Stimulated by Koh et al 2019.
I have been sitting on this paper for a week or so whilst trying to engage comments from obstetrician colleagues. Well they are all too busy catching babies, so I will be going for this blind… (the relevance of this comment may become clearer towards the end, so to speak).
Koh et al are based in Cambridgeshire in the UK, and this is a relatively large cohort study reporting the effects of CAM on induction of labour and pregnancy outcomes in low risk post-dates women. It looks as though all the participants were recruited at Hinchingbrooke hospital – the very place I did my O&G job in the early 90’s after getting back from the first Gulf conflict and 6 months on Ascension Island. That is not the reason I am highlighting the paper – I have only just realised the co-incidence whilst writing this.
The CAM involved acupressure, reflex zone therapy (reflexology) and aromatherapy massage. The acupressure was applied to GB21, LI4 and SP6, and to the ‘pituitary zone’ on the big toe. Firm, pulse-like pressure was applied 30 times over 30 seconds to each point, or for as long as the woman could tolerate.
1044 women were included. 397 received the CAM intervention plus usual care and 647 received usual care alone. 582 (55.7%) were nulliparous.
So, this is observational research on a convenience sample. As there is no randomisation, we cannot be sure that the samples do not differ systematically. The willingness to try CAM for example is likely to be a systematic difference although this is not clear from the paper. We may therefore postulate that such willingness may be associated with certain other decisions within the parturition process.
The primary outcome was the rate of induction of labour (IOL), and there was no difference between the groups (37% in the CAM group vs 39%). But there were some differences in secondary outcomes with quite small p values.
IOL to onset of labour was 2.6 hours longer in the CAM group (p=0.009), and IOL to delivery 3.2 hours longer (p=0.0001). Could the acupressure have worked against the induction methods?
Slightly more alarmingly, the rate of significant perineal trauma was 2.3 times higher (p=0.008) in the CAM group.
When the cohort was divided based on parity, the results for CAM appeared better in nulliparous women, with lower epidural rates, length of labour and blood loss. But there was still a trend towards higher rates of perineal trauma. In the multiparous cohort there were no such positive results and significant perineal trauma was 5.3 times worse!
Perhaps the most worrying statistic was the EMergency Caesarean Section (EMCS) rate. In nulliparous women receiving CAM this was 2.6 times higher (p=0.005).
Neonatal outcomes were all fine, so that leaves us to ponder the reasons for markedly higher rates of perineal trauma, and led me to revise the latest guidelines. Then I came across a paper from the department where one of my obstetric colleagues now works, and that led me to the Episcissors-60 device…
Anyway, the Episcissors-60 device seems to dramatically reduce OASIS. No that is not a reference to the last blog, but an acronym for Obstetric Anal Sphinter InjurieS.
The point is getting the angle right is hard with a distorted perineum, or when you cannot see adequately (hence blind above), and these relatively simple scissors help.
Going back to our cohort from Cambridge, I note that episiotomy rates are very similar in both groups, but I see no mention of Episcissors-60.
So if you are thinking of partaking of some CAM during your next parturition, perhaps consider packing a pair.
1 Koh LM, Percival B, Pauley T, et al. Complementary therapy and alternative medicine: effects on induction of labour and pregnancy outcome in low risk post-dates women. Heliyon 2019;5:e02787. doi:10.1016/j.heliyon.2019.e02787
2 RCOG. The Management of Third-and Fourth-Degree Perineal Tears: Green-top Guideline No. 29. 2015.
3 Mohiudin H, Ali S, Pisal PN, et al. Implementation of the RCOG guidelines for prevention of obstetric anal sphincter injuries (OASIS) at two London Hospitals: A time series analysis. Eur J Obstet Gynecol Reprod Biol 2018;224:89–92. doi:10.1016/j.ejogrb.2018.03.021
4 Freeman RM, Hollands HJ, Barron LF, et al. Cutting a mediolateral episiotomy at the correct angle: evaluation of a new device, the Episcissors-60. Med Devices (Auckl) 2014;7:23–8. doi:10.2147/MDER.S60056