Acupuncture in Obstetrics

Dr. Kathryn Tian

Lecture in BC Women’s Hospital (2002)

·       Acupuncture Method Helps Prevent Breech Birth

1.        Effectiveness of acupuncture in preventing breech birth

2.        Explanation in Chinese medicine theory and modern research

·       Acupuncture Method HelpsControl Labor Pain

1.        Effectivenessof acupuncture in controlling labor pain

2.        Explanationin Chinese medicine theory and modern research

Moxibustionfor Correction of Breech Presentation

A Randomized Controlled Trial

Francesco Cardini, MD; HuangWeixin, MD

Context. Traditional Chinese medicineuses moxibustion (burning herbs to stimulate acupuncture points) of acupoint BL67 (Zhiyin, located beside the outer corner of the fifth toenail), to promoteversion of fetuses in breech presentation. Its effect may be through increasingfetal activity. However, no randomized controlled trial has evaluated theefficacy of this therapy.

Objective. To evaluate the efficacy andsafety of moxibustion on acupoint BL 67 to increase fetal activity and correctbreech presentation.

Design. Randomized, controlled, openclinical trial.

Setting. Outpatient departments ofthe Women's Hospital of Jiangxi Province, Nanchang, and Jiujiang Women's andChildren's Hospital in the People's Republic of China.

Patients. Primigravidas in the 33rdweek of gestation with normal pregnancy and an ultrasound diagnosis of breechpresentation.

Interventions.The 130subjects randomized to the intervention group received stimulation of acupointBL 67 by moxa (Japanese term for Artemisia vulgaris) rolls for 7 days,with treatment for an additional 7 days if the fetus persisted in the breechpresentation. The 130 subjects randomized to the control group received routinecare but no interventions for breech presentation. Subjects with persistentbreech presentation after 2 weeks of treatment could undergo external cephalicversion anytime between 35 weeks' gestation and delivery.

Main OutcomeMeasures. Fetalmovements counted by the mother during 1 hour each day for 1 week; number ofcephalic presentations during the 35th week and at delivery.

Results. The intervention groupexperienced a mean of 48.45 fetal movements vs 35.35 in the control group (P<.001; 95% confidence interval [CI]for difference, 10.56-15.60). During the 35th week of gestation, 98 (75.4%) of130 fetuses in the intervention group were cephalic vs 62 (47.7%) of 130fetuses in the control group (P<.001;relative risk [RR], 1.58; 95% CI, 1.29-1.94). Despite the fact that 24 subjectsin the control group and 1 subject in the intervention group underwent externalcephalic version, 98 (75.4%) of the 130 fetuses in the intervention group werecephalic at birth vs 81 (62.3%) of the 130 fetuses in the control group (P=.02; RR, 1.21; 95% CI, 1.02-1.43).

Conclusion. Among primigravidas withbreech presentation during the 33rd week of gestation, moxibustion for 1 to 2weeks increased fetal activity during the treatment period and cephalicpresentation after the treatment period and at delivery.

JAMA.1998;280:1580-1584

The Mechanism of the Action of Moxibustionon Preventing Breech Presentation

------Western Medicine Explanation

1.     KineticExplanation ------ Active Fetal Movements

“Regarding the efficacy ofthe moxibustion treatment in producing an increase in fetal motility,comparison between the 2 groups proved possible for only the first week oftreatment (or observation) because all the subjects in the intervention groupwho achieved cephalic version in the first week of treatment filled in only thefirst of the 2 record forms used for the weekly AFM counts. The mean value forfetal movements recorded during a 1-hour observation period for 7 days was 48.45for the subjects in the intervention group and 35.35 for the subjects in thecontrol group (difference, 13.08; 95% CI, 10.56-15.60; t test, 10.215; P<.001).”------ JAMA. 1998;280:1580-1584

“The mechanism of action ofmoxibustion appears to be through increased AFMs, which proved significantlystronger in the treated subjects. Although a number of studies in China^{11, 12, 21}have investigated the neurologic path of stimulation by moxibustion and haveshown evidence of its effect on maternal plasma cortisol and prostaglandins, wethink that the mechanism of action of moxibustion is not entirely clear andwarrants further research.” ------ JAMA.1998;280:1580-1584

2.     Relationshipwith the Hormonal Changes

“Determine the urine17-hydroxycorticosteroid, urine17-ketosteroid andplasma cortisol, the researchers found that all of them were significantlyhigher after the moxibustion treatment. It implies that the moxibustiontreatment can stimulate the pituitary-adrenocortical system so that it canincrease the motility of the uterus. And then the fetal movement will alsoincrease.” ------ Yang Jiasan. Acupunctureand Acupoints. Shanghai Science and Technology Press. Pp288-289

