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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 &
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
Introduction
1153
pain have been used. Nonpharmacologic pain relief methods such as ear acupressure or acupuncture have been practised, but researchers reported inconsistent findings. This
study discusses a clinical trial that aims to investigate the
effect of using ear acupressure to relieve immediate postpartum perineal pain.
Background
The rate of perineal pain reported on the first day after
delivery could be as high as 92% (Macarthur & Macarthur
2004, Andrews et al. 2008). Multiparous women were less
likely than primiparous women to complain of perineal
pain after adjusting for the degree of perineal trauma
(Thompson et al. 2002). The severity of perineal trauma
had been found to be related to the prevalence of perineal
pain by Klein et al. (1994) and Albers et al. (1999). Klein
et al. (1994) also reported that spontaneous lacerations
were less painful than episiotomy. 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. 2008), a UK survey (Glazener et al. 1995) and an Australian cohort study (Thompson et al. 2002). Parity, severity of trauma and the mode of
delivery are three major factors associated with the prevalence of perineal pain.
Adequate pain control is necessary for the postpartum
women to resume daily activities and to participate in
childcare. Oral analgesics such as paracetamol (Chou et al.
2010) and rectal analgesics such as diclofenac and indomethacin (Hedayati et al. 2005) had been widely researched
for its effectiveness on perineal pain relief, and the results
were significant. Many nonpharmacologic pain relief methods have been used by women, but not all modalities have
been evaluated by rigorous research. Better researched
modalities are cold therapy and therapeutic ultrasound.
East et al. (2007) found only limited evidence to support
the effectiveness of local cooling treatments, such as ice
packs, cold gel pads, cold or iced baths, in relieving perineal pain following childbirth. Hay-Smith (1998) reported
that there is insufficient evidence to confirm the benefits or
harms of ultrasound for relieving perineal pain.
To have a better understanding of the effect of ear acupressure on perineal pain, databases including the Cochrane
database, EMBASE, Medline, CINAHL and PubMed were
accessed. In addition, the China Journals Full-text Database
was searched as ear acupressure is a treatment modality
founded in Chinese medicine. The number of research on
the effect of ear acupressure or acupuncture on pain relief
is quite limited, and the majority is found in Chinese.
1154
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. The first objective was to compare
the level of pain reported by women in the ear acupressure
group and in the control group. The second objective was
to evaluate the number of paracetamol tablets consumed by
women in these two groups.
Study design
This study was designed as a prospective, randomised
controlled clinical trial with an intervention group and a
control group. The trial was conducted from December
2010July 2011 at an acute hospital in Hong Kong.
2013 John Wiley & Sons Ltd
Journal of Clinical Nursing, 23, 11531164
Original article
groups based on whether an episiotomy had been performed and whether the spontaneous laceration was first or
second degree if episiotomy had been avoided. The participants were randomly allocated to either one of the study
groups by drawing lots from one of the three envelops prepared for first- and second-degree lacerations and episiotomy. If an episiotomy was clinically indicated, a
mediolateral episiotomy would be performed on the left
side of the perineum as a routine practice.
Blinding of intervention
The ear acupressure was achieved by taping seeds of Vaccaria segetalis Garcke on various stimulation points on
both ears (Fig. 1). The apex of the auricle and the Shenmen
point were used to eliminate inflammation and relieve pain.
The point of external genital organs and the point of Anus
were selected for their correspondence to the anatomical
regions (Anon 2002). All women in the intervention group
had the same number of seeds placed on the same points.
Adhesive tapes of 6 mm 9 6 mm in size were used to
secure one seed to each stimulation point; thus, four pieces
of tapes with seeds were applied to each ear. The women
in the intervention group were instructed to press 30 seconds onto each of the seeds every four hours while awake.
Apex of the
auricle
Anus
External genital
organs
Shenmen
1155
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. Figure 2
shows the CONSORT flowchart of this study. Ten women
were not eligible to join the study due to known allergy to
adhesive tape. 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)
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
Original article
Data analyses
The independent samples t-test was used for analyses of
continuous data with normal distribution. Ordinal data
were analysed by the chi-square test. The chi-square test
and the independent samples t-test were used to analyse the
VDPS and VAS scores, respectively. The number of paracetamol tablets taken was categorised into ordinal data for
analysis by the MannWhitney U-test. 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. All statistical tests were two-tailed, 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, 23, 11531164
Ethics consideration
The study was approved by the Research Ethics Committee
of the Kowloon Central and Kowloon East Clusters, Hospital Authority, Hong Kong (Ref: KC/KE-10-0189/ER-5).
