Journal of Midwifery & Women’s Health www.jmwh.

org
Review

Acupuncture and Acupressure in Labor

Judith M. Schlaeger, CNM, PhD, LAc, Elizabeth M. Gabzdyl, CNM, DNP, APN, Jeanie L. Bussell, PhD,
CEU
LAc, Nobuari Takakura, PhD, LAc, Hiroyoshi Yajima, PhD, LAc, Miho Takayama, PhD, RN, LAc,
Diana J. Wilkie, PhD, RN

Acupuncture and acupressure, 2 modalities of Traditional Chinese Medicine, are based on reducing pain and symptoms of disease through balanc-
ing yin and yang. Acupuncture and acupressure have been used in China for reduction of labor pain, labor augmentation, and other intrapartum
indications for more than 2 millennia. This article presents a review of the current literature that has addressed the effects of acupuncture and
acupressure on intrapartum events. Studies of acupuncture have demonstrated that acupuncture may reduce labor pain, the use of pharmacologic
agents, the use of forceps and vacuum-assisted births, and the length of labor. Studies that examined the effect of acupuncture on labor that is
induced or augmented for premature rupture of membranes have found that acupuncture may increase the degree of cervical ripening but does
not reduce the amount of oxytocin or epidural analgesia administration, nor does it shorten length of induced labor. Acupressure may reduce
labor pain and labor duration, but acupressure has not been found to increase cervical ripening or induce labor. There are insufficient studies
about acupuncture and acupressure and their effects on labor at this time, and there is need for further research. Areas of uncertainty include
efficacy, optimal point selection, best techniques, and length of time for point stimulation.
J Midwifery Womens Health 2016;00:1–17  c 2016 by the American College of Nurse-Midwives.

Keywords: acupressure, acupuncture, labor, labor augmentation, pain, persistent cervical lip, Shiatsu, Traditional Chinese Medicine, TCM,
Traditional Japanese Massage

INTRODUCTION needles made of stone were originally used for rudimentary

Acupuncture and acupressure have been practiced through-
out China for more than 2 millennia, but only in the past
several decades has the Western medical community begun to
consider the merit of integrating these therapies. Integration
of these therapeutic modalities may enable optimization
of an individual’s health and well-being. Acupuncture and
acupressure may be used to reduce labor pain, and acupunc-
ture may aid in cervical ripening, but neither acupuncture
nor acupressure have been shown to be effective for in-
duction and/or augmentation of labor. This article reviews
the history of acupuncture and acupressure, the theories of
Traditional Chinese Medicine (TCM), scientific mechanisms
of acupuncture and acupressure, and findings of current
studies that have evaluated the effectiveness of acupuncture
and acupressure for use in labor. We searched the literature
with the goal of reviewing the highest-quality randomized
controlled trials (RCTs) and meta-analyses on the use of
acupuncture and acupressure for 1) the reduction of labor
pain and 2) labor induction and/or augmentation.
BACKGROUND
TCM is a system of Chinese medicine dating back at least 2000
years. Acupuncture and acupressure are 2 of the therapeutic
modalities used in TCM.
History of Acupuncture and Acupressure
The earliest evidence dates use of acupuncture to the Stone
Age approximately 3000 bc.1 Oral tradition asserted that
Address correspondence to Judith M. Schlaeger, CNM, PhD, LAc, Uni-
versity of Illinois at Chicago, College of Nursing (M/C 802), Room 856,
845 S. Damen Ave., Chicago, IL 60612. E-mail: jschlaeg@uic.edu
surgeries. It was observed that pressing these early needles
against the skin on certain points on the body alleviated
disease and/or pain at other locations.2 By 1600 bc (the
Bronze Age in China), stone needles were replaced by bone,
bamboo, and bronze needles that were inserted into then
known acupuncture points.2 Between 600 and 300 bc Daoist
practitioners in deep meditation noticed consistent patterns
of energy movements that they meticulously recorded and
are now known as meridians, which are the pathways that
move qi throughout the body.1
Acupuncture was used to treat women’s reproductive
problems as well. Medical texts written during the Han
dynasty (476-221 bc) that are still in use today include
acupuncture treatments for amenorrhea, irregular menses,
hyperemesis, and threatened abortion.3 By 551 bc Confu-
cianism strongly influenced Chinese society and because of
the Confucian imperative to produce a son, the specialties
of fertility and obstetrics became highly developed areas of
Chinese Medicine.4
In Japan, acupressure originated in the early 1900s as
Shiatsu, from shi (finger) and atsu (pressure), and was first
described in the book Shiatsu Ho by Tenpeki Tamai. By 1957,
Shiatsu incorporated meridian theory and the use of points.5
Theories of Traditional Chinese Medicine
The Theory of Yin and Yang is the basis of all TCM’s
philosophies.3,6 The fundamental tenet is balance using the
concept of complementary opposites. Yin is night, dark, cold,
feminine, inactive, quiet, inward, and toward the earth. Yang
is day, light, hot, masculine, active, loud, outward, and to-
ward heaven. Health is viewed as a balance between yin and
yang; the goal is to rebalance them.1,6 Qi is the vital energy
found everywhere in the universe. Qi flows in every part of

1526-9523/09/$36.00 doi:10.1111/jmwh.12545 
c 2016 by the American College of Nurse-Midwives 1
 ✦ In Traditional Chinese Medicine (TCM), qi is energy that flows through the body’s 14 meridians and can be activated using
acupuncture and acupressure to restore balance and health.
✦ Acupuncture has many documented effects on the body; it reduces pain by activating mu opioid receptors and increasing
serum ␤ endorphins.
✦ Acupuncture and acupressure have been shown to have effects on women in labor, particularly for reduction of labor pain.
✦ Further research is needed that utilizes rigorous double-blind methods and uses standardized study protocols to advance
the science of acupuncture and acupressure use by women in labor.

