Volume 10, Issue 2 (5-2022)
Jorjani Biomed J 2022, 10(2): 45-52 |
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Hosseini Marznaki Z, alimoradi Z, Hakimi M H, Haghighi M, Karkhah S. The Effect of Auricular Acupressure on Postpartum Perineal Pain: A Systematic Review. Jorjani Biomed J 2022; 10 (2) :45-52
URL: http://goums.ac.ir/jorjanijournal/article-1-896-en.html
URL: http://goums.ac.ir/jorjanijournal/article-1-896-en.html
Zohreh Hosseini Marznaki1 
, Zainab Alimoradi2 , Mohammad Hossein Hakimi3 , Maryam Haghighi4 , Samad Karkhah 5
, Zainab Alimoradi2 , Mohammad Hossein Hakimi3 , Maryam Haghighi4 , Samad Karkhah 5
1- Department of Nursing, Amol Faculty of Nursing and Midwifery Sciences, Mazandaran University of Medical Sciences, Sari, Iran.
2- Social Determinants of Health Research Center, Research Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran
3- Department of Nursing, School of Nursing and Midwifery, Ardabil University of Medical Sciences, Ardabil, Iran
4- Emam Reza Hospital, Mazandaran University of Medical Sciences, Sari, Iran.
5- 1. Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran.2. Burn and Regenerative Medicine Research Center, Guilan University of Medical Sciences, Rasht, Iran. , sami.karkhah@yahoo.com
2- Social Determinants of Health Research Center, Research Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran
3- Department of Nursing, School of Nursing and Midwifery, Ardabil University of Medical Sciences, Ardabil, Iran
4- Emam Reza Hospital, Mazandaran University of Medical Sciences, Sari, Iran.
5- 1. Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran.2. Burn and Regenerative Medicine Research Center, Guilan University of Medical Sciences, Rasht, Iran. , sami.karkhah@yahoo.com
Keywords: Complementary Therapies [MeSH], Acupuncture, Ear [MeSH], Postpartum Period [MeSH], Pain [MeSH]
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Discussion
The present study aimed to comprehensively review the available research literature regarding the effect of auricular acupressure on postpartum perineal pain. Based on the findings of this review, auricular acupressure in one of three studies had a significant effect on reducing postpartum perineal pain. Two of three studies reported no side effects of auricular acupressure for participants. However, future studies are needed to confirm the findings of this systematic review.
As the findings of this study showed, auricular acupressure in one of three studies had a significant effect on reducing postpartum perineal pain. Consistent with this finding, an overview of systematic reviews showed that auricular therapy had positive results on pain, but acupuncture, acupressure, and electrical acupuncture were associated with different therapeutic effects (19). A study in Denmark found that auricular acupressure was less effective in reducing pain during surgical repair than local anesthetics (20). Also, a randomized prospective study showed that auricular therapy could reduce the severity of Arthroscopic Meniscectomy pain that was not significant (21). Another study in the USA found that auricular therapy had no significant effect on reducing pain in patients with low back pain (22). In fact, a variety of treatments, including acupuncture/acupressure, electronic acupuncture, and the use of different needles, will lead to different treatment outcomes. Therefore, using the same pattern and the correct method may solve this challenge (19, 23). However, some published studies have reported the effectiveness of auricular therapy on pain management (24-26). A systematic review and meta-analysis showed that auricular therapy affects the severity of acute and chronic pain (24). Another study showed that auricular therapy is effective in a variety of chronic, acute, pre-, and post-operative pain and trauma pain as a simple, inexpensive, effective, and low-risk intervention (25). Also, other review results showed that the use of auricular point acupressure in combination with other interventions, regardless of the severity of pain, better cures acute pain and compared to chronic pain, requires a shorter treatment period (26). Therefore, more scientific evidence is needed for the efficacy of auricular acupressure on postpartum perineal pain.