3.     Relationship with the Nervous System

“HRP(horse radish peroxidase) has special absorptioncapacity on nerve trunk and nerve ending. Implant the HRP dry powder into thepoint of rabbit’s which is analogous to ZhiYin(BL67) point on human being, wefound that there were enzyme labeled cells in the posterior-root neuroganglionsof L2-S1. Implant the HRP dry powder under the uterine serosa of rabbit, wefound that there were enzyme labeled cells in the posterior-root neuroganglionsof T11-S3. At the same time, we found that the sensation segmental dominationof            ZhiYin(BL67) was in therange of the sensation segmental domination of the uterine serosa and 7segments were overlapped. Stimulate the ZhiYin(BL67) point can increase theactivity of the uterus, relax the abdominal muscles and increase the motilityof the fetus. Thus, the position change can be achieved.” ------ Yang Jiasan. Acupuncture and Acupoints.Shanghai Science and Technology Press. Pp288-289

The Mechanism of the Action of Moxibustionon Preventing Breech Presentation

------Chinese Medicine Explanation

1.     WangLiZao.Comprehensive Chinese AcupuncturePrescription. Jianxi Science and Technology Press. Pp606

“ZhiYin point belongs to the bladder meridian offoot TaiYang. It is the Jing(Well) point and the Gen(Root) point of themeridian. The Qi of the bladder meridian can activate the circulation of Qi andblood of the whole body. The foot TaiYang meridian connects with itsinterior-related meridian --- the kidney meridian of foot ShaoYin. Fetus isnourished by the kidney Qi. Moxibustion of ZhiYin point can regulate the kidneyQi so as to correct the fetal position.”

2.     LiuGuanJun.Modern Acupuncture Cases.People’s Health Press. Pp350

“Moxibustion of ZhiYin can regulate the fetus Qi isbecause that ZhiYin is the Jing(Well) point of the bladder meridian. Thebladder and kidney has the interior-exterior relationship and the bladder is anorgan of water. If we moxibust the Jing point of the bladder meridian, we canactivate the Yang Qi and improve the transformative action of Qi. This willbenefit the circulation of body fluid and then the fetus Qi can be regulated.”

3.      YangJiasan. Acupuncture and Acupoints.Shanghai Science and Technology Press. Pp288-289

“Zhi means ‘arrive, get to, reach’; Yin refers tothe kidney meridian of foot ShaoYin. The point is at the tip of the little toe.The Qi of the foot TaiYang meridian connects to the kidney meridian of footShaoYin at this point. That is why it is called ZhiYin.”

“ZhiYin, the root of foot TaiYang, connects deeplyto foot ShaoYin. ZhiYin connects to YongQuan obliquely so that the Qi canarrive at Yin level from Yang level and that is why it called ZhiYin. (HuiYuan Acupuncture)”

“ZhiYin is the ending point of the Qi of footTaiyang. From this point, the Qi connects to the kidney meridian of footShaoYin. It implies that the YangQi has ended and the Yin Qi is starting togrow. From here, the Qi goes into the Yin meridian. That is how the name ofZhiYin comes.(Explanation of the Namesof Acupoints.)”

What is ZhiYin (BL67) point?

------Acupuncture and Moxibustion. NewWorld Press. Pp64

ZhiYin (a Jing point, BL67)

Location: On the lateral side of the small toe,about 0.1 cun to the corner of the toe nail.

Indications: Headache, nasal stuffiness,ophthalmalgia, abnormal fetal position, difficult labor and retention ofplacenta.

Method: Insert the needle 0.1 cun into the skin.

Notes: (1) ZhiYin is often used for abnormal fetalposition, either with acupuncture or moxibustion. Clinical reports show thatusing laser onto ZhiYin can help treat abnormal fetal position with a successrate of 76.26%. Some scholars believe that acupuncture and moxibustion promoteuterine and fetal activities and relax abdominal muscle, which help the fetalposition becomes normal. (2) Vasculature: The arterial network formed by dorsaldigital artery of foot and proper digital plantar artery. Innervation: Properdigital plantar nerve and lateral dorsal cutaneous nerve of foot.

What is Jing Point?

------ Acupuncture and Moxibustion. NewWorld Press. Pp5

“Five Shu Points” refer to the five specificacupoints of the twelve regular meridians located below the elbow or kneejoints, namely, jing(well), ying(spring), shu(stream), jing(river) and he(sea)points. They are located from the tips of fingers and toes to the elbow andknee. Ancient physicians compared the flow of Qi in the meridians to that ofwater, which explains its movement from the surface to the deep in a growingquantity.

