Sage Journals: Discover world-class research

Abstract

Introduction

Severe and unmanageable labor pain can adversely affect maternal and neonatal outcomes. Among non-pharmacological methods, acupressure is increasingly recognized for its intrapartum benefits; however, further supportive evidence is needed.

Objectives

This study aimed to investigate the effect of spleen 6 point (SP6) acupressure on the severity of labor pain, duration of labor, and women's satisfaction.

Methods

A quasi-experimental one-group pretest–posttest design was employed. The intervention was applied to 96 parturient women in a governmental hospital, following specific inclusion criteria. Data were collected using a structured interview questionnaire, a visual analogue pain scale, an observational checklist for labor progress, and a satisfaction assessment tool.

Results

The intensity of labor pain decreased following the application of SP6 acupressure across different stages of cervical dilation. Most participants experienced a shorter duration of both the active phase and second stage of labor compared to standardized references. Additionally, the majority of women reported satisfaction with the intervention.

Conclusion

SP6 acupressure could appear to be an effective non-pharmacological method for reducing the labor pain and could short the labor duration. It was also associated with a high level of maternal satisfaction.

Keywords

acupressure duration labor pain satisfaction severity SP6

Introduction

Labor is a spontaneous physiological process associated with intense and unique pain that differs significantly from other forms of pain in both origin and intensity. Unlike acute or chronic pain resulting from injury or disease, labor pain is physiological yet often described as one of the most severe experiences in a woman's life. It is primarily caused by uterine contractions, cervical changes, and pressure on the pelvic floor muscles and adjacent organs (Beyable et al., 2022).

Globally, approximately 140 million births occur annually (World Health Organization, 2018). In Egypt, an estimated 2.2 million babies are born each year. However, there is a growing concern regarding the high rates of non-medically indicated caesarean sections (CS), placing Egypt among the top five countries where CS rates exceed vaginal deliveries. This trend has prompted national directives to encourage vaginal births, aiming to reduce healthcare costs and mitigate maternal and neonatal risks such as respiratory distress, delayed breastfeeding, increased infections, and surgical complications (World Health Organization, 2021).

Pain intensity and prolonged labor are among the leading reasons why many women opt for caesarean delivery. Thus, ensuring effective labor management and pain relief is essential for promoting positive childbirth experiences and reducing CS rates. It is also a fundamental right for every laboring woman (Gönenç & Terzioǧlu, 2020).

Severe, time-bound, and progressively intensifying labor pain accompanied by emotional stress can adversely affect labor outcomes. Although pharmacological analgesia, particularly neuraxial modality, is widely accepted for its efficacy, it may be linked with adverse perinatal outcomes where it can prolong the duration of labor with a greater frequency of obstetric interventions and can also be associated with intrapartum fever, dural puncture, and postpartum headache. Conversely, non-pharmacological methods, including acupressure, present safer alternatives, especially for women who prefer to avoid medication (Souza et al., 2024; Zuarez-Easton et al., 2023).

Midwives play a central role in implementing non-pharmacological pain management strategies during labor. Among these, acupressure—based on traditional Chinese medicine—has gained attention. This technique involves applying finger pressure on specific acupoints to stimulate the flow of “Qi” (vital energy) through meridians, enhancing physiological function and alleviating symptoms such as pain (Karimi et al., 2020; Raana & Fan, 2020).

The analgesic effect of acupressure can be explained by the gate control theory, which supposes that stimulation of thick sensory nerve fibers can inhibit pain transmission by blocking nociceptive signals at the spinal cord level (Melzack & Wall, 1996; Ropero Peláez & Taniguchi, 2016). Additionally, acupressure may stimulate the release of endogenous opioids such as endorphins, further contributing to pain relief (Altınayak & Özkan, 2022; Karimi et al., 2020).

spleen 6 point (SP6), also known as the Sanyinjiao point, is one of the most frequently utilized acupoints in labor management. It is located at the junction of the spleen, liver, and kidney meridians, and is believed to influence uterine contractility and labor progression by enhancing blood flow and stimulating oxytocin release (Gönenç & Terzioǧlu, 2020; Mafetoni & Shimo, 2015; Najafi et al., 2018; Raana & Fan, 2020; Türkmen & Çeber Turfan, 2020; Yu et al., 2015).