the body via the meridians (Figure 1) which are the pathways
that direct the flow of qi all around the body.7 The meridians
are compared to rivers in the body or branches on a tree. There
are 14 main meridians (Table 1, Figure 1). Qi flows within and
around the body and is in a constant state of transformation.
Qi unites heaven and earth and the body in between.1,6 All
individuals are born with qi and qi is also acquired. It is
maintained and balanced by food, lifestyle, emotions, and
other influences. When the body fails to maintain balance, qi
is disrupted and disease may occur.6 The goal of acupuncture
and acupressure is to activate the qi, restoring balance to
its flow through the body’s meridians, which restores a
healthy and optimal state of being. Qi can be yin or yang.
Acupuncture needles are inserted into specific acupuncture
points on the meridians to stimulate the circulation of qi and
blood. If qi or blood is deficient, acupuncture can strengthen
(tonify) them; if they are in excess, acupuncture can reduce
stagnation or obstruction. Thus, the yin and yang of the body
become balanced, and pain and other symptoms are reduced.
There are 361 acupuncture points located throughout
the body.7 Each point is assigned a number and carries
with it the name of the meridian along which it is located.
For example, GB21 is the 21st point along the gallbladder
meridian. In addition to treating disease, acupuncture and
acupressure are used to reduce pain and facilitate routine
homeostatic functions within the body.8–10 Acupressure
is pressure applied to acupuncture points. It has a similar
therapeutic effect as acupuncture, but it may not penetrate
the meridians as deeply as acupuncture and therefore may
not be as effective for some applications.6,8,9 Acupressure is
noninvasive and administered using firm pressure with the
fingers, knuckles, thumbs, or an appropriate acupressure tool.
Mechanisms of Action
Acupuncture has been documented to have many ac-
tions throughout the body including 1) deactivation of
the limbic-paralimbic-neocorticol network system, which
among other things is responsible for the perception of
sensory pain11,12 ; 2) activation of mu opioid receptors13,14 ; 3)
increase in serum ␤ endorphins15–17 ; 4) increase in adreno-
corticotropic hormone (ACTH) release from the anterior
pituitary, thus decreasing pain15,18 ; 5) downregulation of M1
macrophages, Interleukin-1␤, Interleukin-6, Interleukin-18,
and tumor necrosis factor (TNF), which have inflammatory
functions15,17,19–21 ; 6) upregulation of M2 macrophages,
which have anti-inflammatory functions and increase im-
mune system function of phagocytes, lymphocytes, T cells,
B cells, and NK cells15,17,19 ; and 7) during labor, stimulation of
release of oxytocin from the posterior pituitary.15,22 It is pre-
sumed by researchers and those practicing acupressure that
the mechanisms of acupressure and acupuncture are similar.
However, there is no direct evidence to support this tenet.
USE OF ACUPUNCTURE DURING CHILDBIRTH
Acupuncture must be administered by a licensed acupunctur-
ist, and acupressure can be administered by a trained midwife
or other health care provider in any setting, both in and out of
the hospital. Acupressure can be practiced without a license,
although training is advised for appropriate use. Clinical trials
have been conducted to assess the use of acupuncture for re-
duction of labor pain, promotion of efficient second and third
stages of labor, induction and augmentation of labor, cervical
ripening, and rotating a breech presentation. Other uses that
have not been scientifically evaluated include reduction of a
persistent cervical lip, promotion of fetal descent, reduction
of third-stage blood loss, rotation of a posterior presentation,
calming anxiety, reduction of nausea and vomiting in labor,
reduction of maternal fatigue, and relieving a shoulder dys-
tocia. Although many points may be used during pregnancy
and childbirth, the following points were selected for a focus
in this article: GB 21, LI 4, BL 32, SP 6, BL 60, BL 67, LV 3, and
ST 36 (Table 2).
Acupuncture for Reduction of Labor Pain
A Cochrane review published in 201110 (Table 3) examined
acupuncture from 9 randomized controlled trials (RCTs) for
pain management during labor. A variety of points were used,
including SP6, LI4, BL32, LV3, and ST36. When compared to
no treatment, acupuncture was associated with a reduction
in pain (standardized mean difference [SMD], –1.00; 95%
confidence interval [CI], –1.33 to 0.67). When compared to
placebo, women who had acupuncture reported increased
satisfaction with the method of pain treatment in labor
(relative risk [RR], 2.38; 95% CI, 1.78–3.19); a reduction
in pain and use of pharmacologic agents (RR, 0.72; 95%
CI, 0.58-0.88); a reduction in pain (SMD, –0.55; 95% CI,
–0.92 to –0.19); and a reduction in the duration of labor
(SMD, –1.06; 95% C.I, –1.74 to –0.38). Acupuncture was
also compared to a combined control group (no treatment

2 Volume 00, No. 0, xxxx 2016

 Figure 1. 14 Traditional Chinese Medicine Meridians
Pathways that direct the flow of qi all around the body. They are compared to rivers in the body or branches on a tree.
Source: Deadman et al.7

Table 1. The 14 Traditional Chinese Medicine Meridians of the techniques for different time frames, additional evidence is
Body7 needed before clinical recommendations can be proposed. All
Large Intestine: LI 9 studies had a risk of bias as they were either not blind, only
Stomach: ST single-blind, or types of blinding were not clearly stated by the
authors.
Heart: HT
Subsequently, 2 studies published in 2011 evaluated
Bladder: BL the use of electroacupuncture for pain reduction in labor.
Pericardium: PC Electroacupuncture uses a mild electric current sent though
Liver: LV needles inserted into acupuncture points and is especially
good for the treatment of chronic pain conditions.19 MacKen-
Governing vessel: GV
zie et al conducted a single-blind RCT,23 in which 105 laboring
Lung: LU women were randomized into 4 groups: 1) a manual acupunc-
Spleen: SP ture group; 2) an electroacupuncture group (points used in
Small intestine: SI both groups were LI4, SP6, BL60, and BL67); 3) a sham group
Kidney: KD that either received manual acupuncture or electroacupunc-
ture (needles inserted shallowly next to LI4, SP6, BL60, and
San Jiao: SJ
BL67; and for the sham electroacupuncture group, needles
Gallbladder: GB were attached to an electric stimulation device that was not
Conception vessel: CV turned on); and 4) a usual care control group. Each group
received one treatment of 30 minutes’ duration. There was
no difference in epidural or parenteral analgesia rates in the
and placebo) in 2 studies and found to be associated with electro/manual group compared to the sham and usual care
a reduction in pain (SMD, –0.42; 95% CI, –0.65 to –0.18). group (RR, –1.18; 95% CI, 0.8 to –1.74). Conversely, in a Chi-
Finally, one study compared acupuncture to standard care in nese multicenter single-blind RCT,24 researchers examined
which the women in the acupuncture group had a reduction 350 women in labor randomized into electroacupuncture,
in the rate of forceps and vacuum-assisted births (RR, 0.67; sham electroacupuncture, and no treatment groups. One
95% CI, 0.46-0.98). Taken together, these findings support acupuncture point was treated once for a one-hour duration
the hypothesis that acupuncture can reduce pain in labor. at the end of latent phase of labor. Pain was rated on a 0 to
However, because the studies used different acupuncture 100 visual analog scale (VAS) at baseline, 15 and 30 minutes

