ANESTHESIA AND ANALGESIA . . . Current Researches VOL. 54, NO. 1, JAN.-FEB.

, 1975 83
Acupuncture in Obstetrics
EZZAT ABOULEISH, M.B., B.Ch., M.D."
RICHARD DEPP, M.D.
Pittsburgh, Pennsyl vani a?
Electroacupuncture (ACP) during childbirth
was used in 12 parturients. On the average, it
produced 66 percent analgesia in 7 patients
for 139 minutes while patients were in active,
progressive labor. When ACP no longer could
relieve pain, spinal, epidural, or double-cath-
eter technic produced complete analgesia in all
patients. ACP did not adversely affect the
fetus or uterine contractions and had no harm-
CUPUNCTURE has been used to provide
A analgesia in many surgical procedures,
including cesarean sectionl-3 and vaginal
delivery.4 No doubt it presents favorable
theoretic advantages for childbirth, since no
drugs are administered, the technic seems
simple and inexpensive, and maternal vital
signs are stable.1,3 We therefore tried this
procedure, using electroacupuncture ( ACP) ,
in 12 parturients at term.
MATERIALS AND METHODS
Our subjects consisted of 12 volunteers,
11white and 1 black, all with normal preg-
nancy course and no fetal distress. Seven
patients had spontaneous labor and 5 were
induced. Their ages ranged from 20 to 42
(average 27.6) years. Four patients were
nulliparas. The ACP technic was explained
to each patient prior to the procedure. She
was assured that, if at any time during the
experiment ACP did not relieve her pain,
conventional methods of analgesia would be
used. No tests to select patients were made
before the experiment.
ful aftereffect on mother or neonate. However,
its use as a routine method had disadvantages
because analgesia was inconsistent, unpre-
dictable, and incomplete. The technic was time-
consuming, limited the patient's movement,
added more wires and machinery, and inter-
fered with electronic monitoring of the mother
and fetus.
Before, during, and after ACP, uterine
contractions and fetal heart rate, as well as
pulse, blood pressure, and electrocardio-
gram, were monitored. The ACP was per-
formed by one of the authors (E.A.), using
stainless steel, sterile, disposable 32-gauge
ACP needles. For 9 patients, the needles
were electrically vibrated continuously by
the Chinese Acupuncture Anesthesia Appa-
ratus, Model 71-1, using 9-volt D.C. dry
batteries. I n 3 patients, the NeuroAmp
Model 102A, Lock Electro-Acupuncture De-
vices, San Francisco, California, was used.
The needles were inserted at the selected
points to a depth of 1 to 2.5 cm., depending
on the site. The angle, depth, or site of
insertion was changed until "Teh-Chi"$
was obtained. Extra care was taken during
insertion of the needles into the lower ab-
domen. For the first stage of labor, the
chosen ACP points corresponded to the
__
Y'Teh-Chi": The patient felt warmth, numbness,
or tightness at the site of insertion, sometimes
radiating along the corresponding meridian, and
the operator felt tightness around the needle.
*Associate Professor, Clinical Anesthesiology, Department of Anesthesiology, University of Pittsburgh
School of Medicine and Director of Obstetric Anesthesia, Magee-Womens Hospital, Pittsburgh, Penn-
sylvania 15213.
?Departments of Anesthesiology and Obstetrics, Gynecology and Pediatrics, Magee-Womens Hospital,
Pittsburgh, Pennsylvania.
Paper received: 2/6/74
Accepted for publication: 5/29/74
84 ANESTHESIA AND ANALGESIA. . . Current Researches VOL. 54, No. 1, JAN.-FEB., 1975
CONCEPTION 4
PWT S
( CO- I )
GOVERNING I
( GO- I )
STOMACH 56
PL EEN6 ( SP- 61
A B
Frc. 1. ACP p o i n t s A, during 1st stage; B, during 2nd stage.
Chinese points used to treat pain of dys-
menorrheajzF and those used for cesarean
sections7 (A, fig. 1). The total number of
points used in each patient was usually
eight. For the second stage of labor, the
ACP points were a modification of those
used in FranceR (B, fig. 1).
The frequency used was 5 to 10 cps. The
output from the machine was gradually in-
creased until the patient felt the needles
vibrating without associated discomfort. The
voltage varied between 1 and 5 volts and
the amperage between 10 and 50 microamps,
according to the patients tolerance. The
two electrodes from each socket of the
machine were attached to needles only on
the same side of the patient, to avoid con-
duction of electricity across the body.
If an appreciable degree of pain was felt,
despite ACP for 30 minutes, 25 to 50 mg.
of meperidine was injected intravenously.