Review of Literature

While numerous studies have examined the application of SP6 acupressure during labor, variations in study design, sample populations, pressure techniques, timing of intervention, and outcome measures have led to inconsistent conclusions. Some studies have reported positive outcomes regarding pain reduction and labor progression with SP6 acupressure (Raana & Fan, 2020), whereas others have failed to establish a definitive effect, suggesting that further investigation is required to solidify these findings (Najafi et al., 2018). Moreover, the duration and continuity of acupressure application until the end of the first stage of labor remain underexplored. Existing evidence rarely accounts for the cumulative effect of sustained acupressure during cervical dilation beyond initial phases. Furthermore, most previous studies have been conducted outside the Middle Eastern or North African context, limiting their applicability to culturally and operationally distinct healthcare systems.

Therefore, the present study was designed to evaluate the effect of sustained SP6 acupressure throughout the active first stage of labor in an Egyptian maternity hospital with limited pharmacological resources and a high cesarean section rate. This design allows for an assessment of both physiological efficacy and contextual acceptability, addressing the interplay between intervention continuity and maternal experience. By encompassing labor pain, duration, and satisfaction, our study contributes region-specific evidence that may inform non-pharmacological intrapartum care protocols.

Methods

Study Design and Setting

A quasi-experimental, one-group pretest–posttest design was used to investigate the effect of SP6 acupressure on the severity of labor pain, duration of labor, and maternal satisfaction. In this design, SP6 acupressure served as the independent variable, while labor pain intensity, duration of labor, and women's satisfaction constituted the dependent variables. The study was conducted in a labor unit, where the researcher was present two days per week from May to November 2023, continuing until the required sample size was reached.

Research Hypotheses

SP6 acupressure will reduce the severity of labor pain since mean of pain postintervention will be significantly less than mean of pain pre intervention.

SP6 acupressure will short the duration of labor compared to World Health Organization (2018) benchmarks.

Major of the participants will be satisfied regarding the application of SP6 acupressure.

Population and Sample

The study sample consisted of 115 parturient women. The sample size was calculated using OpenEpi, Version 3, an open-source epidemiological calculator, based on data from a study conducted by Gönenç and Terzioğlu (2020), which reported a satisfaction rate of 93.3% in the acupressure group. The calculation assumed a hypothesized frequency of outcome factor of 96.8%, a margin of error of ±5%, a design effect of 1, and a confidence level of 97.0%. This sample size was determined to be sufficient to meet the study objectives.

Inclusion and Exclusion Criteria

A purposive sampling technique was utilized based on the following inclusion criteria: Primiparous women, aged with 20–35 years, with a term pregnancy free from high-risk complications, carrying a single fetus in cephalic presentation, with a stable condition, and with 4 cm cervical dilation at the time of enrollment. Women were excluded if they received labor pain analgesics, withdrew from the study, or underwent emergency cesarean section. The exclusion of emergency cesarean deliveries was intended to ensure a homogenous sample of women experiencing spontaneous vaginal labor under stable and comparable clinical conditions where all seven cesarean sections were carried out before full cervical dilation that hampers and obstructs the study aim we sought to examine. Therefore, women undergone cesarean sections were excluded to maintain the methodological consistency and enhance the reliability of outcome comparisons.

Research Instruments

The researcher had utilized four data collection tools in sequential order:

Tool 1: Structured Interviewing Questionnaire; this tool was used to assess the general characteristics and pregnancy history of the parturient women, as presented in Table 1.

Table 1.

Frequency Distribution of General Characteristics and Pregnancy History of Parturient Women (n = 115).

A. General characteristics		N	%
Age categories	20–<25 years	55	47.8
	25–<30 years	41	35.7
	30–35 years	19	16.5
		Mean ± SD	Range
		25.29 ± 4.14	(20.0–35.0)
Residence	Rural	24	20.9
Residence	Urban	91	79.1
Educational level	Illiterate	29	25.2
	Primary level	38	33.0
	Secondary level	30	26.1
	High level of education	18	15.7
Working status	Doesn’t work	75	65.2
Working status	Work	40	34.8
B. Pregnancy history		N	%
Number of abortions	None	89	77.4
	Once	21	18.3
	Twice	5	4.3
Regular prenatal follow-up	No	17	14.8
Regular prenatal follow-up	Yes	98	85.2
Fetal gestational age	Early term 37–38 weeks	60	52.2
	Full-term 39–40 weeks	55	47.8
		Mean ± SD	Range
		38.34 ± 1.17	37.0–40.0