The consent form was available in Chinese. Participants
were assured that participation in the study was voluntary
and withdrawal at any time would not affect their plan of
care. Indications for episiotomy were clearly explained to
assure the participants that episiotomy would not be made
for the sake of research. All participants and caregivers
were also reminded that other means of pain relief methods, be it pharmacologic or nonpharmacologic, should not
be withheld at anytime during the study if it was appropriate
to use such methods.
Results
Mothers demographic data
As shown in Table 1, demographic characteristics, such as
age, BMI, smoking status, education level of the two
groups of women, were comparable. There was no significant difference between the groups in terms of parity, the
type of labour onset, the mean duration of the first and
second stages of labour.
Position of the foetal head at birth was not recorded on
the hospital notes in nine cases. No significant difference
was found between the intervention and control groups in
regard to the foetal position at birth. The mean birth
weight of the infant was 330492 g in the intervention
group compared with 318008 g in the control group
(p < 005).
When examining the perineal outcome, it was found that
172 women received an episiotomy, and for those without
an episiotomy, 58 had a first-degree laceration, and 26 had
a second-degree laceration. The distribution of the various
1157
Total (n = 256)
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
Chi-square test.
1158
upon transfer onto the postnatal bed, and at 12, 18, 24,
30, 36, 42 and 48 hours postdelivery. 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. No significant differences were found between the
intervention and control groups in the VDPS results
obtained at any point in time.
Original article
Table 2 Differences in pain level measured by VDPS between the intervention and control groups
Perineal pain perceived by no. of women (collected by midwives)
Intervention group (Ni = 126)
VDPS
No
Mild
Mod
Severe
No
Mild
Mod
Severe
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
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)
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
(060)
(156)
(055)
(150)
(052)
(151)
(053)
(051)
(051)
(050)
(050)
(049)
/
/
/
/
/
/
808%
854%
869%
969%
962%
808%
at all time points after the first six hours. It was noted that
the response rate from the women ranged from 82938%
at different time intervals.
1159
p-value*
12
24
36
48
033
104
154
206
042
115
173
231
039
083
071
077
hours
hours
hours
hours
(02)
(05)
(07)
(010)
(02)
(04)
(07)
(09)
Table 5 Subgroup analysis of VDPS at three time points (12, 24 and 36 hours)
Total
Intervention group
Control group
Mean (SD)
Mean (SD)
Ni
Mean (SD)
Nc
F (p-value)
12 hours
24 hours
36 hours
Between groups [group],
F (p-value)
Within group [time],
F (p-value) [A, 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),
027 (060),
006 (081),
044 (051)
ANCOVA.
Repeated measure.
Adjustment of factors including parity, labour onset, foetal position at birth, type of perinea trauma, birth weight and paracetamol.
Mean (SD)
Intervention group
n
12 hours
2202 (1485)
86
24 hours
2035 (1376)
86
36 hours
1717 (1237)
86
Between groups [group],
F (p-value)
000 (099)
Within group [time],
F (p-value) [A, B]
020 (082) [062, 067]
Interaction effect [time 9 group],
F (p-value) [A, B]
118 (031) [019, 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),
030 (059),
002 (088),
ANCOVA.
Repeated measure.
Adjustment of factors including parity, labour onset, foetal position at birth, type of perinea trauma, birth weight and paracetamol.
1160
Original article
Table 7 Subgroup analysis of paracetamol consumption at 3 time points (12, 24 and 36 hours)
Total
Intervention group
Control group
Mean (SD)
Mean (SD)
Ni
Mean (SD)
Nc
F (p-value)
12 hours
24 hours
36 hours
Between groups [group],
F (p-value)
Within group [time],
F (p-value) [A, 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),
042 (052),
037 (054),
059 (044)
ANCOVA.
Repeated measure.
Adjustment of factors including parity, labour onset, foetal position at birth, type of perinea trauma and birth weight.
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
MannWhitney U-test.
Chi-square test.