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4
Table 2. Acupuncture Points
Name Indications Description Figure
Gallbladder This point has an action of release and descent, which is purported to Located at the crest of the trapezius muscle halfway between the
21 (GB21) facilitate fetal descent in active phase and second stage of labor.30 prominent spinous process of the seventh cervical vertebra (C7) and
The practitioner should palpate deeply on and around the point for the the tip of the acromion process of the scapula.7
most tender spot, in a slight indentation between muscles.

Large Stimulating this point is effective for reduction of labor pain and Located on the dorsum of the hand. It is most easily identified by
intestine 4 promoting stronger and/or more coordinated contractions.27,33–39 bringing the thumb and index finger close together and locating the
(LI4) highest place of the metacarpal bone on the radial aspect.7

Bladder 32 Indications include reduction of labor pain40 and induction of labor.31 Located at the second of the sacrum’s 8 foramen, which are arranged in
(BL32) 2 vertical rows of 4 foramen.7 To find this point, the last lumbar
vertebra and beginning of the sacrum should be located. At the top
of the median sacral crest (see figure) 4 fingertips (not pads) are
placed side by side as if making a guitar chord with the index finger
closest to the lumbar vertebra. Then the fingers should slide away
from the midline (laterally) until the 4 fingertips find the slight
depressions, which are the foramen. The tip of the middle finger
should be in the second sacral foramen (BL32).7 Deep pressure
should be applied to this point.

(Continued)

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 Table 2. Acupuncture Points
Name Indications Description Figure
a
Spleen 6 One of the most important and frequently used points for obstetric Located on the medial aspect of the lower leg, 3 cun superior to the
(SP6) and gynecologic concerns. Indications include labor augmentation, medial malleolus (ankle bone) in a slight depression next to the
for irregular contractions to encourage efficient labor and reducing tibia.7 This is typically a tender point when located correctly.
a persistent cervical lip,35,41,42 reduction of labor pain,24,38,39,41–44
and reduction of the length of labor.39,41,42

Journal of Midwifery & Women’s Health r www.jmwh.org

Bladder 60 It relieves lower back pain.38,44 Located on the foot. It is found in the depression between the lateral
(BL60) malleolus of the ankle and the Achilles tendon.

a
Bladder 67 Well known for its use for version of breech to a cephalic Located on the dorsum of the little toe at the corner formed 0.1 cun
(BL67) presentation.45–47 Together with LI4 it is used to reduce labor from where the lateral aspect and the base of the nail meet.
pain.34 It also stimulates uterine contractions.48

(Continued)

5
6
Table 2. Acupuncture Points
Name Indications Description Figure
Liver 3 (LV3) May soften the cervix49 and reduce pain in labor.44 Located on the dorsum of the foot in the hollow between the bodies of
the first and second metacarpal bones.

a
Stomach 36 Indications include relief of maternal exhaustion in labor and relief of Located on the lower leg, 3 cun below the kneecap in the hollow
(ST36) nausea and vomiting, hiccups, and belching.7 created when the knee is flexed, one fingerbreadth lateral to the crest
of the tibia.7

Source: Deadman et al.7

a
One cun is the width of the thumb, 2 cun is the distance from the middle joint to the tip of the index finger, and 3 cun is equivalent to the width of 4 fingers of one hand held together, at the level of the proximal interphalangeal joint. The
practitioner must adjust the size of the cun measurement according to the size of the person receiving acupressure. If the patient’s hand is larger, the cun will be larger; if the patient’s hand is smaller, the cun will be smaller and adjustments must be
made.

