Inspired by Zamora-Brito et al 2024.[1]
IOL – induction of labour
MFM – Maternofetal Medicine
IF – impact factor
SOL – spontaneous onset of labour
PROM – premature rupture of membranes
CS – caesarean section– key to acronyms
This paper in the American Journal of Obstetrics and Gynecology MFM (IF 3.8) comes from Barcelona and it comes out of the blue for me.
For years I have been teaching that whilst acupuncture may provide adequate pain relief for some women during labour it does not seem to consistently induce the onset of labour and the Cochrane reviews on the topic are consistent with this.[2,3]
Here is a paper that takes a slightly different approach from all that have gone before. The team from Barcelona recruited women (n=212) at the point they were scheduled for IOL and randomised them to daily acupuncture for up to 4 days prior to IOL or to no additional care. The women 18 or over and had singleton pregnancies with a live fetus in cephalic presentation. They were low to medium risk pregnancies as defined by national guidelines.
The primary outcome was the number of women presenting with SOL or PROM before or on the day of scheduled IOL. SOL was defined as regular uterine contractions and a fully effaced cervix dilated to at least 3cm.
The acupuncture protocol was standardised and included the following points – LI4, SP6, LR3, ST36, BL31, BL32, BL60, BL67, GV20, Yintang, CV17. In addition to this, an acupressure ball was placed at Shenmen on the ear. The points LI4, SP6, LR3, BL31, BL32 were stimulated manually every 10 minutes. The women would have been treated in a side-lying position by virtue of being in late pregnancy, so all these points would be accessible. The only difficult one might be SP6 on the upper leg. Getting the sacral points symmetrical would also be a challenge but the precise location of these is unlikely to be critical.
In the acupuncture group, 65% of women were admitted for SOL or PROM compared with just under 40% in the no acupuncture group (p<0.001). There were no differences between groups in perinatal or maternal outcomes. Satisfaction was significantly higher in the acupuncture group; however, the response on this outcome was only 60% in the no acupuncture group compared with almost 100% in the acupuncture group, and given the methodology of the study, asking about satisfaction regarding treatment would be highly biased towards the intervention group.
The ARRIVE trial published in NEJM (IF 96.2) in 2018 compared IOL at 39 weeks in 3062 low risk nulliparous women to expectant management in 3044 women of similar pregnancy status.[4] There were no significant differences in perinatal outcomes; however, CS rates were significantly lower in the IOL group (18.6% vs 22.2%). The results of this trial are likely to push up rates of IOL, particularly in countries where the average maternal age is rising.
Acupuncture may have a role here to reduce the requirement for IOL, but the mean gestational age at delivery in the highlighted trial from Barcelona was 41 weeks, so these results are not really relevant to the question posed by the ARRIVE trial. Whilst this is encouraging research and a very good choice of primary outcome, we clearly need much larger trials with different dates set for IOL.
It was good to note that the Bishop score (an assessment of cervical readiness for labour from 0 to 13)[5] was significantly higher in the acupuncture group with a median of 8 compared with 4 in the no acupuncture group.
Finally, some observers may worry about the lack of a sham control. I would say that this population is already expectant enough to worry about the psychological effect of acupuncture inducing SOL. If that is too cryptic for you, login in and watch the recorded webinar (BMAS members only).
References
1 Zamora-Brito M, Migliorelli F, Pérez-Guervós R, et al. Acupuncture before planned admission for induction of labor (ACUPUNT study): A randomized controlled trial: AJOG at a glance. Am J Obstet Gynecol MFM. 2024;101477. doi: 10.1016/j.ajogmf.2024.101477
2 Smith CA, Crowther CA. Acupuncture for induction of labour. Cochrane Database Syst Rev. 2004;CD002962. doi: 10.1002/14651858.CD002962.pub2
3 Smith CA, Armour M, Dahlen HG. Acupuncture or acupressure for induction of labour. Cochrane Database Syst Rev. 2017;10:CD002962. doi: 10.1002/14651858.CD002962.pub4
4 Grobman WA, Rice MM, Reddy UM, et al. Labor Induction versus Expectant Management in Low-Risk Nulliparous Women. N Engl J Med. 2018;379:513–23. doi: 10.1056/NEJMoa1800566
5 Wormer KC, Bauer A, Williford AE. Bishop Score. StatPearls. Treasure Island (FL): StatPearls Publishing 2024.
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