PREPARE: PRimigravidas Experiencing Postdate Acupressure REsearch

PR.E.P.A.RE for labour: Primigravidas Experiencing Postdates Acupressure Research Research Team: Lyndall Mollart1.4a, Gloria Albert1, Debra Betts2, Bernadette Leiser1, Dr Mutayyab Shah1, Dr Virginia Skinner3, Professor Maralyn Foureur4

Background

Figure 1. Acupressure Points used

NSW Health, Towards Normal Birth Policy Directive1 (PD 2010_045) has highlighted the need to: increase the spontaneously

number

of

women

commencing

GB21

labour

decrease the number of labour interventions. A non-pharmacological, non-invasive technique to stimulate uterine contractions that is simple, safe, effective and without serious side effects may therefore prove beneficial for both mother and baby.

Figure 2: Study Flowchart

Research using acupressure has found stimulation of specific meridian points can initiate or assist effective uterine contractions, and shorten the length of labour 2-7.

There is no statistically significant difference between women receiving Acupressure and women receiving Usual care- in the rate of spontaneous vaginal birth (37.5% vs 57.1%, p=0.210; Odds Ratio 0.45, 95% CI 0.13- 1.59). Descriptive data is shown in Table 2. The use of pharmacological pain relief was similar in both groups.

Aims Determine whether women experiencing their first, term pregnancy, who have reached 41weeks gestation, were more likely to commence labour spontaneously using specific acupressure points than women receiving usual care Establish an effect size for an appropriately powered RCT

Women’s Survey A total of 29 surveys were returned (66%) with18 from the Acupressure group (18/22, 82%) and11 from the Usual Care Group (11/22, 50%). Participant’s views on being involved in a research project is summarised in Figure 4. Women’s comments about being randomised

Method A randomised controlled trial feasibility study was conducted in a public maternity unit in outer metropolitan NSW with a proposed sample size of 60 participants. After obtaining written informed consent, eligible participants were randomly allocated to either usual antenatal care or usual care + acupressure intervention (as per Diagram 2).

There was no statistically significant difference between women receiving Acupressure and women receiving Usual care in the rate of spontaneous onset of labour (A= 47.8% vs U= 52.2%, p=0.763; Odds Ratio 0.83, 95% CI 0.23-2.72). Descriptive data on the number of women commencing spontaneous labour is shown in Figure 3 .

Birth Outcomes

Therefore the following study was undertaken.

2.

From 13th February to 30th July 2013, 71 women were eligible to participate. A total of 44 women were randomised, with 27 women declining to participate (Figure 4; Table 1). In addition 10 women were not eligible due to strong preference to use acupressure. Nearly all women (94%) were randomised between 40+5 weeks and 40+ 7 weeks.

Onset of labour

Acupressure is one technique that has been trialled for this purpose

1.

Preliminary Findings

“I was excited to participate in this study but very disappointed when I wasn’t selected [acupressure group] & felt let down” “I was lucky to be in the acupressure group. I would have been disappointed if I was in the control group”

Table 1: Eligible women not randomised

“It was a quick process & glad to be a part of research. The person who contacted me was very polite & explained the study well.”

Usual Care

Antenatal Clinic/Day Assessment Unit (DAU) appointment at approximately 40wks+10 days (+/-2 days) for maternal/fetal wellbeing assessment (vaginal examination to determine Bishop score, and CTG) and date for medical induction (prior to 40wks+14days).

Acupressure Group 100% women agreed/strongly agreed that they received enough information on the use and location of the 3 acupressure points. Nearly all women always used the 3 acupressure points as per the study protocol (17/19, 89.5%) and only 1 woman did not use the points at all. Most women found using acupressure made them feel actively involved in their care (14/18,78%).

Usual Care + intervention

Participants in this group also received instruction on three acupressure points - Spleen 6 (SP6), Large Intestine 4 (LI4), and Gall Bladder 21 (GB21) from a research assistant or accredited midwife (Diagram1). . The participants also received a written instruction sheet with diagrams; a diary sheet to record use of acupressure points on a daily basis; and a CD with short Y-tube videos of the 3 acupressure points.

Figure 3: Gestation- Spontaneous labour

DATA COLLECTION Data was obtained from the hospital obstetric database (ObstetriX) and clinical records, including:

Clinical outcome measures for labour and birth including onset of labour (spontaneous or labour induction), mode of birth, length of labour and analgesia and other pain relief options used.

Funding Table 2: Mode of Birth (n=44)

Survey: To explore women’s experiences of participating in an RCT, and the use of any natural strategies to ‘induce’ labour. For woman randomised to the acupressure intervention, the participants completed additional questions on compliance with using the three points during pregnancy, and if they were also used during labour and any partner involvement with the acupressure points. The women were asked to return their completed diary sheet with their survey for review of compliance with intervention protocol. Focus groups: Conducted with staff (midwives and medical staff) to examine the acceptability of complementary and alternative therapies such as acupressure in mainstream maternity care and treatment of pregnancy related conditions and views on the randomised controlled trial. DATA ANALYSIS Data was analysed using the Statistical Package for Social Science V19.0 (SPSS). Multivariate analyses tested for differences between groups of women. Categorical data was analysed using Chi Square and Fisher’s exact test (due to the small sample size). Demographic and patient survey data was analysed using univariate descriptive analysis.

Our findings should be interpreted with caution as the study was underpowered. The study demonstrated acceptability by women with acupressure, participation in the trial and compliance with completing questionnaires. Compliance with the acupressure was highly acceptable although challenges with women agreeing to be randomised was identified. An appropriately powered RCT is in future plans, contingent upon funding. Ethics Approval HREC/12/HWKE/281: ANZCTR:12613000145707

1. Demographic information including age, model of care, and past medical and surgical history 2.

Conclusion

Figure 4: Women’s Views on Participation in Study (29/44)

• • •

NSW Health Nursing and Midwifery Office (NaMO) Innovation Scholarship Central Coast Local Health District Research Small Grant Australian College of Midwives NSW Branch Scholarship

References 1.

NSW Health. 2010. Maternity- Towards Normal Birth Policy Directive 2010_045, Northern Sydney,

2.

NSW Australia. Chung, Hung, Kuo, Huang, 2003. Effects of LI4 & BL67 on labour pain and uterine contractions in the first stage of labour. Journal of Nursing Research, 11;4:251-9.

3.

Lee K, Chang S Kang D. 2004. Effects of SP6 acupressure on labour pain and length of delivery time in women during labour. Journal of Alternative & Complementary Medicine. l0, (6), Dec, 959-65.

4.

Ingram J, Domagala C, Yates S. 2005. The effects of shiatsu on post-term pregnancy. Complement aryTherapy Medicine. 13(1):11-5.

5.

Hamidzadeh A, et al. 2012. Effects of LI4 Acupressure on labour pain in the first stage of labour. Journal of Midwifery and Women’s Health, 57, (2), March/April, 133-38.

6.

Hjelmstedt A, Shenoy S, Stener-Victorin E, Lekander M, et al 2010. Acupressure to reduce labour pain: a randomised controlled trial. Acta Obstetricia et Gynecologica, 98:1453-1459.

7.

Kashanian & Shahali. 2010. Effects of acupressure at the SP6 on the process of active labour in nulliparas women. JMFNM 23,(7), 638-41

Affiliations 1.

CC Kids & Families, Central Coast Local Health District, NSW Australia

2.

University of Western Sydney, NSW Australia

3.

Charles Darwin University, Northern Territory Australia

4.

University of Technology , Sydney, NSW Australia

4a. Ph D Candidate, University of Technology Sydney NSW Australia