Remark: Q16 are rated on a 0 to 5 numeric scale with 0 indicating strongly disagree and 5 indicating strongly agree. Q7 is answered yes
or no with space provided for elaboration.
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%). Informed consent was obtained from 549 women, but only 266 (485%)
were successfully enrolled in the study. The loss of participants was mainly due to confounding factors that arose
during the intrapartum period.
2013 John Wiley & Sons Ltd
Journal of Clinical Nursing, 23, 11531164
1161
as long as they are evenly distributed between the intervention and control groups. 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.
The VDPS score was not significantly different between
the study groups before suturing. This was to ensure that
the baseline VDPS score was similar between the groups
before any intervention was carried out. However, there
were no differences observed in the VDPS results during the
first two days of hospitalisation. The majority of women
rated the perineal pain as being mild in both intervention
and control groups, 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. The highest
levels of pain by VAS were noted during the first
1218 hours in both intervention and control groups with
a gradual decline observed as time passed. The mean VAS
scores were generally lower in the intervention group after
the first six hours, but no statistical significance was
reached at any point in time. The accumulative mean consumption of paracetamol was generally lesser in the intervention group, although not statistically significant. These
results basically echo with the finding of Kindberg et al.
(2008) that perineal pain in 2448 hours postpartum was
less common in women randomised to ear acupuncture
even though statistical significance was not reached.
Many missing values were noted in both VDPS and VAS
at every time point, and this reflected that both the
midwives and mothers did not follow the instructions
closely. A subgroup analysis of 86 participants at three
time points was made to reduce the effect of missing
values on the results. However, this selected sample was
much smaller than the intended sample size, and no significant difference between the intervention and control
groups was observed.
The response rate ranged from 8192% for individual
questions with an average response rate of 90% obtained for
the overall questionnaire. Based on the questionnaire, 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. However, it could not be ensured that the mothers did
not communicate with each other about the different treatment they received; therefore, blinding of the participants
could not be guaranteed. 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; however, full compliance was not
1162
observed in either group. Although not statistically significant, more women in the intervention group agreed that they
had less perineal pain because of the ear acupressure. They
were also more likely to use ear acupressure again in subsequent delivery and to recommend ear acupressure to others.
Study limitation
This study had certain limitations that needed to be
addressed. First, selection bias could occur because not all
eligible women admitted to this hospital were approached
due to manpower constraints. The sample of participants
recruited had comprised of more primiparous women than
usual, and generalisation of the study results could be questioned if the sample was not representative of the larger
population.
Second, 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. Because racial differences in perineal
trauma have been reported by several authors (Goldberg
et al. 2003, Hopkins et al. 2005, Dahlen & Homer 2008)
with Asian, particularly Chinese, women at higher risk of
severe trauma, this study was purposely designed to look at
one particular racial group alone.
Third, 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. 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. Responses for
the credibility questionnaire showed that full compliance to
the instruction was not achieved. Further survey would be
recommended to evaluate the relationship between
frequency of acupressure point stimulation and its effect on
pain relief. There was no standard recommendation on the
frequency and duration of point stimulation.
Fourth, paracetamol was also offered in the current setting for relief of breast engorgement pain. Thus, the consumption of paracetamol might not have truly reflected the
womens need to relieve perineal pain. Further study should
consider this confounding variable and should specify the
indication for taking other pain relief measures.
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. No
2013 John Wiley & Sons Ltd
Journal of Clinical Nursing, 23, 11531164
Original article
statistical significance was observed between the intervention and control groups in terms of pain perception measured by the VDPS, VAS and the mean accumulative
consumption of paracetamol. However, 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. Standardisation of the intervention from application of seeds and
tapes to stimulation of the points should be vigilantly
controlled in future. Future research could evaluate the
frequency and duration of point stimulation on the effectiveness of pain relief. A study sample with women of
different parity and ethnic groups would probably make
the results more generalisable.
Acknowledgements
Relevance to clinical practice
It was noted that 74 participants were lost due to the
unavailability of practitioner on site, and this raised the
question of practicality of using ear acupressure in a busy
clinical setting. Familiarity with the application process and
training of additional midwives in performing this task
would probably facilitate the implementation of this intervention, but further evidence to prove its effectiveness
would first of all be required.
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
Contributions
Study design: WSCK, WHL; data collection and analysis:
WSCK, WHL and manuscript preparation: WSCK.
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