Tool 2: Visual Analogue Scale (VAS) for Pain Assessment; the second tool was a VAS for measuring the severity of subjective labor pain. This scale was adopted from Delgado et al. (2018); Couper et al. (2006); and Mattacola et al. (1997). Pain was recorded and measured before and immediately after acupressure on SP6 point at these cervical dilation intervals: 4–5 cm, 6–7 cm, and 8–10 cm, as shown in Table 2. Each participant was asked to mark a point along a horizontal line representing her perceived pain intensity, with the left end labeled “No pain” and the right end labeled “Extreme pain.” Pain levels were categorized as follows: no pain (0), mild pain (1–3), moderate pain (4–6), and severe pain (7–10).

Table 2.

Comparison of Labor Pain Severity Before and After SP6 Acupressure Application Among Parturient Women (n = 96).

Pain level At 4–5 cm	Pre-intervention		Post-intervention		Marginal homogeneity test^a	P
Pain level At 4–5 cm	N	%	N	%	Marginal homogeneity test^a	P
Mild pain	0	0.0	5	5.2	72.000	.000**
Moderate pain	96	100.0	91	94.8
Severe pain	0	0.0	0	0.0
	Mean ± SD5.32 ± 0.59Range4.00–6.00		Mean ± SD4.40 ± 0.62Range3.00–6.00		Paired t-test^b	P
	Mean ± SD5.32 ± 0.59Range4.00–6.00		Mean ± SD4.40 ± 0.62Range3.00–6.00		27.336	.000**
Pain level at 6–7 cm	Preintervention		Post-intervention		Marginal homogeneity test^a	P
Pain level at 6–7 cm	N	%	N	%	Marginal homogeneity test^a	P
Moderate pain	0	0.0	5	5.2	97.000	.000**
Severe pain	96	100.0	91	94.8	97.000	.000**
	Mean ± SD8.02 ± 0.35Range7.00–9.00		Mean ± SD7.15 ± 0.48Range6.00–8.00		Paired t-test^b	P
	Mean ± SD8.02 ± 0.35Range7.00–9.00		Mean ± SD7.15 ± 0.48Range6.00–8.00		20.571	.000**
Pain level at 8–10 cm	Preintervention		Postintervention		Marginal homogeneity test^a	P
Pain level at 8–10 cm	N	%	N	%	Marginal homogeneity test^a	P
Severe pain	96	100.0	96	100.0	Test statistics cannot be computed as variable is constant.
	Mean ± SD10.00 ± 0.0Range10.00–10.00		Mean ± SD9.32 ± 0.47Range9.00–10.00		Paired t-test^b	P
	Mean ± SD10.00 ± 0.0Range10.00–10.00		Mean ± SD9.32 ± 0.47Range9.00–10.00		14.114	.000**

P > .05: non-significant *P ≤ .05: significant **P < .01: highly significant.

Marginal Homogeneity test: The marginal homogeneity test, an extension of the McNemar test, was used when variables included more than two categories.

Paired t-test: The paired samples t-test was used to evaluate the statistical significance of differences between pre and postintervention means within the same group.

Tool 3: Observational Checklist for Labor Progress and Feto-Neonatal Condition; this third tool was adapted from Sharma et al. (2022); the American Academy of Pediatrics Committee on Fetus and Newborn (2015); World Health Organization (2000); World Health Organization (1994). This checklist was utilized to investigate labor progress by assessing the rate of cervical dilation following the intervention as shown in Table 3A, administration of oxytocin, and duration of the active phase of first stage of labor and the second stage as cleared in Tables 3B‒D respectively. The active phase was considered started from 4 cm until full cervical dilation (10 cm) while the second stage was considered started from full cervical dilation until delivery of fetus. Also, fetal condition was evaluated based on fetal heart rate which monitored by cardiotocography whereas neonatal condition was assessed using Apgar scores at 1 and 5 min, as illustrated in Table 4.

Table 3.

Frequency Distribution of Cervical Dilation Rate, Oxytocin Administration, and Duration of Labor Following SP6 Acupressure Among Parturient Women (n = 96).