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 Table 3. 2011 Cochrane Review Acupuncture for Treating Labor Pain
Author
Year
Country N Acupuncture Points
Borup10 607 BL 23, 24, 25, 26, 31–34, 36, 60, CV20
2009 and sishencong,
Denmark ear points: uterus, shenmen,
endocrine, EX-HN3 yintang, LV3,
SP6, SP9, ST36, GB34,
HT7, PC6, LI10, LI11, LU7, LI 4
Journal of Midwifery & Women’s Health r www.jmwh.org
Hantoushzadeh10 150 LI4 analgesia, BL32 back pain, BL60
2007 back pain, SP6 severe pain during
Iran contractions, ST36 general pain,
LV3 analgesia, GB34 cervical rigidity,
HT7 anxiety, nervousness
Huang10 324 Group 1: ST36, CV3, and CV4.
2008 Additional points for excess were
China BL32 and LV3 and for deficiency
were LI4 and SP6.
Group 2: An acu-point nerve
stimulator, stimulated point with
2/100 Hz of dilatational wave.
Martensson10 128 GV20, LI4 and SP6. Midwife’s choice
2008 of 4 to 7 local points from BL23,
Sweden BL24, BL54, EX19, GB25-29 and
KD11. Needles were retained for
40 min and stimulated every 10 min
and were repeated as needed.
7
Control Group
Control group 1 (n = 144):
TENS
Control group 2 (n = 149):
Traditional analgesics
Minimal acupuncture
1) Electro-acupuncture group,
n = 82
2) TENS group, n = 82
3) Control group (breathing),
n = 81
4) Spinal-epidural analgesia
group, n = 79
Sterile water injection
Blinding Result(s)
No blinding reported Use of pharmacologic and invasive methods significantly lower in
acupuncture group (acupuncture vs traditional, P ⬍ .001;
acupuncture vs TENS, P = .031).
Pain scores were comparable.
Acupuncture did not influence duration of labor or use of oxytocin.
Mean Apgar score at 5 min and umbilical cord pH value significantly
higher among newborns in acupuncture group compared with
newborns in the traditional analgesic or TENS groups.
Participant: yes A VAS pain score in the study group was lower after 2 hours compared
Clinician: no to the control group.
Outcome assessor: yes Active phase duration and oxytocin units administered were lower in
the study group compared to the control group.
Study group patients had greater willingness to receive acupuncture
again compared to the control group.
No blinding reported VAS scores for the acupuncture group were better than TENS, and the
control groups, but not as good as the spinal-epidural analgesia
group (P = .05)
No blinding reported Sterile water injections yielded greater pain relief (P ⬍ .001) during
childbirth compared to acupuncture.
Women in the sterile water group had a higher degree of relaxation
(P ⬍ .001) compared to the acupuncture group.
Women’s own assessment of the effects also favored sterile water
injections (P ⬍ .001).
There were no significant differences in requirements for additional
pain relief after treatment between the 2 groups.
(Continued)
 Table 3. 2011 Cochrane Review Acupuncture for Treating Labor Pain

8
Author
Year
Country N Acupuncture Points Control Group Blinding Result(s)
10 198 No blinding reported
Nesheim Point selection based on participant’s Control group 1: Study Meperidine was given to 11% of the acupuncture group, 37% of the no
2003 needs at BL32, GV20, BL60, BL62, midwife, no acupuncture acupuncture group (P ⬍ .0001), and 29% of the control group.
Norway HT7, LV3, GB34, CV4, LI10, LI11, Control group 2: Standard care The use of other analgesics was lower in the acupuncture group.
BL23, BL27, BL28, BL32, LI4, SP6, Patient satisfaction was high: 89 of 103 patients said they would want
PC6, 7, ST36. acupuncture during another labor.

Qu10 36 Electro-acupuncture at points LI4 and No pain relief No blinding reported The electro-acupuncture group was found to exhibit a lower pain
2007 SP6. intensity and a better degree of relaxation than the control group
China (P = .018, P = .031).
There was a significant difference in concentration of ␤ endorphins
and 5-HT (serotonin) in peripheral blood between the 2 groups at
the end of the first stage (P = .037, P = .030).

Ramnero10 100 GV20, yintang, LU7, BL 25-36, BL54, No acupuncture. Both No blinding reported Acupuncture treatment during labor significantly reduced the need of
2002 GB 25-29, CV 2, CV3, LI4, GB41, acupuncture and control epidural analgesia (12% vs 22%; RR, 0.52; 95% CI, 0.30–0.92).
Sweden LV3, BL60, KD3, SP6 groups had access to The acupuncture group had a significantly better degree of relaxation
conventional analgesia. compared with the control group (MD, –0.93; 95% CI, –1.66 to
–0.20).

Skilnand10 210 HT7, LU7, ST30, ST29, GB34, ST36, Minimal acupuncture Participant: yes There were significantly lower mean pain scores and significantly less
2002 SP8, SP6, KD3, GB41, LV3, GV20, Data collectors: yes need for pharmacologic analgesia in the study group compared with
Norway BL34, BL32, LI4, BL67, BL60 the control group.
The women given real acupuncture spent less time in active labor and
needed less augmentation than the control group.

Ziaei10 90 GV20, yintang, ST36, SP6, LI4, CV2, Control group 1 (n = 30): Participant: yes Fewer women needed augmentation of labor in the acupuncture group
2006 CV3 “pretend” acupuncture, Clinician: no than the 2 control groups.
Iran 6 points normally used for Analysts/outcome There were no significant differences among the groups in pain scores,
vaccinations and other assessors: unclear relaxation scores, duration of labor, rate of cesarean births, and birth
injections used. weight.
Control group 2 (n = 30): no
intervention.

