Ye Zan (叶赞), Zhai Wei (翟伟)

Changsha Hospital of Traditional Chinese Medicine, Hunan Province, Changsha 410100, China

Abstract

Keywords: Acupoint Therapy; Acupoint Pressure Therapy; Point, Hegu (LI 4); Point, Sanyinjiao (SP 6); Analgesia, Obstetrical; Uterine Inertia; Parturition

The widespread labor analgesia has largely reduced the maternal pain intensity during parturition, and lowered fear for vaginae parturition, which is conducive to lowering the cesarean section rate. However, some research showed labor analgesia may affect uterine contraction and labor progression[1], which may lead to uterine inertia. It manifests as the reduction of uterine contraction force and a longer labor time, which may cause asphyxia neonatorum and increase cesarean section rate, higher risk for postpartum hemorrhage and other complications during puerperium. We used Anrou-pressing and kneading Hegu (LI 4) and Sanyinjiao (SP 6) to treat uterine inertia during painless parturition, and the report is given as follows.

1 Clinical Materials

1.1 Diagnosis criteria for uterine inertia

The diagnosis criteria for uterine inertia referred theObstetrics and Gynecology[2]: difficult labor caused by labor force abnormity in the 1st or 2nd labor stages.

1.2 Inclusion criteria

Continuous epidural analgesia delivery; conforming to the diagnosis criteria; aged between 21 and 37 years; gestational age between 37 and 42 weeks; fetal parietal presentation with abnormity in the 1st labor stage; a slow progression during the latent phase in the 1st labor stage, the 4 h dilatation of the cervix ＜1 cm, or the latent period lasted over 8 h, or dilatation of the cervix ＜1 cm/h during the active period in the 1st labor stage, multipara ＜1.5 cm/h; uterine inertia with ‘+’ in uterine contraction intensity palpation test, or duration ＜30 s, or uterine contraction frequency during the latent period ＜2 times in 10 min, or uterine contraction frequency during the active period ＜2.5 times in 10 min; informed consented.

1.3 Exclusion criteria

Birth canal abnormity; abnormal fetal position, including sincipital presentation, anterior asynclitism, face presentation; fetal development abnormity, such as huge fetus, fetus small for gestational age fetus, etc.; with serious heart, cerebral, liver, kidney or endocrine, hemopoietic diseases; with mental disorders.

1.4 Statistical methods

Data were processed by SPSS version 24.0 software. Ranked data were compared using Mann-WhitneyUtest; measurement data conforming to normal distribution with equal variance were expressed as mean ± standard deviation (±s), paired-samplet-test was for intra-group comparisons, and independent- samplet-test for inter-group comparisons. The non- parameter test was used for data that did not conform to normal distribution or with unequal variance. AP-value less than 0.05 indicated statistical significance.

1.5 General data

A total of 100 parturient with continuous epidural analgesia delivery showing uterine inertia in our maternity ward were recruited between May 2015 and October 2017. By SPSS programming in randomization[3], the 100 cases were divided into an acupoint group and a medicine group, with 50 cases in each group. In the acupoint group, parturient’s age ranged 21-37 years, their height ranged 153-170 cm, their prenatal body mass ranged 55-83 kg, their gestation age ranged 259-291 d, their menarche age ranged 12-16 years old, and their menstrual cycle ranged 25-37 d. In the medicine group, parturient’s age ranged 22-36 years, their height ranged 155-172 cm, their prenatal body mass ranged 58-81 kg, their gestation age ranged 259-288 d, their menarche age ranged 11-15 years old, and their menstrual cycle ranged 25-35 d. Between- group comparisons of the age, height, prenatal body mass, gestation age, menarche age and menstrual cycle showed no statistical significance (allP＞0.05), indicating the comparability (Table 1).

Table 1. Comparison of the general data between the two groups

2 Treatment Methods

In the two groups, analgesia delivery should be stopped immediately when uterine inertia appeared.

2.1 Acupoint group

Acupoints: Bilateral Hegu (LI 4) and Sanyinjiao (SP 6).

Methods: Acupoints were located based on theNomenclature and Location of Acupuncture Points(GB/T 12346-2006)[4]. An-pressed the targeted acupoints with the finger pulps of the two hands, pushed downward with increasing intensity and made circular Rou-kneading. Patients may feel endurable soreness, numbness, heaviness or distension. Attached the finger pulp to the acupoint skin to drive subcutaneous tissue, made circular movement around the acupoint and avoided friction between finger and skin. The Rou-kneading manipulation should be consistent with the force gradually increasing and then decreasing to guarantee a mild, even and continuous circular movement. The frequency of the circular movement was 100 times/min, 2 min for each acupoint. Rou-kneaded bilateral Hegu (LI 4) anticlockwise first, then Rou-kneaded bilateral Sanyinjiao (SP 6) clockwise. Repeated the above manipulations if the effect was not obvious.