Jing points are the places where the Qi of themeridians starts to flow, just like the water coming out of a well. Ying pointsare where the Qi of the meridian starts to flourish, like the water in aspring. Shu points are the places where the Qi of the meridians flourishes andrushes out, just like the water flowing in a stream. Jing points are where theQi of the meridians flows like the water in a river. He points are where the Qiof the meridians accumulates like the confluence of rivers into a sea.

ACUPUNCTURE FOR PAINLESS LABOR

Pei De'en, Huang Yaolan.

(Nanjing Maternity andChildren Health Hospital, Jiangsu)

Since 1972, investigation of pain relief byacupuncture in labor was carried out in this hospital. This paper is to reportour clinical experience in 200 cases in 1978 and 1981. Selection of points wasbased on the location of pain. Bilateral Ciliao(BL32) was selected as mainpoint for lumbo-sacral ache. Puncturing from Fujie(SP14) to Qichong(ST30) forabdominal pain associated with lumbo-sacral ache. The electric acupunctureapparatus was G6805 with continuous wave which had a pulse output voltage of3-5 volts. The  frequency of 4000/minwas for Ciliao(BL32) and 1500-5000/min for penetrating FuJie(SP14 ) toQichong(ST30). Stimulation was given with increasing intensity and frequentreadjustment. Acupuncture was used in primiparas when the cervix was 3-4 cmdilated, and in multiparas when the cervix was 50px dilated. Two hundred caseswere treated and the pain in 85 cases was completely relieved (Grade I) whilethe pain in 107 cases was markedly relieved (Grade II). Grade I and grade IIresults were categorized as effective, giving an effective rate of 96%. Therewere 8 cases with grade III result (no effect). In respect to its effect onuterine contraction, 138 cases showed enhancement following acupuncture and 59cases showed no change, no data were available in 3 cases. Weakening of uterinecontraction was not noticed. Regarding to the effect on new born, there was nocase of asphyxia after acupuncture treatment which implies that acupuncture didnot adversely affect the new born.

Based on ourtrial of acupuncture for painless labor, we believe that acupuncture mayproduce nerve impulses which may travel along the peripheral nerves to lateralfuniculus of the spinal cord and finally to the brain. This will interact withthe pain impulses from uterus to result in pain relief. Acupuncture may alsostimulate the body to release certain chemical substance to raise the painthreshold and the cerebral cortex to exert function of suppression andadjustment of nerve, resulting in coordination with uterine contractions andshortening the course of labor. According to traditional Chinese medicine, themeridian system connects the internal viscera with the external extremities andit is effective for treating diseases if points are selected according to thecirculation of meridians.

DoesAcupuncture Affect Labor and Delivery?

By Tim Gorski, MD

Review of: Tempfer, C., Zeisler, H., Heinzl, H.,Hefler, L., Husslein, P., Kainz, C.H. Influence of Acupuncture on MaternalSerum Levels of Interleukin-8, Prostaglandin F2alpha, and Beta-Endorphin: AMatched Pair Study. Obstet Gynecol.1998; 92:245-248.

“A Viennese research team reported last year that"prenatal acupuncture treatment significantly reduced the duration oflabor and may be proposed as a valuable tool in prenatal preparation."^[1]Their claim is based on an unblinded matched case study, which involvedcomparing 40 women who had four weekly acupuncture sessions in the last monthof their pregnancies with another group of women of similar age and parity(number of previous children, if any) who gave birth at about the same time.The authors assessed intrapartum blood pressures, length of the first andsecond stages of labor, use of oxytocin and analgesics, frequency of episiotomyand/or lacerations, birth weight, and umbilical cord pH in an effort todemonstrate that acupuncture could affect these variables. Also measured wereserum levels of interleukin-8 and prostaglandin F2 hormones thought to beimportant in cervical ripening and preparation for labor, as well as serumlevels of endorphin, a demonstrated marker of the pain and stress of humanparturition.^[2]

The authors reported that there were no differencesbetween the acupuncture and control groups for any of the measured variablesexcept for the length of the first stage of labor. Among those who received theacupuncture, the first stage of labor was said to be an average of more thantwo hours with P<.001 on a paired t test. This formed the basis of theauthors' major conclusion. Several of the same authors of this report publisheda similar case-control study in which they also purported to show that theacupuncture-treated patients required less oxytocin during labor.^[3]

There are several serious difficulties with thisreport. The most troublesome is the authors' arbitrary selection of 3 cmdilation for the beginning of the first stage of labor. “