The experiment was then continued for 10
minutes more and pain sensation was re-
estimated.
RESULTS
In one patient, ACP was started with oxy-
tocin induction of labor. However, before
the patient felt any uterine pain, ACP was
discontinued because she disliked the vibra-
tion of the needles. Eleven patients were in
active labor and had experienced moderate
to severe pain before ACP was started;
these served as their own controls.
ACP neither relieved pain of labor in 4
patients nor did it accentuate pain in any
parturient. However, following ACP, 7 pa-
tients, on the average, experienced 66 per-
cent relief of preexisting pain. The hypoal-
gesia occurred on the average 10 minutes
after initiation of ACP and lasted for 139
minutes during active progressive labor
(table).
One patient, gravida 2, para 1, with a
4260 gm. occipitoposterior fetus, delivered
spontaneously under ACP alone and had
90 percent relief of pain. I n 2 patients, the
fetal head was crowning before spinal
block was performed for episiotomy and for-
ceps delivery. No attempt was made to
deliver these 2 patients under ACP alone,
since analgesia was incomplete. Four other
patients experienced varying degrees of pain
relief. However, no patient was completely
free of pain.
When ACP was no longer adequate for
pain relief, the addition of an intravenous
injection of 25 to 50 mg. meperidine did not
sufficiently raise the patients threshold of
pain to justify continuation of ACP. Re-
gional analgesia was then instituted, using
spinal in 3, epidural in 3, and combined
epidural and caudal in 4 patients. Compared
with ACP, pain relief produced by regional
analgesia was complete and there was
warmth, dryness, and vasodilation of the
feet.
Maternal electrocardiogram was recorded
before, during, and after ACP in 5 patients.
I n all cases, there was electrical interfer-
ence corresponding with the rate of im-
pulses discharged from the ACP machine.
Lead I was spared (fig. 2) except in cases
where hand points (L-14) were used. Uter-
ine contractions were monitored externally
in 4 patients and internally in 6. ACP
Acupuncture . . . Abouleish and Depp 85
TABLE
Severity of Pain, Stage of Labor, Degree of Relieft and Duration of ACP
Est i mat ed
Dur at i on of dur at i on of
St age of l abor - Degr ee ACP bef or e Tot al dur at i on pai n r el i ef
Car e Severi ty o f pai n At start of At t er mi nat i on of r el i ef , pai n r el i ef , of ACP, b y ACP,
number at start of ACP ACP of ACP percent mi nutes mi nuter mi nutes
1 Moderate 3 6 90 5 445 440
3 Severe 7 14 90 35 67 28
4 Severe 5 5 10 5 35 30
5 Severe 5 8 60 5 110 105
7 Severe 9 12 90 5 117 112
8 Moderate 2 4 80 10 240 230
12 Severe 7 12 40 5 30 25
Average 5 9 66 10 149 139
*lst stage =0-10 corresponding to cervical dilatation in cm.
2nd stage =11 head at perineum, crowning
3rd stage =13 delivery of placenta
12 actual delivery, expulsion phase
14 after delivery of placenta
?Pain severity and relief as evaluated by the patient.
caused no significant changes in baseline
muscle tonus, force, or frequency of uterine
contractions.
In 10 patients, fetal monitoring was con-
tinuously recorded, extemlly in 4 and in-
ternally in 6. ACP showed no significant
effect on fetal heart tracings. There was no
change in baseline variability, rate, or ap-
pearance of abnormal fetal heart rate pat-
terns. However, in 4 patients there was
electrical interference of fetal monitoring
during ACP (figs. 3 and 4) . Although fetal
electrocardiogram showed no premature
beats or significant changes in the R-R in-
terval, the electric impulse from the ACP
machine was recorded in 2 patients (fig. 5 ) .
The 1-minute Apgar score was 8-to-9 and
the 5-minute score was 10 in all patients.
Patient interviews were conducted the fol-
lowing day, not by the anesthesiologist, but
by the Delivery Room Head Nurse. Nine
patients indicated they were delighted with
the experiment and would like to have ACP
again for future delivery because no drugs
were used, they were alert, and had no after-
effects. Two patients stated they would not
like to have ACP again because it did not
relieve the pain. One patient indicated she
did not like the vibrations of the needles.
A questionnaire was sent to each obstetri-
cian involved in the delivery of the 12 pa-
tients, to evaluate ACP as a method for
obstetric analgesia. One obstetrician con-
sidered ACP as a good technic, three as
fair, four as of no value, and four did not
comment because they were absent during
ACP.
