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The effectiveness of acupressure at LI 4 and SP 6 point on uterine contraction in the first stage of labor on primiparous women

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Background: Maternal Mortality Rate is still dominated by causes such uterine contractions, prolonged labor. Cesarean section and labor induction are still an effort to prevent these complications. Meanwhile, these solutions have complications such as infection risk, hypertonic contraction, fetal trauma, etc. In this study, acupressure technique is one of the answers to increase uterine contractions so that cesarean section and labor induction can be avoided. Acupressure is a non-pharmacological, non-invasive uterine stimulation technique, which is simple, safe, effective, and without serious side effects. This study aims to analyze the increase of uterine contractions in the first stage of normal labor with acupressure treatment Method: This study is a randomized controlled trial on 39 primiparous mothers during the active phase of the first stage of normal labor were equally assigned to two intervention groups [acupressure on LI 4 (n = 13) or SP 6 (n = 13)] and a control group (n = 13). The intervention group received routine labor care and acupressure in LI 4 or SP 6 point bilaterally for 20 minutes; control group just received routine labor care. Results: There were significant differences between the three study groups at the frequency (p = 0.000), duration (p = 0.000) and interval of the uterine contraction (p = 0.000). After post hoc test, the mean of frequency, duration, and interval uterine contraction most significant increased between SP 6 and control group (p = 0.000). Conclusion: Acupressure on LI 4 and SP 6 point are effective in increasing uterine contraction compared with the control group with the most significant result in acupressure at SP 6 point. © 2018, Indian Journal of Public Health Research and Development. All rights reserved.
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Effectiveness of Acupressure at LI 4 and SP 6 Point on
Uterine Contraction in the First Stage of Labor on
Primiparous Women
C K Wardani,1 M N Widyawati,2 and Suryono Suryono 3
1,2Postgraduate Applied Science Program in Midwifery, Poltekkes Kemenkes
Semarang, Tirto Agung Street Pedalangan, Banyumanik, Semarang,
Indonesia
3Departement of Physics, Diponegoro University, Prof Soedarto SH Street,
Tembalang, Semarang, Indonesia
Email: wardhani_christy@yahoo.com1
Abstract. Maternal Mortality Rate still dominated by causes such uterine contractions.
Cesarean section and labor induction are still an effort to prevent these complications.
Meanwhile, these solution have complications. Acupressure is one of the solutions to
increase uterine contraction. This study analyze the increase of uterine contractions in the
first stage of normal labor with acupressure treatment. This study is a randomized controlled
trial on 39 primiparous mothers during the active phase of labor were divided to two
intervention groups [acupressure on LI 4 (n = 13) or SP 6 (n = 13)] and a control group (n =
13). The intervention groups received a routine labor care and acupressure in LI 4 or SP 6
point bilaterally for 20 minutes, control group just received a routine labor care. There were
significant differences between the three study groups at the frequency (p = 0,000), duration
(p = 0,000) and interval of the uterine contraction (p = 0,000) with the most significant result
between SP 6 and control group (p = 0,000). Acupressure on LI 4 and SP 6 point is effective
in increasing uterine contraction compared with control group with the most significant result
in acupressure at SP 6 point.
1. Introduction
Maternal Mortality Rate is still dominated by causes such uterine contractions, prolonged
labor. Cesarean section and labor induction are still an effort to prevent these complications.1
Meanwhile, these solution have complications such as infection risk, hypertonic contraction, fetal
trauma, etc.2 In this study, acupressure technique is one of the solutions to increase uterine
contractions so that cesarean section and labor induction can be avoided.