Limitations
The main limitation of the present study is the lack of meta-analysis due to the limited number of studies. Also, the limited number of studies may affect the outcome of this systematic review.
Implications for practice
Auricular acupressure can be used as a non-pharmacological intervention with no side effects to reduce postpartum perineal pain in the clinic. Also, auricular acupressure is a simple, low-cost, and practical intervention that can be used as an alternative to pharmacological interventions.
Implications for future research
Limited studies have evaluated the effect of auricular acupressure on postpartum perineal pain. Therefore, it is suggested that future researchers design well-designed interventions in this area.
Conclusion
Overall, auricular acupressure in one of three studies had a significant effect on reducing postpartum perineal pain. Also, two of three studies reported no side effects of auricular acupressure for participants. Therefore, it seems that auricular acupressure can be used as a simple, low-cost, and practical intervention to reduce postpartum perineal pain. However, future well-designed studies are needed to confirm the findings of this systematic review.
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Introduction
The episiotomy is a surgical incision of the perineal muscles that is carried out to enlarge the soft tissue space of the inferior pelvic aperture, avert perineal injuries during delivery, facilitate it, and reduce the time of fetal descent at the end of the second stage of delivery (1). The episiotomy is related to some adverse effects/outcomes such as fatigue, post-procedure pain, insomnia, and difficulty in sitting and hugging the baby (2, 3). Perineal pain is the most common and early problem of episiotomy (4). Since this pain delays, the mother's closeness to the baby (even prevent the mother-baby emotional relationship) and unable the mother to care for the baby (5), the pain caused by the episiotomy must be minimized so that the mother can do the role of mother in peace and without stress (6).
There are various medical and non-pharmacological methods that can be used to decrease perineal pain (7). Due to side effects, many of the medications may have an adverse effect on the baby (8). Therefore, the use of non-pharmacological therapies, such as complementary medicine has been recommended due to their proven effectiveness and having a holistic care approach (9). However, the information published on non-pharmacological methods used to control pain after episiotomy is rare. Acupressure is a non-pharmacological method based on the principles of acupuncture (10). Ear therapy or auricular therapy as part of acupressure includes the use of the ear and its relationship with different parts of the body in the diagnosis and treatment of diseases (11), which returns the body to a harmonious and balanced state. By stimulating the ear parts, its benefits can be enjoyed for days and even weeks (12).
In a large number of clinical studies, the positive effects of auricular therapy have been confirmed, but a limited number of researchers have discussed the effects of auricular therapy on reducing pain after episiotomy. Since non-pharmacological interventions such as auricular therapy are safe, low risk, and have minimal side effects in controlling pain after episiotomy, further study and review of the literature in this field is necessary. Therefore, this study aimed to comprehensively review the available research literature regarding the effect of auricular acupressure on postpartum perineal pain.
Materials and Methods
The systematic review was performed based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (13).
Search strategy
An extensive systematic search was performed on online electronic databases, including Scopus, PubMed/MEDLINE, ProQuest, Web of Science, and Cochrane via keywords extracted from Medical Subject Headings from the earliest to June 30, 2021. Keywords were selected based on the PICO style (Participants, Intervention, Comparison, and Outcome) to answer the research question. In this study, auriculotherapy was selected as an intervention, and postpartum perineal pain was selected as the outcome. The search syntax was customized based on the specific attributes of each database. For example, the search strategy in the PubMed/MEDLINE database was (“Impact” OR “Effect” OR “Improve” OR “Influence” AND “Intervention”) AND (“Postpartum Period” OR “Labor Pain” OR “Obstetric Pain”) AND (“Auriculotherapy” OR “Auricular Acupuncture” OR “Ear Acupuncture” OR “Auricular Acupressure” OR “Ear Acupressure”). The language of the studies was limited to English. The search process was conducted by two researchers, independently. In the present study, the gray literature including conference presentations, expert opinion, dissertations, research and committee reports, and ongoing research was ignored due to inaccurate results (14).