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Abbreviations: TENS, transcutaneous electrical nerve stimulation; VAS, visual analog scale.
after the start of the treatment, and one, 2, 3, and 4 hours after
the needle was withdrawn. Mean (standard deviation [SD])
scores demonstrated a significant reduction in labor pain at
30 minutes after the start of the electroacupuncture treatment
(76.0 [22.5]) in women who received electroacupuncture
when compared to the women in the sham electroacupunc-
ture treatment (81.6 [19.2], P ⬍ .05) and in women who
received no treatment (85.4 [16.0], P ⬍ .05). Similarly, at both
2 and 4 hours after the needles were withdrawn, the women
who received electroacupuncture reported less pain (85.4
[15.9] and 82.4 [17.1], respectively) compared to the women
in the sham acupuncture group (89.4 [13.6], P ⬍ .05 and 91.5
[14.4], P ⬍ .05, respectively) or the no treatment group (92.2
[12.1], P ⬍ .05 and 94.5 [8.8], P ⬍ .05, respectively).
Acupuncture for Labor Induction
A 2013 Cochrane review25 (Table 4) examined 14 RCTs of
acupuncture for labor induction and cervical ripening that in-
cluded 2220 women. The acupuncture points used included
ST36, LV3, LI4, SP6, BL32, BL60, and BL67. There was greater
cervical ripening as evidenced by increased Bishop scores over
a 24-hour period in the acupuncture compared to the sham
control group (mean difference [MD], 0.40; 95% CI, 0.11–
0.69) and usual care group (MD, 1.30; 95% CI, 0.11–2.49).
No differences were found when the acupuncture group
was compared to the sham control groups and the usual care
groups with regard to the rate of oxytocin augmentation, need
for epidural analgesia, rate of forceps and vacuum-assisted
births, rate of meconium-stained amniotic fluid, rate of Ap-
gar scores less than 7 at 5 minutes, rate of perineal tears, and
length of labor.
A 2007 Norwegian unblinded RCT26 of 106 nulliparous
women with premature rupture of membranes (PROM) at
term were randomized 1:1 into an acupuncture and a control
group for augmentation of labor. Acupuncture points needled
depended on the patient presentation and included LI4, SP6,
LV3, and BL32. There was no difference in 1) median times
from PROM to active labor in the acupuncture (15 hours)
compared to the control group (20.5 hours, P = .34); 2) me-
dian duration of active phase in the acupuncture (6.6 hours)
compared to the control group (5.5 hours, P = .35); 3) length
of time from PROM to birth in the acupuncture (31.5 hours)
compared to the control group (25.3 hours, P = .65); and 4)
rate of oxytocin augmentation if no labor within 48 hours post
ruptured membranes in the acupuncture (12.5%) compared
to the control group (17.0%, P = .53). A power analysis cal-
culated the minimum sample size to be 208 women, and thus,
this study was not adequately powered and may not have been
able to detect differences between the groups.
USE OF ACUPRESSURE DURING CHILDBIRTH
In addition to acupuncture, RCTs have been conducted on the
use of acupressure for reduction of labor pain, promotion of
efficient second and third stages, induction or augmentation
of labor, and cervical ripening. Other uses that have not been
scientifically evaluated are the same as those not evaluated for
acupuncture.
Journal of Midwifery & Women’s Health r www.jmwh.org
In TCM, in order to locate acupressure points, a unit of
measurement called a cun (“soon”) is used. One cun is the
width of the thumb, 2 cun is the distance from the middle joint
to the tip of the index finger, and 3 cun is equivalent to the
width of 4 fingers of one hand held together at the level of the
proximal interphalangeal joint. The practitioner must adjust
the size of the cun measurement according to the size of the
person receiving acupressure. If the patient’s hand is larger, the
cun will be larger; if the patient’s hand is smaller, the cun will
be smaller and adjustments must be made.7
No adverse reactions or sequelae have been reported from
any acupressure technique. Contraindications to the use of
acupressure in labor include fetal distress, uterine tachysys-
tole, and tetanic contractions. Maternal and fetal well-being
should be continuously assessed.
Acupressure Studies for the Reduction of Labor Pain
A Cochrane review10 published in 2011 (Table 5) that ex-
amined acupressure (4 trials) for pain management in labor
included 549 women. A variety of points were used, including
SP6, LI4, and BL67. Compared to placebo, acupressure was
associated with a reduction in pain (SMD, –0.55; 95% CI,
–0.92 to –0.19); a reduction in the duration of labor (SMD,
–1.06; 95% CI, –1.74 to –0.38); and reduced cesarean rates
(RR, 0.24; 95% CI, 0.11–0.54). In the studies that had a
combined control group in which one had no treatment
and one had placebo acupressure, the groups that received
acupressure demonstrated a reduction in pain (SMD, –0.42;
95% CI, –0.65 to –0.18) and reduced cesarean rates (RR,
0.48; 95% CI, 0.22–1.04). All 4 studies had a risk of bias
as they were either not blind, only single blind, or types of
blinding were not clearly stated by the authors. These findings
support the postulate that acupressure may reduce pain in
labor. However, additional evidence is needed before clinical
recommendations can be proposed.
Three acupressure studies that assessed reduction of
labor pain were published subsequent to the 2011 Cochrane
review. A 2014 single-blinded RCT27 evaluated 149 term
nulliparous and multiparous women in active labor who were
evenly randomized to either acupressure (n = 50) or touch
(n = 50) to LI4 bilaterally, or a usual care group (n = 49).
Acupressure was applied with rotation and vibration for 60
seconds on and off for 30 minutes. The correct pressure was
attained when the acupressurist’s nail bed turned white. The
same cycle was used for the touch group. Women in all 3
groups rated their pain on a 0 to 10 VAS. Mean (SD) VAS
scores demonstrated a reduction in pain in the acupressure
group at 30 minutes after intervention compared to the touch
and control groups (VAS score of 5.65 [1.87] vs 6.85 [1.89]
and 8.18 [1.59], respectively). One hour after intervention,
the mean VAS scores demonstrated further difference in pain
relief (P = .11) in the acupressure group compared to the
touch and the control groups (VAS score of 6.51 [2.21] vs
7.64 [2.22] and 8.68 [1.54], respectively).
A 2014 Turkish single-blinded RCT28 included 100 nul-
liparous women randomized 1:1 to an acupressure and usual
care control group. Acupressure was administered to SP6 bi-
laterally, from the beginning to the end of a contraction, start-
ing at 2 to 3 cm dilation for a total of 15 contractions, at 5 to
9
10
Table 4. 2013 Cochrane Review of Acupuncture for Labor Induction
Author
Year
Country N Acupuncture Points Control Blinding Result(s)
25 89
Asher LI4, SP6, BL32, and BL54 Control group 1 (n = 30): Participant: yes for There were no statistically significant differences among groups for
2009 30 min treatment up to 5 times in sham acupuncture acupuncture groups time from enrollment to birth (P = .20), rates of spontaneous labor
United States 2 wks Control group 2 (n = 30): Prenatal care provider: (P = .66), or rates of cesarean births (P = .37).
standard prenatal care yes Rates of maternal and neonatal outcomes were not significantly
different.

Gaudernack25 100 LV3, ST36, CV4; additional points Standard care No blinding reported The duration of labor was significantly reduced (MD, 1.7 h; P = .03).
2006 according to TCM diagnosis The need for oxytocin infusion to augment labor in the study group
Norway There were a total of 8 points used. compared to the control group (odds ratio, 2.0; P = .018).
The needles were retained for Participants in the acupuncture group who needed labor induction
20 min. had a significantly shorter duration of active phase than the ones
induced in the control group (MD, 3.6 h; P = .002)

Gaudet25 16 Electro-acupuncture at SP6, ST43, and Sham acupuncture Participant: yes for There was a difference in intervention to birth interval of 62 hours in
2008 BL60 with manual stimulation of LI4. acupuncture groups favor of the treatment group.
Canada Patients received electro-stimulation on Obstetric provider: yes Women in the treatment group had shorter labors by a mean of 2 h and
4 points at 1-2 Hz for 30-45 min. 20 min.