Part I: Labor progress
A. Rate of cervical dilation	Preintervention		Postintervention
	At 4 cm		4–5 cm		6–7 cm		8–10 cm
	N	%	N	%	N	%	N	%
Primary dysfunction (cervix dilated < 1 cm/hr)	96	100.0	80	83.3	0	0.0	0	0.0
Cervix dilated (1–1.2 cm/hr)	0	0.0	16	16.7	81	84.4	6	6.2
Increased cervical dilatation rate (<1.2 cm/hr)	0	0.0	0	0.0	15	15.6	90	93.8

B. Administration of oxytocin	Oxytocin preintervention		Oxytocin postintervention		McNemar test (P)
B. Administration of oxytocin	N	%	N	%	McNemar test (P)
No	45	46.9	59	61.5	6.036 (.014*)
Yes	51	53.1	37	38.5	6.036 (.014*)
C. Duration of active phase	N			%
≤180 min	6			6.25
<180–300 min	84			87.5
>300–420 min	6			6.25
Mean ± SD	257.75 ± 45.76 min
D. Duration of 2nd stage	N			%
>60 min	87			90.6
≥60–120 min	9			9.4
Mean ± SD	44.02 ± 16.76 min

*Significant P-value <0.05.

Table 4.

Frequency Distribution of Fetal and Neonatal Conditions Following SP6 Acupressure Among Parturient Women (n = 96).

PART II: Fetal and neonatal condition
A. Fetal condition fetal heart rate	PreIntervention AT 4 cm	Post-intervention
	PreIntervention AT 4 cm	4–5 cm			6–7 cm			8–10 cm
	^aN. FHRN (%)	^aN. FHRN (%)	^bB. cardia	^cT. cardia	^aN. FHRN (%)	^bB. cardia	^cT. cardia	^aN. FHRN (%)	^bB. cardia	^cT. cardia
	96 (100.0)	96 (100.0)	0 (0.0)	0 (0.0)	96 (100.0)	0 (0.0)	0 (0.0)	96 (100.0)	0 (0.0)	0 (0.0)
B. Neonatal condition	At 1 min				At 5 min
	Reassure Apgar score (7–10)	Moderately a bnormal (4–6)	Low and never good (0–3)		Reassure Apgar score		Moderately abnormal		Low and never good
	N (%)	N (%)	N (%)		N (%)		N (%)		N (%)
	88 (91.7)	8 (8.3)	0 (0.0)		96 (100.0)		0 (0.0)		0 (0.0)

N: Normal (120–160 beat/min).

B. cardia: Bradycardia (>110 beat/min).

T. cardia: Tachycardia (<160 beat/min).

Tool 4: Maternal Satisfaction with SP6 Acupressure. It was adapted from Gönenç and Terzioǧlu (2020). It was checked during the fourth stage of labor (the first 2-hr postdelivery) to assess maternal satisfaction with the SP6 acupressure technique. This tool comprised six statements: This method helped in relieving labor pain, This method was bearable and easy to apply, This method positively influenced labor progress, This method helped in gaining a sense of self-control over labor pain, You would prefer to use this natural method in future childbirth, You would recommend this method to others.

Each item was rated on a 3-point Likert scale: “Agree” (3 points), “Uncertain” (2 points), and “Disagree” (1 point). A total score of 11–18 (≥60%) indicated satisfaction, while a score of 6–10 (<60%) indicated dissatisfaction, as illustrated in Figure 1.

Figure 1.

Satisfaction Levels Among Parturient Women Regarding the Application of SP6 Acupressure (n = 96).

All data collection tools were reviewed by a panel of three expert professors to assess their content validity and applicability. Furthermore, internal consistency was evaluated using Cronbach's alpha coefficient, which yielded a value of 0.733 for the observational checklist and 0.840 for the satisfaction tool, indicating acceptable to good reliability.

Before initiating data collection, the researcher attended a structured training program conducted by a licensed physiotherapist, consisting of one-hour sessions over three consecutive days. This training focused on the anatomical identification of the SP6 point, proper finger placement, duration, and the appropriate amount of pressure to be applied. To ensure procedural fidelity, the physiotherapist conducted a skills evaluation at the end of the training. The assessment included a practical demonstration in which the researcher was required to accurately locate the SP6 acupoint and perform the technique in alignment with clinical standards. The researcher was permitted to begin data collection only after being deemed competent and receiving direct approval from the physiotherapist.