Inclusion and exclusion criteria
Published English experimental studies focusing on the effect of auricular acupressure on postpartum perineal pain were included in this systematic review. Observational studies, letters to the editor, case reports, conferences, qualitative studies, and reviews were excluded.
Study selection
Data management was performed using EndNote X8 software. The study selection process was conducted in the following steps: 1) removal of duplicates, 2) evaluation of the title and abstract of studies, and 3) evaluation of the full text of the articles. The reference list of included studies was assessed to prevent the loss of relevant data.
Data extraction and quality assessment
Information such as first author name, year of publication, location, sample size, male/female ratio, age, design, and aim (s) of the study, interventions, and key findings of studies was extracted from the included studies. The risk of bias was assessed for the included studies using the Cochrane Risk of Bias Assessment Tool. This tool evaluates selection bias (random sequence generation and allocation concealment), performance bias (blinding of participants and personnel), detection bias (blinding of outcome assessment), attrition bias (incomplete outcome data), and reporting bias (selective reporting), other biases (15). Two researchers assessed the risk of bias for the included studies, independently.
Results
Study Selection
In total, 263 articles were obtained through initial database searches and three articles were found by hand-searching of the references. After evaluating duplicate records, 33 studies were excluded. After evaluating the title, abstract, and full text of the articles, three studies (16-18) were included in this systematic review (Figure 1).
Study Characteristics
A total of 386 women with a mean age of 29.79 years were included in the systematic review. All studies had a Randomized Control Trial (RCT) design. Of the participants, 192 women were in the intervention group. In two studies (17, 18) only the visual analogue scale (VAS) was used to assess pain and in one study (16) the verbal descriptive pain scale (VDPS) and VAS were used. Of the included studies, one study (18) was conducted in the USA, one study (16) in Hong Kong, and one study (17) in Croatia (Table 1).
Quality assessment
Based on the Cochrane Risk of Bias Assessment Tool, two studies (16, 18) had a low risk of bias and one study (17) had a high risk of bias (Figures 2 and Table 1).
The episiotomy is a surgical incision of the perineal muscles that is carried out to enlarge the soft tissue space of the inferior pelvic aperture, avert perineal injuries during delivery, facilitate it, and reduce the time of fetal descent at the end of the second stage of delivery (1). The episiotomy is related to some adverse effects/outcomes such as fatigue, post-procedure pain, insomnia, and difficulty in sitting and hugging the baby (2, 3). Perineal pain is the most common and early problem of episiotomy (4). Since this pain delays, the mother's closeness to the baby (even prevent the mother-baby emotional relationship) and unable the mother to care for the baby (5), the pain caused by the episiotomy must be minimized so that the mother can do the role of mother in peace and without stress (6).
There are various medical and non-pharmacological methods that can be used to decrease perineal pain (7). Due to side effects, many of the medications may have an adverse effect on the baby (8). Therefore, the use of non-pharmacological therapies, such as complementary medicine has been recommended due to their proven effectiveness and having a holistic care approach (9). However, the information published on non-pharmacological methods used to control pain after episiotomy is rare. Acupressure is a non-pharmacological method based on the principles of acupuncture (10). Ear therapy or auricular therapy as part of acupressure includes the use of the ear and its relationship with different parts of the body in the diagnosis and treatment of diseases (11), which returns the body to a harmonious and balanced state. By stimulating the ear parts, its benefits can be enjoyed for days and even weeks (12).
In a large number of clinical studies, the positive effects of auricular therapy have been confirmed, but a limited number of researchers have discussed the effects of auricular therapy on reducing pain after episiotomy. Since non-pharmacological interventions such as auricular therapy are safe, low risk, and have minimal side effects in controlling pain after episiotomy, further study and review of the literature in this field is necessary. Therefore, this study aimed to comprehensively review the available research literature regarding the effect of auricular acupressure on postpartum perineal pain.