Gribel25 72 Electro-acupuncture at LI4, ST36, LV3, Misoprostol No blinding reported There were no significant differences in labor frequency (P = .07) and
2011 SP6, BL23, and BL32. time of induction (P = .29).
Brazil All 6 points were stimulated every There was an absence of obstetric complications, a higher duration of
7 hours in 1 to up to 3 sessions in a labor (P = .036), and a tendency for higher patient satisfaction (P =
24-hour period of hospitalization. .046) in patients receiving acupuncture.
A higher frequency of cesareans (P = .014) and obstetric
complications (9.3%) were observed among control patients.

(Continued)

Volume 00, No. 0, xxxx 2016

 Table 4. 2013 Cochrane Review of Acupuncture for Labor Induction
Author
Year
Country N Acupuncture Points Control Blinding Result(s)
Harper25 56 Acupuncture at LI4, SP6, BL31, Standard care No blinding reported Mean time to birth occurred 21 hours sooner in the acupuncture
2006 and BL32. group, but this difference did not reach statistical significance (P =
United States Electro-acupuncture at sacrum .36).
BL31 and BL32 with current at 2 Compared to controls, women in the acupuncture group tended to be
Hz for 30 min for 3 out of 4 more likely to labor spontaneously (70% vs 50%, P = .12) and less
consecutive days. likely to give birth by cesarean (39% vs 17%, P = .07).
Of women who were not induced, those in the acupuncture group

Journal of Midwifery & Women’s Health r www.jmwh.org

were more likely to give birth than the controls at any point after
enrollment (P = .05).

Long25 400 Auricular acupuncture was applied
1994 to points: Inner genitals,
China Sympathetic, Shenmen, Liver,
Yuanzhong and Adrenal gland,
using a white mustard seed or a
pill with adhesive plaster.
Rivanol (ethacridine lactate)
[antiseptic] was also supplied.
Rivanol only No blinding reported The average induction time in the auricular point pressing group was
10 hours earlier than in the control group.
The average stage of labor was shortened by 12 hours.
The amount of bleeding was reduced by 27.25 mL.
Injury to the placenta was decreased by 50%.
The mental state of the patients in the auricular point pressing group
was better than patients in the control group.

MacKenzie25 105 For manual and Control group 1: Sham Participant: no No difference between onset of labor in acupuncture compared to 2
2011 electro-acupuncture: LI4, SP6, manual acupuncture; no Acupuncturist: no sham groups and no treatment control group.
UK BL60, BL67. needle stimulation Intrapartum clinician: No difference in length of first stage (P = .29) in acupuncture group
For sham manual and sham Control group 2: Sham yes compared to 2 sham groups and the acupuncture group compared to
electro-acupuncture: shallow electro-acupuncture; the no treatment control group (P = .33)
insertion of needles adjacent to needles attached to wires No difference in length of second stage (P = .78) in acupuncture group
LI4, SP6, BL60, BL67 Control group 3: No compared to 2 sham groups and the acupuncture groups compared
treatment to the no treatment control group (P = .34)

(Continued)

11
12
Table 4. 2013 Cochrane Review of Acupuncture for Labor Induction
Author
Year
Country N Acupuncture Points Control Blinding Result(s)
25 50 SP6 No treatment No blinding reported
Martinez Patients who received acupuncture had significantly more frequent
2004 (P ⬍ .05) and greater intensity (P = .01) of uterine contractions than
Philippines the controls.
There was a significant reduction in the interval of uterine
contractions after acupuncture treatment (P ⬍ .05).
Duration of uterine contractions was significantly prolonged
(P = 0.08).

Modlock25 125 BL67, LI4, SP6, GV20 Sham acupuncture (Park Participant: yes The primary endpoint was achieved in 7 women (12%) in the
2010 sham needle) acupuncture group and 8 women (14%) in the control group (P =
Denmark .79). Stratification for parity and fetal gender did not alter the results.

Rabl25 56 LI4 and SP6 Standard care Participants not blinded Cervical length in the acupuncture group was shorter than that in the
2001 control group on day 6 and day 8 after EDC (P = .04 for both).
Austria In the acupuncture group the time period from the first positive
fibronectin test to birth was 2.3 days, while that in the control group
was 4.2 days (P = .08).
The time period from EDC to birth was on average 5.0 days in the
acupuncture group and 7.9 days in the control group (P = .03).
Labor was induced in 20% of women in the acupuncture group (n = 5)
and in 35% in the control group (n = 7) (P = .3).
Overall duration of labor, and first and second stage of labor were not
different in the 2 groups.
In 56% of women who underwent acupuncture (n = 14) and in 65% of
controls (n = 13), oxytocin was used to augment labor (P = .54).

(Continued)

Volume 00, No. 0, xxxx 2016

 Table 4. 2013 Cochrane Review of Acupuncture for Labor Induction
Author
Year
Country N Acupuncture Points Control Blinding Result(s)

Journal of Midwifery & Women’s Health r www.jmwh.org

25 553 Acupuncture
Romer ST36, SP6, GB34, BL67 Nonspecific acupuncture The mean (SD) duration of labor in patients receiving specific
2000 weekly for 36 weeks including GV20, PC6, participants blinded acupuncture, nonspecific acupuncture, and no acupuncture was 470
Germany HT7. (190), 536 (200), and 594 (241) min, respectively (P ⬍ .002, t-test).
Nonrandomized usual care The cervical maturation was more pronounced in the treatment group
group also assessed (relative Bishop score change 5.9 (1.3), 4.0 (0.9), and 3.6 (1.0) points,
respectively; P ⬍ .0001).
The cervical length change differed significantly among the groups
(15.9 (4.8), 9.8 (3.4), and 8.9 (3.3) mm, respectively).
The specific acupuncture group also was associated with a significant
increase in the rate of de novo funneling at the level of the internal os.