2.2 Medicine group

Added 2.5 U oxytocin to 500 mL 0.9% sodium chloride injection for intravenous drip, set the primary dripping speed at 5 drip/min and adjusted the speed according to uterine contraction force. Increased oxytocin dosage for cases without a satisfactory effect. Stopped dripping immediately when uterine contraction ≥5 times in 10 min or uterine contraction lasted for over 1 min or fetal heart rate was abnormal.

The parturient in both groups can receive artificial rupture of membranes or softening cervix method for trial-produce for 2-4 h. For cases under fetal distress or without labor stage, applied cesarean section in time.

3 Therapeutic Efficacy Evaluation

3.1 Observation items

3.1.1 Labor time

The labor time of all stages was recorded in the two groups. Generally the latent period in the 1st labor stage lasted for 8 h, the active period in the 1st labor stage lasted for 4 h, the 2nd labor stage lasted for 1-2 h, and the 3rd labor stage lasted for 5-15 min, at most 30 min.

3.1.2 Maternal and child safety

The postpartum hemorrhage amount within 24 h was recorded, and the newborn Apgar score within 1 min was evaluated.

Parturient delivery hemorrhage amount: The hemorrhage amount ＜500 mL within 24 h was considered safe[5].

The newborn Apgar score: This item was used to test the risk of suffocation and its severity in newborns. Apgar score ranged 0-10 points, in which 8-10 points indicated a normal condition, 4-7 points indicated a mild suffocation, and 0-3 points indicated a severe suffocation[5].

3.2 Therapeutic efficacy criteria[6]

Marked effect: After treatment, the dilatation of the cervix ≥1.5 cm/h, and the palpable uterine contraction intensity was ‘+’.

Effective: After treatment, the dilatation of the cervix ≥1.0 cm/h while ＜1.5 cm/h, and the palpable uterine contraction intensity was ‘+’.

Invalid: After treatment, the dilatation of the cervix ＜1.0 cm/h, and the palpable uterine contraction intensity was ‘±’.

3.3 Results

3.3.1 Comparison of the labor stage

Between-group comparisons of the latent and active periods in the 1st labor stage and the 2nd labor stage showed statistical significance (allP＜0.05); the latent and active periods in the 1st labor stage and the 2nd labor stage in the acupoint group were substantially shorter than those in the medicine group, indicating Anrou-pressing and kneading acupoints can shorten the latent and active periods in the 1st labor stage and the 2nd labor stage. Between-group comparison of the 3rd labor stage showed no statistical significance (P＞0.05), (Table 2).

Table 2. Comparison of the labor progression (±s, h)

Table 2. Comparison of the labor progression (±s, h)

Note: Compared with the medicine group, 1) P＜0.05

Group n The latent period in the 1st labor stage The active period in the 1st labor stage The 2nd labor stage The 3rd labor stage Acupoint 50 8.04±3.271) 4.13±2.331) 0.71±0.401) 0.16±0.08 Medicine 50 9.33±3.32 5.24±2.05 0.78±0.47 0.18±0.05

3.3.2 Comparison of the 24 h postpartum hemorrhage amount and newborn Apgar score

The 24 h postpartum hemorrhage amounts in the two groups were within normal range, and the between-group comparison showed no statistical significance (P＞0.05). The 1 min newborn Apgar score in the two groups ranged between 8 and 10 points, indicating normal newborns, and the between-group comparison showed no statistical significance (P＞0.05), (Table 3).

Table 3. Comparison of the 24 h postpartum hemorrhage amount and newborn Apgar score

3.3.3 Comparison of the labor progession

By Mann-WhitneyUtest, the between-group comparison of the labor stage showed statistical significance (P=0.000), indicating a better effect in the acupoint group (Table 4).

Table 4. Comparison of the labor stage (case)

4 Discussion

Methods such as artificial rupture of membrane and intravenous dripping of small dosage oxytocin are common methods in modern gynecology and obstetrics department to strengthen uterine contraction and promote labor stage. However, such methods are usually accompanied by some serious complications including hyper-contraction, fetal distress, umbilical cord prolapse, hemorrhage, infection and amniotic fluid embolism[7]. Such factors may bring grave suffering or even life-threatening danger to mother and baby. Acupuncture and moxibustion have a long history in China. It owns the advantages of analgesia, promoting cervical ripening, accelerating uterine contraction, shortening labor stage and reducing postpartum hemorrhage. Among which, the method of puncturing Hegu (LI 4) and Sanyinjiao (SP 6) is the most common method to promote labor stage, especially for those in the late phase of pregnancy[8-9].