Materials and Methods
The systematic review was performed based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (13).
Search strategy
An extensive systematic search was performed on online electronic databases, including Scopus, PubMed/MEDLINE, ProQuest, Web of Science, and Cochrane via keywords extracted from Medical Subject Headings from the earliest to June 30, 2021. Keywords were selected based on the PICO style (Participants, Intervention, Comparison, and Outcome) to answer the research question. In this study, auriculotherapy was selected as an intervention, and postpartum perineal pain was selected as the outcome. The search syntax was customized based on the specific attributes of each database. For example, the search strategy in the PubMed/MEDLINE database was (“Impact” OR “Effect” OR “Improve” OR “Influence” AND “Intervention”) AND (“Postpartum Period” OR “Labor Pain” OR “Obstetric Pain”) AND (“Auriculotherapy” OR “Auricular Acupuncture” OR “Ear Acupuncture” OR “Auricular Acupressure” OR “Ear Acupressure”). The language of the studies was limited to English. The search process was conducted by two researchers, independently. In the present study, the gray literature including conference presentations, expert opinion, dissertations, research and committee reports, and ongoing research was ignored due to inaccurate results (14).
Inclusion and exclusion criteria
Published English experimental studies focusing on the effect of auricular acupressure on postpartum perineal pain were included in this systematic review. Observational studies, letters to the editor, case reports, conferences, qualitative studies, and reviews were excluded.
Study selection
Data management was performed using EndNote X8 software. The study selection process was conducted in the following steps: 1) removal of duplicates, 2) evaluation of the title and abstract of studies, and 3) evaluation of the full text of the articles. The reference list of included studies was assessed to prevent the loss of relevant data.
Data extraction and quality assessment
Information such as first author name, year of publication, location, sample size, male/female ratio, age, design, and aim (s) of the study, interventions, and key findings of studies was extracted from the included studies. The risk of bias was assessed for the included studies using the Cochrane Risk of Bias Assessment Tool. This tool evaluates selection bias (random sequence generation and allocation concealment), performance bias (blinding of participants and personnel), detection bias (blinding of outcome assessment), attrition bias (incomplete outcome data), and reporting bias (selective reporting), other biases (15). Two researchers assessed the risk of bias for the included studies, independently.
Results
Study Selection
In total, 263 articles were obtained through initial database searches and three articles were found by hand-searching of the references. After evaluating duplicate records, 33 studies were excluded. After evaluating the title, abstract, and full text of the articles, three studies (16-18) were included in this systematic review (Figure 1).
Study Characteristics
A total of 386 women with a mean age of 29.79 years were included in the systematic review. All studies had a Randomized Control Trial (RCT) design. Of the participants, 192 women were in the intervention group. In two studies (17, 18) only the visual analogue scale (VAS) was used to assess pain and in one study (16) the verbal descriptive pain scale (VDPS) and VAS were used. Of the included studies, one study (18) was conducted in the USA, one study (16) in Hong Kong, and one study (17) in Croatia (Table 1).
Quality assessment
Based on the Cochrane Risk of Bias Assessment Tool, two studies (16, 18) had a low risk of bias and one study (17) had a high risk of bias (Figures 2 and Table 1).
Figure 1. Flow diagram of the studies
Figure 2. Methodological quality assessment of included studies
Table 1. Basic characteristics of the studies included in the systematic review
VAS: Visual Analogue Scale; VDPS: Verbal Descriptive Pain Scale; RCT: Randomized Control Trial; SD: Standard Deviation.
The effect of auricular acupressure on postpartum perineal pain
In this systematic review, three studies (16-18) assessed the effect of auricular acupressure on postpartum perineal pain. Of the studies included, two studies (16, 17) evaluated auricular acupressure and one study (18) evaluated Battlefield Auricular Acupuncture plus standard analgesia (Table 2).