Tremeau25 128 CV2, CV3, CV4, LIV3, BL60, Control group 1: sham Participant blinding Bishop scores in the 3 groups after a 10-day interval show a significant
1992 GB34, ST36, LI4, SP6, BL67 acupuncture unclear progression of 2.61 points in the group treated with acupuncture
France Control group 2: usual care compared to 0.89 and 1.08 in the placebo and control groups.

13
14
Table 5. 2011 Cochrane Review of Acupressure for Treating Labor Pain
Author
Year
Country N Acupuncture Points Control Blinding Result(s)
10
Chung 127 LI4, BL67 1. Effleurage Participant: no No significant reduction in pain in latent phase or transition
2003 Over 20 min with 3-5 kg of 2. Usual care control Outcome assessor: yes There was a significant reduction of pain in active phase (acupressure
Taiwan pressure applied for 5 min 0.17 [1.7], effleurage 0.66 [1.66], control 0.81 [1.23]; P .041).

Hjelmstedt10 212 Acupressure at SP6 bilaterally Control group 1: light touch at Participant: unclear A reduction of labor pain was found in the acupressure group and was
2010 during contractions over a SP6 bilaterally during Clinician: no most noticeable immediately after treatment (acupressure group vs
India 30-minute period contractions Outcome assessor: yes standard care group P ⬍ .001; acupressure group vs touch group
Control group 2: standard care P ⬍ .001).

Kashanian10 120 SP6 during contractions for a Touch at SP6, performed by Participant: unclear The mean duration of active phase was shorter in the case group
2010 total acupressure time of same investigator, for same Clinician: no (252.37 [108.50] min vs 441.38 [155.88], P = .0001).
Iran 30 minutes duration of time Outcome assessor: yes Six patients (10%) in the case group and 25 patients (41.7%) in the
control group gave birth via cesarean (P = .0001).
The severity of pain in the case group was less than the control group
(5.87 [1.77] vs 6.79 [1.52], P = .003).
Twenty-five women (41.7%) in the case group and 38 women (63.3%)
in the control group needed oxytocin (P = .017).
The amount of necessary oxytocin in the case group was less than the
control group (73.33 [97.19] mL vs 126.6 [97.19] mL, P = .003).

Lee10 75 SP6 (n = 36) × 30 min Touch control (n = 39) × Participant: yes 30 minute post-treatment VAS was: acupressure 7.0 ± 1.8 and touch
2004 30 minutes outcome assessor: yes control 8.3 ± 1.8, P ⬍ .021); and 60 minute post treatment pain
Korea intensity (acupuncture 7.7 ± 1.5 and touch control 8.9 ± 1.7, P ⬍
.012)

Abbreviation: EDC, estimated date of confinement.

