Smith Caroline A, Collins Carmel T, Levett Kate M, Armour Mike, Dahlen Hannah G, Tan Aidan L, Mesgarpour Bita
Western Sydney University, NICM Health Research Institute, Locked Bag 1797, Penrith, New South Wales, Australia, 2751.
South Australian Health and Medical Research Institute, Women and Kids, 72 King William Road, Adelaide, South Australia, Australia, 5006.
Cochrane Database Syst Rev. 2020 Feb 7;2(2):CD009232. doi: 10.1002/14651858.CD009232.pub2.
Many women would like to avoid pharmacological or invasive methods of pain management in labour and this may contribute towards the popularity of complementary methods of pain management. This review examined evidence about the use of acupuncture and acupressure for pain management in labour. This is an update of a review last published in 2011.
To examine the effects of acupuncture and acupressure for pain management in labour.
For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, (25 February 2019), the Cochrane Central Register of Controlled Trials (the Cochrane Library 2019, Issue 1), MEDLINE (1966 to February 2019), CINAHL (1980 to February 2019), ClinicalTrials.gov (February 2019), the WHO International Clinical Trials Registry Platfory (ICTRP) (February 2019) and reference lists of included studies.
Published and unpublished randomised controlled trials (RCTs) comparing acupuncture or acupressure with placebo, no treatment or other non-pharmacological forms of pain management in labour. We included all women whether nulliparous or multiparous, and in spontaneous or induced labour. We included studies reported in abstract form if there was sufficient information to permit assessment of risk of bias. Trials using a cluster-RCT design were eligible for inclusion, but quasi-RCTs or cross-over studies were not.
Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the certainty of the evidence using the GRADE approach.
We included 28 trials with data reporting on 3960 women. Thirteen trials reported on acupuncture and 15 trials reported on acupressure. No study was at a low risk of bias on all domains. Pain intensity was generally measured on a visual analogue scale (VAS) of 0 to 10 or 0 to 100 with low scores indicating less pain. Acupuncture versus sham acupuncture Acupuncture may make little or no difference to the intensity of pain felt by women when compared with sham acupuncture (mean difference (MD) -4.42, 95% confidence interval (CI) -12.94 to 4.09, 2 trials, 325 women, low-certainty evidence). Acupuncture may increase satisfaction with pain relief compared to sham acupuncture (risk ratio (RR) 2.38, 95% CI 1.78 to 3.19, 1 trial, 150 women, moderate-certainty evidence), and probably reduces the use of pharmacological analgesia (RR 0.75, 95% CI 0.63 to 0.89, 2 trials, 261 women, moderate-certainty evidence). Acupuncture may have no effect on assisted vaginal birth (very low-certainty evidence), and probably little to no effect on caesarean section (low-certainty evidence). Acupuncture compared to usual care We are uncertain if acupuncture reduces pain intensity compared to usual care because the evidence was found to be very low certainty (standardised mean difference (SMD) -1.31, 95% CI -2.14 to -0.49, 4 trials, 495 women, I = 93%). Acupuncture may have little to no effect on satisfaction with pain relief (low-certainty evidence). We are uncertain if acupuncture reduces the use of pharmacological analgesia because the evidence was found to be very low certainty (average RR 0.72, 95% CI 0.60 to 0.85, 6 trials, 1059 women, I = 70%). Acupuncture probably has little to no effect on assisted vaginal birth (low-certainty evidence) or caesarean section (low-certainty evidence). Acupuncture compared to no treatment One trial compared acupuncture to no treatment. We are uncertain if acupuncture reduces pain intensity (MD -1.16, 95% CI -1.51 to -0.81, 163 women, very low-certainty evidence), assisted vaginal birth or caesarean section because the evidence was found to be very low certainty. Acupuncture compared to sterile water injection We are uncertain if acupuncture has any effect on use of pharmacological analgesia, assisted vaginal birth or caesarean section because the evidence was found to be very low certainty. Acupressure compared to a sham control We are uncertain if acupressure reduces pain intensity in labour (MD -1.93, 95% CI -3.31 to -0.55, 6 trials, 472 women) or assisted vaginal birth because the evidence was found to be very low certainty. Acupressure may have little to no effect on use of pharmacological analgesia (low-certainty evidence). Acupressure probably reduces the caesarean section rate (RR 0.44, 95% CI 0.27 to 0.71, 4 trials, 313 women, moderate-certainty evidence). Acupressure compared to usual care We are uncertain if acupressure reduces pain intensity in labour (SMD -1.07, 95% CI -1.45 to -0.69, 8 trials, 620 women) or increases satisfaction with pain relief (MD 1.05, 95% CI 0.75 to 1.35, 1 trial, 105 women) because the evidence was found to be very low certainty. Acupressure may have little to no effect on caesarean section (low-certainty evidence). Acupressure compared to a combined control Acupressure probably slightly reduces the intensity of pain during labour compared with the combined control (measured on a scale of 0 to 10 with low scores indicating less pain) (SMD -0.42, 95% CI -0.65 to -0.18, 2 trials, 322 women, moderate-certainty evidence). We are uncertain if acupressure has any effect on the use of pharmacological analgesia (RR 0.94, 95% CI 0.71 to 1.25, 1 trial, 212 women), satisfaction with childbirth, assisted vaginal birth or caesarean section because the certainty of the evidence was all very low. No studies were found that reported on sense of control in labour and only one reported on satisfaction with the childbirth experience.