1. Auricular acupressure: In one study, participants in the intervention group received an application of tapes and seeds of Vaccaria segetalis Garcke on four designated acupressure points on both ears. The apex of the auricle and the Shen Men points were used to relieve pain and inflammation. Anus and external genital organs points were also used for their correspondence to the anatomical regions. Participants received the same number of seeds. Four adhesive tapes of size 6×6 mm were used to secure one seed to each stimulation point. The intervention was performed every four hours for 30 seconds (16). In another study, auricular acupuncture was performed using three needles on the dominant ear based on French auriculotherapy guidelines at three points including the internal genital area, external genital area, and Shen Men. Sterile 0.2 × 1.4 mm press needles were used for auricular acupuncture 6 to 8 hours after childbirth by a certified acupuncturist (17).
2. Battlefield Auricular Acupuncture plus standard analgesia: One study (18) evaluated Battlefield Auricular Acupuncture plus standard analgesia. In the intervention group, a qualified physician placed semi-permanent acupuncture needles into all five standard Battlefield Auricular Acupuncture points (Point Zero, Shen Men, Thalamic point, Omega 2, and Cingulate Gyrus) bilaterally for a total of ten needles. Patients were followed up once daily for 10 days (18).
The number of acupressure points varied from 3 to 5 (16-18). In most cases, auricular acupressure was used at points of Shen Men (n=3) (16-18) and the external genital area (n=2) (16, 17). Overall, auricular acupressure in one study had a significant effect on reducing postpartum perineal pain (17). Two studies (17, 18) reported no side effects of auricular acupressure for participants (Table 2).
In this systematic review, three studies (16-18) assessed the effect of auricular acupressure on postpartum perineal pain. Of the studies included, two studies (16, 17) evaluated auricular acupressure and one study (18) evaluated Battlefield Auricular Acupuncture plus standard analgesia (Table 2).
1. Auricular acupressure: In one study, participants in the intervention group received an application of tapes and seeds of Vaccaria segetalis Garcke on four designated acupressure points on both ears. The apex of the auricle and the Shen Men points were used to relieve pain and inflammation. Anus and external genital organs points were also used for their correspondence to the anatomical regions. Participants received the same number of seeds. Four adhesive tapes of size 6×6 mm were used to secure one seed to each stimulation point. The intervention was performed every four hours for 30 seconds (16). In another study, auricular acupuncture was performed using three needles on the dominant ear based on French auriculotherapy guidelines at three points including the internal genital area, external genital area, and Shen Men. Sterile 0.2 × 1.4 mm press needles were used for auricular acupuncture 6 to 8 hours after childbirth by a certified acupuncturist (17).
2. Battlefield Auricular Acupuncture plus standard analgesia: One study (18) evaluated Battlefield Auricular Acupuncture plus standard analgesia. In the intervention group, a qualified physician placed semi-permanent acupuncture needles into all five standard Battlefield Auricular Acupuncture points (Point Zero, Shen Men, Thalamic point, Omega 2, and Cingulate Gyrus) bilaterally for a total of ten needles. Patients were followed up once daily for 10 days (18).
The number of acupressure points varied from 3 to 5 (16-18). In most cases, auricular acupressure was used at points of Shen Men (n=3) (16-18) and the external genital area (n=2) (16, 17). Overall, auricular acupressure in one study had a significant effect on reducing postpartum perineal pain (17). Two studies (17, 18) reported no side effects of auricular acupressure for participants (Table 2).