Volume 00, No. 0, xxxx 2016

6 cm dilation for a total of 10 contractions, and at 9 to 10 cm
dilation for a total of 10 contractions. Pressure administered
was standardized at 3 to 5 kg pressure for each acupressure
cycle. Pain was rated on a 0 to 10 VAS. Median pain scores in
the acupressure compared to the control group demonstrated
a reduction in pain in the latent phase (3.0 vs 4.0, P ⬍ .001),
active phase (7.0 vs 8.0, P ⬍ .001), and 2 hours postpartum
(2.0 vs 3.0, P ⬍ .001).
A 2012 Iranian single-blinded RCT29 included term nulli-
parous and multiparous women who were stratified and ran-
domized to a block design in active labor at term. Fifty women
received acupressure to LI4; 50 women received control touch
to LI4 for the duration of each contraction for a single session
lasting 20 minutes. Pain was rated on a 0 to 10 VAS; scores
were obtained at baseline, immediately after, 20 minutes after,
and hourly until birth. There was a significant reduction in
mean (SD) scores in the acupuncture group immediately and
20, 60, and 120 minutes post treatment (5.4 [0.81], 6.5 [0.89],
7.1 [1.6], 8.6 [0.75], respectively), compared to the control
touch group (6.7 [1.4], 8.3 [1.1], 8.9 [2.0], 9.8 [0.38], respec-
tively, P ⬍ .001). There was a significantly shorter active phase
(2.4 [0.8] vs 3.1 [1.1] hours respectively, P ⬍.001) and second
stage (20.5 [16.4] vs 28.5 [20.1] minutes respectively, P ⬍ .08).
Acupressure Studies for Labor Induction
Two 2015 RCTs used acupressure for induction of labor. One
RCT from the United Kingdom30 had 130 nulliparous women
at 41 weeks’ gestation randomized into an acupressure group
(n = 70) that received acupressure 20 times intermittently and
a sham control (n = 60) that received acupressure 20 times
intermittently to the olecranon. No differences were found in
treatment groups with regard to the number of hours until la-
bor in the acupuncture (median, 103 [46] hrs) compared to
the sham control (median, 72 [38] hrs; P ⬍ .19), need for oxy-
tocin, or mode of birth in the acupuncture versus the sham
control group.
Stimulating the Points With Acupressure
One point may be stimulated singularly or in combination
with other points during acupressure. When one or multiple
points are to be stimulated, the first point treated should be the
one most easily accessible. The most effective and safest proto-
col has not yet been determined. However, for the reduction
of labor pain, Hamidzadeh29 used 5 pressures per minute to
be administered with each contraction for a period of 20 min-
utes to LI4 while in active labor. In clinical practice we have
observed empirically that firm, deep, constant, and/or circu-
lar rotating pressure applied with the thumbs, fingertips, or
knuckles to the LI4 and SP6 points for a period of approxi-
mately 5 minutes and repeated as needed reduces labor pain.
However, we have not performed any trials that have tested
this method in a formal study. If possible, the same bilateral
point should also be stimulated. If both points are not easily
accessible, it is acceptable to stimulate one at a time. Points can
also be stimulated by being pinched between the thumb and
index finger. A ballpoint pen cap, a pencil eraser, or a special-
ized acupressure tool can also be used. Points should be stimu-
lated based on the tolerance of the woman as well as the person
Journal of Midwifery & Women’s Health r www.jmwh.org
administering the acupressure. Pressure should be deep and
firm. Enough pressure should be used to stimulate the points.
The point will most likely be tender to mildly painful. It should
be remembered that this is not massage or light touch.
DISCUSSION
It is difficult to evaluate the overall findings of the acupunc-
ture and acupressure trials reviewed since there were no
shared study designs, methodologies, or consistency of
acupuncture points used between studies. No apparent at-
tempts by investigators have been made to replicate any pre-
viously published RCTs on acupuncture or acupressure for re-
duction of labor pain or induction/augmentation of labor. No
2 trials tested the same points, retained needles for the same
duration, or used the same acupressure techniques. Only 2
trials25 that examined the use of acupressure for the reduc-
tion of labor pain were consistent in the manner in which they
quantified and applied the same amount of pressure with each
acupressure cycle. Thus, clinical practice guidelines cannot be
developed until standardized study protocols are devised that
offer investigators a substrate for implementing consistent re-
peatable acupuncture and acupressure interventions that can
be tested in future trials.
Another limitation is that all studies had a risk of bias
for blinding. RCTs that compared acupuncture to a usual care
group were at high risk for bias because the women were not
blind to the intervention. No double-blind studies were con-
ducted even though some stated they were double blind.
All of the acupressure studies examined the use of one or
2 points for the reduction of labor pain. This may be adequate
to produce a therapeutic effect for this indication. However,
for labor induction or augmentation, more than 2 points may
need to be used at one time. We postulate that an acupunc-
ture point prescription may need to be formulated and ad-
ministered. This is a set of acupuncture points that reflects
and treats a specific patient’s energetic imbalance. Only one
RCT31 on induction of labor with acupuncture stated that the
patients were assessed and treated according to their TCM
pattern diagnosis.
In spite of these limitations, many of the studies that have
been conducted have used large samples and have overall
found positive effects for both acupuncture and acupressure.
This suggests that once more rigorous approaches are applied
to the research process the results will more clearly document
the effectiveness of these modalities.
Future acupuncture research on reduction of labor pain
and induction or augmentation of labor should have TCM
practitioners categorize women according to their TCM pat-
tern diagnosis and administer the correct point prescriptions.
Each TCM diagnostic pattern group and its corresponding
point prescription needs to be studied as a separate entity. In
this way laboring women will be best served by TCM research.
Current TCM research in reduction of labor pain and
induction or augmentation needs to move away from the
random phase of experimentation that currently exists.
Conducting scientific acupressure and acupuncture studies
that can be double blinded, replicated, and used for specific
indications such as labor pain and augmentation is a crucial
next step. It is essential to establish TCM research protocols to
15
allow the forward movement of the TCM research trajectory.
Investigators must be able to replicate previous results, add
new knowledge, and advance the science.
CONCLUSION
Research studies to date suggest acupuncture and acupressure
in labor are beneficial.25,28,29,32 The history, philosophy, and
scientific mechanisms of TCM have been reviewed along with
acupuncture and acupressure techniques and indications.
This review provides insight into these sometimes complex
and difficult to understand practices. The use of acupuncture
and acupressure for women in labor has potential for treating
many indications and is consistent with the holistic frame-
work of midwifery care. Acupuncture can be administered
only by a licensed acupuncturist, and acupressure can be
administered by a trained certified nurse-midwife/certified
midwife (CNM/CM) in any setting, both in and out of the
hospital. No license is necessary to administer acupressure,
although appropriate training, practice, and judgment are
advised.
AUTHORS
Judith M. Schlaeger, CNM, PhD, LAc, is an assistant profes-
sor at the University of Illinois at Chicago College of Nursing
in the Department of Women, Children and Family Health
Science. She is a practicing CNM and licensed acupuncturist.
She received her PhD in Acupuncture Science at Guangzhou
University of Chinese Medicine.
Elizabeth M. Gabzdyl, CNM, DNP, APN, is a clinical assis-
tant professor at the University of Illinois at Chicago College
of Nursing in the Department of Women, Children and Fam-
ily Health Science. She is a practicing CNM. She has a special
interest in using acupressure in labor and complementary and
alternative medicine.
Jeanie L. Bussell, PhD, LAc, is a licensed acupuncturist in pri-
vate practice who specializes in the use of acupressure in labor
and infertility.
Nobuari Takakura, PhD, LAc, is chairman and professor of
the Department of Acupuncture and Moxibustion, Faculty of
Health Sciences, and a professor of the Doctor’s Program of
Health Sciences of the Graduate School of Health Sciences,
Tokyo Ariake University of Medical and Health Sciences. He
is a licensed acupuncturist; licensed moxibustionalist; and a
licensed Anma, massage, and Shiatsu therapist.
Hiroyoshi Yajima, PhD, LAc, is an assistant professor in the
Department of Acupuncture and Moxibustion, Faculty of
Health Sciences, and an assistant professor of the Doctor’s
Program of Health Sciences of the Graduate School of Health
Sciences, Tokyo Ariake University of Medical and Health
Sciences. He is a licensed acupuncturist; licensed moxibus-
tionalist; licensed Anma, massage, and Shiatsu therapist; and
a licensed judo therapist.
Miho Takayama, PhD, RN, LAc, is an assistant professor in
the Department of Acupuncture and Moxibustion, Faculty
of Health Sciences, Tokyo Ariake University of Medical and
Health Sciences. She is a public health nurse; a licensed
16
acupuncturist; licensed moxibustionalist; and a licensed
Anma, massage, and Shiatsu therapist.
Diana J. Wilkie, PhD, RN, FAAN, is Professor, Prairieview
Trust–Earl and Margo Powers Endowed Professor, and Di-
rector, Academic Center of Excellence in Palliative Care Re-
search and Education, Department of Biobehavioral Nursing
Science, College of Nursing, University of Florida. She is an
internationally renowned pain expert.
CONFLICT OF INTEREST
The authors have no conflicts of interest to disclose.
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