Acupressure is a non-invasive, non-farmacological, simple, safe, effective without serious
side effect method which is used to augment labor, provide labor pain relieve, and shorten the first
stage of labor duration.3 Many studies have proven that acupressure can increase uterine
contractions. From 7 studies on the effects of acupressure on the duration of labor, 5 studies
showed the results of the duration of the first stage of labor were shorter acupressure compared to
those not given acupressure. A variety of acupoints are useful to increasing uterine contraction and
shorten the first stage of labor duration, are LI 4 and SP 6 points.4
Research on acupressure for the advancement of childbirth has been widely studied, but until
now the results of the study have not calculated and recorded the frequency, duration and interval
in detail. Meanwhile the detailed recording is important to assess the progress of labor. Most of the
research results are only the duration of labor and the frequency of uterine contractions only. In this
study, uterine contractions were calculated and recorded in detail and analyzed for the increase
between the point acupressure intervention group LI 4, SP 6 point, and the control group.
2. Methods
2.1 Setting and Participants
This randomized controlled trial post test only design was carried out on primiparous
women in 11 community health center at Semarang, Central Java, Indonesia from 22 May to
22 July 2018. The trial was approved by the Ethics Comittee of Health Polytechnic Semarang,
Indonesia. The inclusion criteria were : primiparous women in normal labor, 20 35 years old,
at term pregnancy (37 - 42 weeks of gestation), fetal vertex presentation, and being in active
phase of first-stage labor with cervical dilatation of 4 cm and presence of at least three
uterine contractures within 10 min, mother and fetal were health (not suffering from diseases
that cause labor complications), singleton pregnancy, Body Mass Index (BMI) 18.5 -25.0,
mother eats before delivery. The exclution criterion were : mother get labor augmentation
using uterotonics, having coitus in the last 24 hours, there are wounds on the SP-6 and LI-4
acupressure points, delivery time > 24 hours or long labor, patients fall on early membranes
rupture.
2.2 Randomization and intervention
The first step of the trial is randomized of 11 community health centers in Semarang
(cluster sampling) to assigned the locations into three groups. The primiparous women who
were admitted for normal delivery to the community health centers and met the inclusion
criteria were selected goal-oriented and then were assigned to three groups that included: a
group that received acupressure on LI4 point, a group that received acupressure on SP 6
points, and the control group.
Before beginning the intervention, cervical dilatation and uterus contractions were
checked. Acupressure was applied bilaterally during the contraction on Hugo point (LI4),
which is located on the medial midpoint of the frst metacarpal within the skin of the thumb
and the index fnger or on San Yin Jiao Point (SP 6) which is located on the three cun above
the medial maleolus (Fig. 1).
Figure 1. Location of LI 4 and SP 6 points5
The respondents of LI 4 group were asked to lie down in supination position and the
researcher sat in beside them. The researcher applied pressure to the LI 4 point of the both
hands by her both thumbs. To prevent any discomfort, the pressure was applied with Pu
technique which is pressing the point gently, at the beginning it must be done gently then
gradually the strength of the emphasis is added until it feels a light sensation but does not hurt.
Emphasis with a clockwise circular massage. Applying pressure was stopped by the end of
each contraction and was started again by the beginning of another contraction. This was
repeated during 20 minutes.
The respondents of SP 6 group were asked to lie down in supination position and the
researcher sat in front of their leg. The researcher applied pressure to the SP 6 point of the
both legs by her both thumbs. The pressure technique and duration of giving acupressure were
same with the aforementioned group. For the control group, the researcher attended the
bedside of the respondents and performed all the routine labor care but did not applied
acupressure. The researcher just conducted the palpation examination to measure the
frequency, duration, and interval of uterine contraction.
2.3 Outcome measurement
The assessment of respondent’s age, eduaction, and occupation were use a queationaire.
To keep the confidentiality of respondents, we use codes to identify replacing the respondent’s
name. The frequency, duration, and interval of uterine contraction were measured by palpation
examination at respondent’s abdoment during the first stage of labor. The WHO’s partograph
is used to record the frequency of uterine contraction and cervical dilatation. The duration and
interval of uterine contraction were recorded in observation sheet.
2.4 Statictical Analysis
The minimum number of sample size for each group was determined to be 9.