“In addition, a large number of other factors mayinfluence the duration of labor, and particularly the latent phase of the firststage of labor. One of these is obstetric analgesia. Although the authors ofthis report, interestingly enough, do not seem troubled by the fact that thepatients who received acupuncture did not have a reduced need for analgesics,these women may have received it later than those in the matched group if therewas an expectation that less analgesia would be necessary. This information is,unfortunately, not provided. “

“Sadly, this work and others like it are predictablyseized upon as validating the "chi energy" notions of a prescientificvitalistic philosophy of medicine. This is untrue, of course. But the elementof acupuncture in this setting does have the unfortunate effect of distorting,distracting from, and confusing more rational and well-substantiated ideasabout the still-to-be-discovered anatomical, physiological, psychological, andbiochemical details of human parturition. “

CiLiao(BL32)

Location: On the sacrum, medial and inferior to theposterosuperior iliac spine, just at the second posterior sacral foramen.

Indications: Lumbosacral pain, irregularmenstruation, leukorrhagia, impotence, seminal emission, hernia, numbness andpain in the lower limbs.

Method: Insert the needle perpendicularly, 1-1.2 candeep.

Notes: Vasculature: The posterior branches of thelateral sacral artery and vein. Innervation: The posterior ramus of the secondsacral nerve.

FuJie(SP14)

Location: On the lower abdomen, 4 cun lateral to theanterior midline and 1 cun below the center of umbilicus.

Indications: Pain around the umbilicus, diarrhea andhernia.

Method: Insert the needle perpendicularly, 1-1.2 cundeep.

Notes: Vasculature: The 11th intercostal artery andvein. Innervation: The 11th intercostal nerve.

QiChong(ST30)

Location: 5 cun below the umbilicus and 2 cun lateralto the anterior midline.

Indication: Lower abdominal pain, hernia, irregularmenstruation, dysmenorrhea, impotence and swollen vulva.

Method: Insert the needle perpendicularly, 0.5-1 cundeep.

Notes: Vasculature: The branches of superficialepigastric artery and vein, and inferior epigastric artery and vein.Innervation: Ilioinguinal nerve.

Mechanism of the Effectiveness of Acupuncture on Treating Pain

------ Dr. Ruth Kidson. Acupuncture for Everyone.Pp152-153

1.     Nervous System Theory

“What is interesting is that in the nervous systemtheory of acupuncture, depending on which part of the body is stimulated, thenervous impulses that seem to be responsible for producing the effect appear tobe carried in different ways. It is therefore difficult to propound an overalltheory explaining in western terms how acupuncture works.

For example, experimentshave been performed in which stimulation of the skin on the back of ratsproduced changes in their intestines. The results were found to be the samewhether a rat’s nervous system was intact or its spinal cord had been divided,cutting off the body from the brain. From this it was deduced that brain wasnot involved, and that all the nervous impulses controlling the effects ofstimulation were carried by the spinal cord. However, a similar experimentperformed on fish, where stimulation of the lower part of the bowel producedchanges in the skin was found to be effective even if the spinal cord had beendestroyed. In this case, a different mechanism seemed to be involved, theeffects apparently being produced by the sympathetic nervous system.”

2.     EmbryoTheory

“ In his book Acupuncture: The Ancient Chinese Art ofHealing, Felix Mann puts forward the theory that the responses obtainedin various organs of the body when points on the skin are stimulated tie inwith the way in which the body develops as an embryo. Each section of the body,together with its nerve supply, develops from a different section of theembryo. Physicians call these sections dermatomes. Very often both an organ andthe acupuncture points that affect it lie in the same dermatome. However, Mannpoints out that the “acupuncture points of the legs and head do not fit in withwhat is known of dermatomes.” This means that another theory has to be found toexplain how acupuncture works in these parts of the body.”

3.     EndorphinTheory

“While the medicalprofession struggles to understand how acupuncture works, acupuncture as amethod of pain relief has become quite respectable thanks to the discovery ofendorphins.

Endorphins are substancesproduced by the body that have the effect of controlling pain. Secretion oflarge amounts of endorphins occurs automatically in response to severe pain ---for instance, during childbirth and after serious injury. It would appear thatthe level of endorphins circulating in the bloodstream under normal conditionsvaries from person to person. This may explain why different people havedifferent pain thresholds, some being able to tolerate pain far more readilythan others.

Stimulation of acupuncturepoints that produce anesthetic effects has been shown to release endorphinsinto the body. What has not been explained – at least not in Western terms – iswhy stimulation of these particular points and not others produces theseeffects.”

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