Hegu (LI 4) and Sanyinjiao (SP 6) are the forbidden acupoints for women in pregnancy; meanwhile, such points are effective for promoting labor stage as recorded in the ancient and modern documents.Tong Ren Shu Xue Zhen Jiu Tu Jing(Illustrated Manual of Acupuncture Points of the Bronze Figure) is the first document that lists Hegu (LI 4) as the forbidden point for pregnant women.Pu Ji Fang(Prescriptions for Universal Relief) puts that Hegu (LI 4), Sanyinjiao (SP 6), Jianjing (GB 21) and Qichong (ST 30) are acupoints for promoting labor stage.Shen Ying Jing(Miraculous Effective Classic of Acupuncture) records the method of reinforcing Hegu (LI 4) and reducing Sanyinjiao (SP 6) to treat labor difficulty. Similar acupuncture method of reinforcing Hegu (LI 4) and reducing Sanyinjiao (SP 6) is also recorded inYi Xue Gang Mu(Compendium of Medicine) to promote labor process.Zhen Jiu Da Cheng(CompleteCompendiumofAcupunctureand Moxibustion) records Duyin (EX-LE 11), Hegu (LI 4) and Sanyinjiao (SP 6) to treat labor difficulty.

Hegu (LI 4) is the Yuan-Primary point of the Large Intestine Meridian, and the lung is internally and externally connected with the large intestine. The lung governs qi in the body. Therefore, reinforcing Hegu (LI 4) has the function of tonifying qi. Sanyinjiao (SP 6) is the crossing point of the Liver, Spleen and Kidney Meridians, so reducing Sanyinjiao (SP 6) can release blood. Thus the manipulation of reinforcing Hegu (LI 4) and reducing Sanyinjiao (SP 6) can promote labor stage through affecting qi-blood aspect, the Thoroughfare Vessel, Conception Vessel and Zang-fu organs[10]. Such methods have long been used to treat labor difficulty in history. Zhang YF,et al[11]have found Hegu (LI 4) and Sanyinjiao (SP 6) can obvious affect uterine contraction, and the combination of the two points can supplement qi and regulate blood, which is beneficial to uterine contraction regardless of deficiency or excess pattern. Hegu (LI 4) point has functions of facilitating qi-blood movement and analgesia, thus produces a two-way regulation of the uterine smooth muscles[12]. Some scholars hold that puncturing Hegu (LI 4) can promote the synthesis and release of prostaglandin E2(PGE2), and thus promote cervical ripening and uterine contraction to facilitate delivery[13]. Modern literature reported that stimulating Sanyinjiao (SP 6) can decrease pain intensity during delivery and shorten the labor process[14-17]. Needling Sanyinjiao (SP 6) can stimulate trunk sensory nerve fibers, and then excite spinal cord center and pelvic plexus by sympathetic nerve to generate biological changes in uterine muscles to promote contraction. The combination of Hegu (LI 4) and Sanyinjiao (SP 6) is a typical acupoint pair for delivery. Such combination can coordinate uterine contraction through a two-way regulation, and therefore reduce pain severity and shorten labor process during delivery[18-20]. The effects of analgesia and facilitating labor process are generated through activating endogenous analgesia system[8], and will not influence the 2nd labor stage or safety indicators[9]. Besides, stimulating such two points can regulate qi and calm spirit, and relieve tension and fear in parturient[21], which are beneficial to the cooperation and labor process during delivery.

An-pressing acupoints pertains to the category of finger acupuncture therapy. This manipulation has a long history which is frequently mentioned inZhou Hou Bei Ji Fang(Handbook of Prescriptions for Emergencies). Such method is free from apparatus and medicine, but owns the merits of safety and convenience. With proper usage, it can produce a rapid clinical effect. Moreover, the painless manipulation is easily accepted by old people, women and children.

This study showed Anrou-pressing and kneading Hegu (LI 4) and Sanyinjiao (SP 6) can shorten the latent and active periods in the 1st labor stage and the 2nd labor stage in uterine inertia patients during painless parturition. Such method had a better effect compared with intravenous oxytocin. It showed no influence on 24 h postpartum hemorrhage amount and newborn Apgar score. To sum up, Anrou-pressing and kneading Hegu (LI 4) and Sanyinjiao (SP 6) is both safe and effective for uterine inertia during painless parturition, and worth clinical popularization.

Conflict of Interest

There is no potential conflict of interest in this article.

Acknowledgments

This work was supported by Traditional Chinese Medicine Science Research Planning Project of Hunan Province (湖南省中医药科研计划项目, No. 2019138).

Statement of Informed Consent

Informed consent was obtained from all individual participants.

Received: 15 January 2020/Accepted: 13 March 2020