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, Pennsylvania? 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 A N D METHODS Our subjects consisted of 12 volunteers, 11 white 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. In 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
Transcript
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, Pennsylvania?
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 A N D METHODS Our subjects consisted of 12 volunteers,
11 white 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. In 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
P W T S (CO-I)
GOVERNING I (GO- I ) STOMACH 56
P L E E N 6 (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 section’s7 (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 patient’s 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. In 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 patient’s 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. In 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
Estimated Duration of duration of
Stage of labor - Degree ACP before Total duration pain relief Care Severity o f pain At start of At termination of relief, pain relief, of ACP, by ACP,
number a t start of ACP ACP of ACP percent minutes minuter minutes
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- n i 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, patient’s 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, JAN.-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) patient’s 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.