The Procedure

All SP6 acupressure interventions were administered solely by the trained researcher, who had completed a structured hands-on training program and demonstrated competency under the supervision of a licensed physiotherapist. To ensure consistency, the technique was applied in a standardized manner throughout the study. At 4 cm of cervical dilation, bilateral SP6 acupressure was performed with the participant in a supine position and legs extended. The researcher applied steady, direct vertical pressure to the SP6 point using both thumbs, gradually increasing the pressure until the participant reported tolerable discomfort, which was visually confirmed by thumbnail blanching.

Each participant received one 20-min acupressure session during each cervical dilation interval—4–5 cm, 6–7 cm, and 8–10 cm—regardless the time taken for dilation of the cervix. This resulted in a total of three standardized sessions per participant. The pressure was maintained in a non-circular, perpendicular manner, in alignment with standardized clinical training and previously published SP6 acupressure protocols (e.g., Gönenç & Terzioğlu, 2020; Mafetoni & Shimo, 2015).

The anatomical location of the SP6 point is illustrated in Figure 2 that retrieved from World Health Organization (1985); Mafetoni and Shimo (2015) and Maleki et al. (2024). Of the initial 115 participants, 96 completed the full intervention protocol; 19 were excluded based on predetermined criteria (withdrawal, analgesic use, or emergency cesarean delivery) as shown in Figure 3. Pain assessments were conducted immediately before and after each session to capture real-time changes in perceived pain intensity at each cervical dilation interval.

Figure 2.

Anatomical Location of Spleen 6 Point (SP6).

Figure 3.

Flowchart of Participant Enrollment, Exclusion, and Analysis in the SP6 Acupressure Study.

Ethical Consideration

Institutional Review Board Approval was obtained from the Scientific Research Ethical Committee of the Faculty of Nursing. An official permission to conduct the study was also secured from the director of the hospital where the research was implemented. Written informed consent was obtained from all participants following a clear explanation of the study objectives, using supportive media to describe the SP6 acupressure intervention. Participants were assured of their right to anonymity and confidentiality, as well as their freedom to accept, decline, or withdraw from the study at any stage without any consequences.

Statistical Analysis

Data were collected, reviewed, coded, tabulated, and entered into a personal computer by the researcher using the Statistical Package for the Social Sciences (IBM SPSS, Version 20.0). Parametric statistical tests were applied, as the sample size was deemed appropriate for such analysis. Descriptive statistics for quantitative data were presented as mean (X̄), standard deviation (SD), and range, while qualitative data were summarized using frequency and percentage.

For inferential statistics, the McNemar test was employed to assess significant differences in paired nominal data. The marginal homogeneity test, an extension of the McNemar test, was used when variables included more than two categories. Additionally, the paired samples t-test was used to evaluate the statistical significance of differences between pre and postintervention means within the same group.

Results

A total of 96 parturient women completed the full SP6 acupressure intervention and were included in the final analysis. Figure 3 presents the participant flowchart, illustrating enrollment, exclusions, and the final sample.

Frequency distribution of the general characteristics and pregnancy history of the parturient women (n = 115) are presented in Table 1. The majority of participants were aged between 20 and <25 years (47.8%), with a mean age of 25.29 ± 4.14 years, indicating that the study population was relatively young. Most women resided in urban areas (79.1%) and had attained either primary (33.0%) or secondary education (26.1%). A significant proportion (65.2%) was not employed.

In terms of obstetric history, 77.4% of women reported no prior abortions, and 85.2% had attended regular prenatal follow-up visits. Regarding gestational age, more than half (52.2%) delivered at early term (37–38 weeks), with a mean gestational age of 38.34 ± 1.17 weeks. These findings reflect a generally healthy obstetric profile among the study population, which provides a solid foundation for evaluating the effects of the intervention.