AUTHORS' CONCLUSIONS: Acupuncture in comparison to sham acupuncture may increase satisfaction with pain management and reduce use of pharmacological analgesia. Acupressure in comparison to a combined control and usual care may reduce pain intensity. However, for other comparisons of acupuncture and acupressure, we are uncertain about the effects on pain intensity and satisfaction with pain relief due to very low-certainty evidence. Acupuncture may have little to no effect on the rates of caesarean or assisted vaginal birth. Acupressure probably reduces the need for caesarean section in comparison to a sham control. There is a need for further high-quality research that include sham controls and comparisons to usual care and report on the outcomes of sense of control in labour, satisfaction with the childbirth experience or satisfaction with pain relief.
许多女性希望避免在分娩时使用药物或侵入性疼痛管理方法，这可能促使补充性疼痛管理方法更受欢迎。本综述研究了针刺和指压用于分娩疼痛管理的证据。这是对2011年发表的一篇综述的更新。
研究针刺和指压用于分娩疼痛管理的效果。
本次更新中，我们检索了Cochrane妊娠与分娩试验注册库（2019年2月25日）、Cochrane对照试验中央注册库（Cochrane图书馆2019年第1期）、MEDLINE（1966年至2019年2月）、CINAHL（1980年至2019年2月）、ClinicalTrials.gov（2019年2月）、世界卫生组织国际临床试验注册平台（ICTRP）（2019年2月）以及纳入研究的参考文献列表。
比较针刺或指压与安慰剂、无治疗或其他非药物分娩疼痛管理形式的已发表和未发表的随机对照试验（RCT）。我们纳入了所有女性，无论初产妇还是经产妇，以及自然分娩或引产的女性。如果有足够信息允许评估偏倚风险，我们纳入以摘要形式报告的研究。采用整群RCT设计的试验符合纳入标准，但准RCT或交叉研究不符合。
两位综述作者独立评估试验是否纳入及偏倚风险，提取数据并检查其准确性。我们采用GRADE方法评估证据的确定性。
我们纳入了28项试验，共3960名女性的数据报告。13项试验报告了针刺，15项试验报告了指压。没有一项研究在所有领域的偏倚风险都很低。疼痛强度通常用0至10或0至100的视觉模拟量表（VAS）测量，分数越低表示疼痛越轻。针刺与假针刺相比与假针刺相比，针刺对女性所感受到的疼痛强度可能几乎没有影响或没有影响（平均差（MD）-4.42，95%置信区间（CI）-12.94至4.09，2项试验，325名女性，低确定性证据）。与假针刺相比，针刺可能会提高对疼痛缓解的满意度（风险比（RR）2.38，95%CI 1.78至3.19，1项试验，150名女性，中等确定性证据），并且可能会减少药物镇痛的使用（RR 0.75，95%CI 0.63至0.89，2项试验，261名女性，中等确定性证据）。针刺对辅助阴道分娩可能没有影响（极低确定性证据），对剖宫产可能几乎没有影响或没有影响（低确定性证据）。针刺与常规护理相比我们不确定针刺与常规护理相比是否能降低疼痛强度，因为证据的确定性非常低（标准化平均差（SMD）-1.31，95%CI -2.14至-0.49，4项试验，495名女性，I=93%）。针刺对疼痛缓解满意度可能几乎没有影响（低确定性证据）。我们不确定针刺是否能减少药物镇痛的使用，因为证据的确定性非常低（平均RR 0.72，95%CI 0.60至0.85，6项试验，1059名女性，I=70%）。针刺对辅助阴道分娩可能几乎没有影响（低确定性证据）或剖宫产（低确定性证据）。针刺与无治疗相比一项试验比较了针刺与无治疗。我们不确定针刺是否能降低疼痛强度（MD -1.16，95%CI -1.51至-0.81，163名女性，极低确定性证据）、辅助阴道分娩或剖宫产，因为证据的确定性非常低。针刺与无菌水注射相比我们不确定针刺对药物镇痛的使用、辅助阴道分娩或剖宫产是否有任何影响，因为证据的确定性非常低。指压与假对照相比我们不确定指压是否能降低分娩时的疼痛强度（MD -1.93，95%CI -3.31至-0.55，6项试验，472名女性）或辅助阴道分娩，因为证据的确定性非常低。指压对药物镇痛的使用可能几乎没有影响（低确定性证据）。指压可能会降低剖宫产率（RR 0.44，95%CI 0.27至0.71，4项试验，313名女性，中等确定性证据）。指压与常规护理相比我们不确定指压是否能降低分娩时的疼痛强度（SMD -1.07，95%CI -1.45至-0.69，8项试验，620名女性）或提高对疼痛缓解的满意度（MD 1.05，95%CI 0.75至1.35，1项试验，105名女性），因为证据的确定性非常低。指压对剖宫产可能几乎没有影响（低确定性证据）。指压与联合对照相比与联合对照相比，指压可能会略微降低分娩时的疼痛强度（以0至10的量表测量，分数越低表示疼痛越轻）（SMD -0.42，95%CI -0.