Considering the possibility of missing some cases, sample size for each group was determined
to be 13. Data were analyzed using SPSS version 16.0. Chi square test was used to determine
the difference of respondent’s eduaction and occupation among three groups. ANOVA was
used to determine the mean difference of respondent’s age, also to determine the difference of
interval and followed by Bonferroni post hoc test to determine which group that had the most
significant result compared with control group. Kruskal-Wallis Test was used to compare
obstetric caracteristics, frequency, and duration ofuterine contraction between three groups of
study, because of lack of normal distribution and followed by Mann-Whitney test. For all
analyses the statistical significance was defined as P < 0.05.
3. Result
3.1 Demographic and obstetric characteristics
All of 39 women completed the study (Fig. 2). As presented in Table 1, there was no
significant difference in demographic (age, education, and occupation) and obstetric
(gestational age, cervical dilatation) characteristics among the groups.
Table 1. Comparison of demographic and obstetric characteristics among the three groups
Variables
LI 4
(n = 13)
SP 6
(n = 13)
Control
(n = 13)
p
Age (mean ± SD) years
23.6 ± 1.8
22.7 ± 1.8
23.4 ± 2.1
0.865a
Education n (%)
Elementary
Junior High
Senior High
College or above
1 (7.7)
2 (15.4)
9 (69.2)
1 (7.7)
0 (0)
5 (38.5)
8 (61.5)
0 (0)
0 (0)
2 (15.4)
10 (76.9)
1 (7.7)
0.516b
Occupation n (%)
Housewife
Employed
Gov. employee
Enterpreneur
3 (23.1)
5 (38.5)
2 (15.4)
3 (23.1)
4 (30.8)
6 (46.1)
1 (7.7)
2 (15.4)
1 (7.7)
7 (53.8)
1 (7.7)
4 (30.8)
0.777b
Gestational Age (mean ± SD)
weeks
39.9 ± 0,8
39.9 ± 0.9
39.9 ± 0.9
0.966c
Cervical Dilatation (mean ± SD)
cm
4.5 ± 0.7
4.8 ± 0.8
4.8 ± 0.7
0.362c
aANOVA
bChi Square
cKruskal Wallis
3.2 Uterine Contraction
Table 2 presents the difference of mean uterine contraction (frequency, duration, and
interval) among groups. Kruskal wallis test demonstrated significant difference in frequency
of uterine contraction between LI 4, SP 6 and control group (p = 0,000). Kruskal Wallis also
attested significant difference in duration of uterine contraction between LI 4, SP 6 and control
group (p = 0,000). ANOVA test proved significant difference in interval of uterine contraction
between LI 4, SP 6 and control group (p = 0,000).
Table 2. Comparison of uterine contraction among the three groups
Variables
LI 4
(n = 13)
SP 6
(n = 13)
p
Frequency (mean ± SD) times/10
minutes
3.5 ± 0.2
3.7 ± 0.1
0.000a
Duration (mean ± SD) second
43.8 ± 0.9
47.8 ± 1.4
0.000a
Interval (mean ± SD) minute
3.3 ± 2.5
2.9 ± 0.2
0.000b
aKruskal Wallis
bANOVA
Table 3 presents comparison of uterine contraction (frequency, duration, and interval)
among three groups. The efficacy of frequency of uterine contraction from view of the women
was significantly greater in LI4 and SP 6 groups compared with controls, with most significant
difference in SP 6 group (p = 0.000). The difference of duration of uterine contraction from
view of the women was significantly greater in LI4 and SP 6 groups compared with controls,
with most significant difference in SP 6 group (p = 0.000). The difference of interval of
uterine contraction from view of the women was significantly greater in LI4 and SP 6 groups
compared with controls, with most significant difference in SP 6 group (p = 0.000).
Table 3. Post hoc test of uterine contraction among the three groups
Variables
Group
Group
Mean DIfference
Sig.