Comparison of Labor Pain Severity Before and After SP6 Acupressure Application Among Parturient Women (n = 96) are presented in Table 2. A statistically significant reduction in the severity of labor pain among parturient women following the application of SP6 acupressure at different stages of cervical dilation. At 4–5 cm dilation, all participants initially reported moderate pain; however, following the intervention, 5.2% reported mild pain, with the mean pain score significantly decreasing from 5.32 ± 0.59 to 4.40 ± 0.62 (p < .001). Similarly, at 6–7 cm dilation, the proportion of women experiencing severe pain decreased from 100% to 94.8%, with 5.2% reporting moderate pain postintervention. The mean pain score significantly declined from 8.02 ± 0.35 to 7.15 ± 0.48 (p < .001). At the advanced dilation of 8–10 cm, although all participants continued to report severe pain, a statistically significant decrease in the mean pain score was observed—from 10.00 ± 0.00 to 9.32 ± 0.47 (p < .001). These findings indicate that SP6 acupressure is most effective during the early and mid-active phases of labor (4–7 cm), with a diminishing, though still statistically significant, effect during the transition phase (8–10 cm).

Frequency Distribution of Cervical Dilation Rate, Oxytocin Administration, and Duration of Labor Following SP6 Acupressure among Parturient Women (n = 96) are displayed in Table 3. In Part I-A, there is a clear transition from primary cervical dysfunction (dilation < 1 cm/hr) at the early stage (4 cm) in all women (100%) to increased cervical dilation rates in subsequent stages. By the 8–10 cm stage, 93.8% of women showed a cervical dilation rate >1.2 cm/hr, suggesting that SP6 acupressure contributed to a more efficient labor progression. Part I-B indicates a statistically significant reduction in the administration of oxytocin postintervention (from 53.1% to 38.5%; p = .014), as revealed by the McNemar test. This finding supports the potential of SP6 acupressure to reduce the need for pharmacological augmentation of labor. In Part I-C, the majority of women (87.5%) experienced an active labor phase lasting between 180–300 min, with a mean duration of approximately 258 min. These results reflect a labor course within the acceptable clinical time frame, potentially facilitated by the acupressure intervention. Finally, Part I-D shows that most women (90.6%) had a second stage of labor lasting under 60 min, with a mean duration of 44.02 ± 16.76 min, which is favorable and within normal limits. These outcomes collectively highlight the beneficial impact of SP6 acupressure in promoting more efficient and less medically managed labor.

The fetal and neonatal outcomes following the application of SP6 acupressure among parturient women are presented in Table 4. The fetal heart rate (FHR) was consistently within the normal range (120–160 bpm) at all stages of cervical dilation (4–10 cm) following the intervention, with no instances of bradycardia or tachycardia recorded. This indicates that SP6 acupressure did not adversely affect fetal well-being during labor.

Regarding neonatal condition, the Apgar scores demonstrate favorable outcomes. At one minute after birth, 91.7% of neonates had reassuring scores (7–10), while 8.3% were moderately abnormal (scores of 4–6), and none scored below 4. By 5 minutes, all neonates (100%) achieved reassuring Apgar scores, with no reported abnormalities. These results suggest that SP6 acupressure had no negative impact on neonatal vitality and may support favorable neonatal transition in the immediate postnatal period.

Satisfaction levels among parturient women regarding the application of SP6 acupressure is illustrated in Figure 1. The bar chart shows two categories: Dissatisfaction and Satisfaction. Approximately 11.46% of the women reported dissatisfaction with the SP6 acupressure intervention, while approximately 88.54% reported satisfaction. This figure highlights that the majority of the participants were satisfied with the SP6 acupressure technique, indicating its effectiveness in providing relief and enhancing their childbirth experience.

Discussion

Labor pain is a distressing experience for women of reproductive age, often leading to significant physical and psychological challenges during and after childbirth when the acupressure could have a promising effect on the labor process. In light of this, the present study aimed to investigate the effects of Spleen 6 (SP6) point acupressure on labor pain severity, duration, and maternal satisfaction.

The analgesic effect of SP6 acupressure can be understood via the gate control theory of pain since acupressure can activate the peripheral sensory receptors and modulate pain transmission at the level of spinothalamic tract. Additionally, stimulating Sanyinjiao point may increase the release of β-endorphin in the blood which excites the endogenous analgesia system. This activation inhibits the ascending pathway of pain impulses through descending pathway where endorphins binding receptors complex blocks the transmission of pain signals from reaching into the brain and ultimately producing an analgesic effect. These mechanisms collectively support the physiological plausibility of acupressure's effects during labor (Zhang et al., 2025).

