & 318. Perinatol 1974; 178 224-9.

3 West Z. Acupuncture in Pregnancy 9 Lyrendas S, Lutsch H, Hetta J,

and Childbirth.Churchill Lindberg B, Gynecol. Obstet.24;
Livingstone; p2001. 217-224.

4 Rabl M, Ahner R, Bitschnau 10 Zeisler H, Tempfer C, Mayerhofe

M, Zeisler H, Husslein P.
Acupuncture for cervical
ripening and induction of labour
at term - a randomised controlled
trail. Wien Klin Wochenschr 2001;
113 (23-24): 942-6.
5 Smith C, Crowther C, Beilby J.
Acupuncture to treat nausea and
vomiting in early pregnancy:
a randomized trial. Birth.2002,
Mar:29 (1):1-9.
Kr, Barrada M Husslein P.
Influence of acupuncture on
duration of labour Gynecol Obstet
Invest 1998; 46:22-5.
11 Rabl M, Ahner R, Bitschnau
M, Zeisler H, Husslein P.
Acupuncture for cervical
ripening and induction of labour
at term a randomised controlled
trail. Wien Klin Wochenschr 2001;
113 (23-24): 942-6.