Frequency
LI 4
SP 6
Control
0,1
0,3
0,065a
0,000a
Duration
LI 4
SP 6
Control
1,1
5,1
0,199a
0,000a
Interval
LI 4
SP 6
Control
0,2
0,5
0,018b
0,000b
aMann Whitney
bBonferroni
4. Discussion
In this study, we investigated and compared the effect of LI 4 and SP 6 acupressure with
control group on uterine contraction in active phase of first-stage of labor. In the present study, the
significant increase of frequency and duration of uterine contraction, also the significant decrease
of interval of uterine contraction, between intervention and control group supports the effectiveness
of applying pressure to LI4 and SP 6 points in increasing uterine contraction. This result also
showed that acupressure on SP 6 points is more effective than on LI4 point in increasing uterine
contraction.
The results of this study are in line with the research conducted by Ozgoli6 on the effects of
acupressure LI 4 and BL 32 on delivery outcomes, one of which is the result of the acupressure
effect of uterine contractions.6 The results of this study esults of this confirm our results concerning
stimulation of LI 4 point. But the result of these study is not showed significant different because
apllied unilateral pressure. In this study researcher applied bilateral pressure, that probably
responsible for its higher effectiveness in comparison with applying unilateral pressure.
This study is also in line with the randomized controlled trial study conducted by Mafetoni
and Shimo7 about the effects of acupressure on the progress of labor and the incidence of cesarean
section. The results of this study indicate that mothers who were given acupressure therapy at SP
point 6 duration of labor were significantly different compared to placebo and control groups. The
results of this study confirm our results concerning stimulation of SP 6 point. In this study,
acupressure at point SP 6 was shown to increase the hormone oxytocin which can facilitate labor.
This is while we measuring uterine contraction by palpation examination considering our
limitations in measuring by biomarkers (biophyscal or biochemical markers).
Acupressure is a non-invasive therapy for labor and makes parturients stay comfortable
during labor. Experimental studies of the effects of acupressure on the duration of the 1st stage of
labor have been widely performed in Asia. In these studies, the acupressure point that gives the
most significant results is the SP 6 point, then the point LI is 4.8-11 The results of this study confirm
our results concerning stimulation of SP 6 point.
Acupressure at point SP 6 has a strong influence on the reproductive organs. Stimulation at
this point can increase the concentration of yin energy that can initiate labor. The effect of
acupressure Yin energy can increase uterine contraction because it has been shown to increase the
oxytocin hormone.12 During labor, there is a blockage of the meridian which causes the flow of
meridians to flow through the body. Stimulus at point SP 6 or LI 4 can open blockages and
facilitate meridian flow. This also makes the mother calmer during labor. Stimulus at this point can
also increase the hormone oxytocin from the pituitary gland which causes an increase in uterine
contractions during labor.13,14
5. Conclusion
This study proves that acupressure at LI 4 and SP 6 points is a non-pharmacological, non-
invasive uterine stimulation technique that is simple, safe, effective, and without serious side
effects that significantly increased frequency and duration, also decreased interval of uterine
contraction with the most significant results in acupressure at SP 6 point.
The weaknesses of our study are the factors that influence labor contractions such as
psychological factors (fear, anxiety, tension, stress) have not been controlled. Assessment of
uterine contractions has not used biomarkers (biophyscal or biochemical markers). Further trials
are needed to control the psychological factors and using biomarkers to get more valid result.
6. Conflict of Interest
Authors states that they have no conflicts of interest to the material of this manuscript.
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Analisis Lanjut Data Riskesdas 2010) Persentase Operasi Caesaria Di Indonesia Melebihi Standard Maksimal
  • T Suryati
Suryati T 2012 (Analisis Lanjut Data Riskesdas 2010) Persentase Operasi Caesaria Di Indonesia Melebihi Standard Maksimal, Apakah Sesuai Indikasi Medis? Buletin Penelitian Sistem Kesehatan. 15(4):331-8.
  • L J Mollart
  • J Adam
  • M Foureur
Mollart LJ, Adam J, Foureur M 2015 Impact of Acupressure on Onset of Labour Duration : A Systematic Review Women. Birth. 28(3):199-206.
Acupuntura tradicional: a arte de inserir 2
  • Y Yamamura
Yamamura Y 1998 Acupuntura tradicional: a arte de inserir 2. Ed (São Paulo: Roca)