Examination of patients 24 and 72 hours
after delivery showed no apparent changes
at the ACP sites or tenderness of calf mus-
cles. All patients had a smooth postpartum
course and were discharged with their
neonates at the expected time.
DISCUSSION
There is much interest in ACP in many
fields of medicine, including anesthesiology.
The impression that ACP is used routinely
in China to produce analgesia for all types
of surgery is erroneous. It has recently been
stated that ACP is used in only 20 percent
of surgical patients, while regional analge-
sia, such as spinal and epidural, constitutes
the highest percentage -of anesthetic tech-
ni c ~. ~, ~, ~ The success rate of ACP to produce
analgesia for surgery, even in China is lim-
ited (60 to 70 percent),lO and it is least
effective in the lower part of the body.3
There is no complete relief from pain under
ACP but there is a state of hypoalgesia,
depending on the pain threshold of the pa-
tient.
During the course of our study, a report
of the results of manual electroacupuncture
in 10 obstetric patients was published.11
86 ANESTHESIA AND ANALGESIA . . . Current Researches VOL. 54, No. 1, JAN.-FEB., 1975
FIG. 2. Maternal ECG during acupuncture. (Note interference in all leads except lead I.)
Pain relief was adequate in 1, partial in 3,
and absent in 6 patients. In our study, to
determine the suitability of ACP for routine
use in obstetrics, excitable patients purpose-
ly were not excluded, and no special pre-
liminary tests were performed.
Because of the small number of cases,
no meaningful conclusions can be drawn
regarding ACP hypoalgesia and severity of
pain, its site, stage of labor at the start of
ACP, patients age, gravidity, parity, race,
social status, oxytocin administration, size,
presentation of the fetus, or regarding site
or combination of sites for ACP. There
were no apparent harmful effects on pa-
tients, uterine contractions, fetus, or neo-
nates and the majority of subjects liked the
procedure.
CONCLUSIONS
Comparing ACP with regional analgesia
for childbirth in the same group of patients:
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88
ANESTHESIA AND ANALGESIA . . . Current Researches VOL. 54, No. 1, J AN.-FEB., 1975
FIG. 5. Fetal ECG during acupuncture-A, before;
B, during; C, after. (Note impulses from acupunc-
ture machine recorded during ACP.)
(1) ACP analgesia was incomplete, unpre-
dictable, and inconsistent; (2) it was time
consuming; (3) needles were apt to become
dislodged; (4) patients movements were
restricted; (5) added wires and machinery
were attached to the parturient; (6) there
was interference with electronic monitoring
of the mother and fetus.
Thus far, the practicality of ACP for
vaginal delivery is questionable. Further
studies are required to limit the number of
points used, to explore distant points that
may not interfere with maternal or fetal
monitoring, for example, ear points; to im-
prove the quality of analgesia; and to over-
come other mentioned difficulties.
ACKNOWLEDGMENT
Our gratitude is extended to the patients
who volunteered for this experiment, to the
obstetricians of Magee-Womens Hospital,
and to the Delivery Room Head Nurse,
Miss M. L. Roth, and to Miss Anne Francis
for their cooperation.
REFERENCES
1. Dimond EG: Acupuncture anesthesia. J AMA
218:1558-1563, 1971
2. Mayrhofer 0: Personal communication
3. McIntyre J WR: Observations on the prac-
tice of anesthesia in the Peoples Republic of China.
Anesth & Analg 53:107-110, 1974
4. Fox J W: Acupuncture: what it could mean
to the patient and the anesthetist. Clin Trends
Anesth 2:l-4, 1972
5. Wei-Plng W: Chinese Acupuncture. Rust-
ington, Sussex, England, Health Science Press, 1962,
P 50
6. Kao FF: Acupuncture Therapeutics. New
Haven, Connecticut, Eastern Press, 1973, pp 33, 38,
40, 73
7. Roccia L: Personal experience with acu-
puncture in general surgery. Amer J Chinese Med
1:329-335, 1973
8. Darras J C: The First World Symposium on
Acupuncture and Chinese Medicine, San Francisco,
California, 1973
9. Bonica J J : Anesthesiology in the Peoples
Republic of China. Anesthesiology 40: 175-186, 1974
10. Wang J K: The practice of acupuncture in
China. Anesth & Analg 53:111-112, 1974
11. Palahniuk RJ , Shnider SM. Wu SW: Acu-
puncture analgesia in obstetrics. ASA Scientific
Abstracts, 1973, pp 49-50
* * *
The natural flights of the human mind are not from pleasure to pleasure, but from
-Samuel J ohnson
hope to hope.