Table 2. Interventions of the studies included in the systematic review.
| First Author/year | Type of intervention | Number of acupressure points | Acupressure points | Description |
| Kwan et al., /2014 16 | Auricular acupressure | Four |
|
Participants in the intervention group received an application of tapes and seeds of Vaccaria segetalis Garcke on four designated acupressure points on both ears. The apex of the auricle and the Shen Men points were used to relieve pain and inflammation. Anus and external genital organs points were also used for their correspondence to the anatomical regions. Participants received the same number of seeds. Four adhesive tapes with size 6×6 mm was used to secure one seed to each stimulation point. The intervention was performed every four hours for 30 seconds. |
| Kim et al., /2019 18 | Battlefield Auricular Acupuncture plus standard Analgesia |
Five |
|
In the intervention group, a qualified physician placed semi-permanent acupuncture needles into all five standard Battlefield Auricular Acupuncture points bilaterally for a total of ten needles. Patients were followed up once daily for 10 days. |
| Jaić et al., /2019 17 | Auricular acupuncture | Three |
|
Auricular acupuncture was performed using three needles on the dominant ear based on French auriculotherapy guidelines at three points including internal genital area, external genital area, and Shen Men. Sterile 0.2 × 1.4 mm press needles were used for auricular acupuncture 6 to 8 hours after childbirth by a certified acupuncturist. |
Discussion
The present study aimed to comprehensively review the available research literature regarding the effect of auricular acupressure on postpartum perineal pain. Based on the findings of this review, auricular acupressure in one of three studies had a significant effect on reducing postpartum perineal pain. Two of three studies reported no side effects of auricular acupressure for participants. However, future studies are needed to confirm the findings of this systematic review.
As the findings of this study showed, auricular acupressure in one of three studies had a significant effect on reducing postpartum perineal pain. Consistent with this finding, an overview of systematic reviews showed that auricular therapy had positive results on pain, but acupuncture, acupressure, and electrical acupuncture were associated with different therapeutic effects (19). A study in Denmark found that auricular acupressure was less effective in reducing pain during surgical repair than local anesthetics (20). Also, a randomized prospective study showed that auricular therapy could reduce the severity of Arthroscopic Meniscectomy pain that was not significant (21). Another study in the USA found that auricular therapy had no significant effect on reducing pain in patients with low back pain (22). In fact, a variety of treatments, including acupuncture/acupressure, electronic acupuncture, and the use of different needles, will lead to different treatment outcomes. Therefore, using the same pattern and the correct method may solve this challenge (19, 23). However, some published studies have reported the effectiveness of auricular therapy on pain management (24-26). A systematic review and meta-analysis showed that auricular therapy affects the severity of acute and chronic pain (24). Another study showed that auricular therapy is effective in a variety of chronic, acute, pre-, and post-operative pain and trauma pain as a simple, inexpensive, effective, and low-risk intervention (25). Also, other review results showed that the use of auricular point acupressure in combination with other interventions, regardless of the severity of pain, better cures acute pain and compared to chronic pain, requires a shorter treatment period (26). Therefore, more scientific evidence is needed for the efficacy of auricular acupressure on postpartum perineal pain.
Limitations
The main limitation of the present study is the lack of meta-analysis due to the limited number of studies. Also, the limited number of studies may affect the outcome of this systematic review.
Implications for practice
Auricular acupressure can be used as a non-pharmacological intervention with no side effects to reduce postpartum perineal pain in the clinic. Also, auricular acupressure is a simple, low-cost, and practical intervention that can be used as an alternative to pharmacological interventions.
Implications for future research
Limited studies have evaluated the effect of auricular acupressure on postpartum perineal pain. Therefore, it is suggested that future researchers design well-designed interventions in this area.
Conclusion
Overall, auricular acupressure in one of three studies had a significant effect on reducing postpartum perineal pain. Also, two of three studies reported no side effects of auricular acupressure for participants. Therefore, it seems that auricular acupressure can be used as a simple, low-cost, and practical intervention to reduce postpartum perineal pain. However, future well-designed studies are needed to confirm the findings of this systematic review.
Type of Article: Review Article |
Subject:
General medicine
Received: 2022/03/16 | Accepted: 2022/05/28 | Published: 2022/06/13
Received: 2022/03/16 | Accepted: 2022/05/28 | Published: 2022/06/13
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