Through the current research findings, the first hypothesis is accepted. The finding of lower mean of pain postintervention is in line with the major of previous studies, which found a significantly lower postintervention pain mean in the acupressure group compared to control/placebo groups during the active phase (Çelik & Okumuş, 2019; Mafetoni & Shimo, 2016; Tanjung et al., 2023). This finding also aligns with systematic reviews affirming that acupressure is an effective non-pharmacological method for pain relief in the early stages of labor (Devi & Lepcha, 2021; Karimi et al., 2020; Najafi et al., 2018; Raana & Fan, 2020). Conversely, Morgan Farahat Khatap et al. (2015) reported that pain scores decreased only immediately after SP6 acupressure and showed no significant difference compared to the control group.

Also, the mean postintervention pain score at 8–10 cm dilation (9.32 ± 0.47) was statistically significantly lower than the preintervention score (10.00 ± 0.00; p < .001). However, the clinical impact of this reduction appeared limited, as all participants continued to report severe pain. This suggests that, while SP6 acupressure retains a measurable analgesic effect even in advanced labor, its perceived efficacy diminishes as labor progresses. This may be attributed to the physiological characteristics of late first-stage labor, during which the frequency and intensity of uterine contractions markedly increase, producing severe somatic pain mediated by afferent sensory fibers that may exceed the modulatory capacity of pressure stimuli.

This statistically significant difference aligns with findings by Gönenç and Terzioǧlu (2020) who observed reduced pain scores during the transition phase. However, Türkmen and Çeber Turfan (2020) reported no significant difference between groups. Mafetoni and Shimo, (2015) found a minor reduction in pain, suggesting that SP6 acupressure may be most effective up to 8 cm cervical dilation.

Regarding pharmacological analgesia use, only a small percentage of participants received analgesia after acupressure. This may be attributed to the shortage of anesthesiology staff for epidural administration, occasional unavailability of injectable analgesics, and limited availability of senior obstetricians for supervision. Mafetoni and Shimo, (2015) reported no significant difference, possibly due to infrequent application of acupressure. In contrast, studies by Raana and Fan (2020) and Türkmen and Çeber Turfan (2020) emphasized the importance of consistent 30-min intervals for effective pain relief.

While concerning the effect of acupressure on labor duration, acupressure as a part of traditional Chinese medicine (TCM) assumes that human body contains vital energy called Qi “one of the fundamental invisible energy” circulates inside the body through the channels named with meridians that must remain in balance to facilitate the circulation of air, nutrients, and blood, serve as a nutritive substance, and to maintain the functional activities and the human bodily health. Historically, acupressure has the ability to correct the flow of this Qi by applying pressure to specific acupuncture points on the skin surface (Karimi et al. 2020; Lin et al., 2022).

Accordingly, Sanyinjiao point (SP6) is located at the intersection of the spleen, liver, and kidney meridians—organs believed to regulate function of the uterus and reproductive system. Thus, stimulating SP6 point is thought to harmonize the flow of vital energy, improve blood circulation, and relieve uterine stagnation. Furthermore, SP6 acupressure could have an oxytocin mediated effect which enhances the labor progression (Arunita et al., 2023; Gönenç & Terzioǧlu, 2020; Mafetoni & Shimo, 2015).

The observed labor progression patterns in this study, particularly during the active phase and the second stage, suggest a potentially beneficial influence of SP6 acupressure on cervical dilation and overall labor efficiency. When compared to the World Health Organization (2018) benchmarks, which allow for longer durations in both first and second stages, the relatively expedited labor progression among participants may reflect the intervention's capacity to enhance uterine contractility and hormonal responses associated with cervical ripening. These findings are consistent with the second hypothesis that lend to support that SP6 acupressure may contribute to more efficient labor trajectories in primiparous women.

It is well established that cervical dilation increases as labor progresses. Nevertheless, SP6 acupressure may facilitate labor progression by enhancing uterine blood flow and stimulating oxytocin release (Gönenç & Terzioğlu, 2020; Türkmen & Çeber Turfan, 2020; Yu et al., 2015).

Despite variations in labor duration across countries and ethnic groups, several studies support the labor-shortening effect of SP6 acupressure (Çelik & Okumuş, 2019; Najafi et al., 2018). Similarly, Türkmen and Çeber Turfan (2020) and Mafetoni and Shimo (2015) reported significantly shorter active phases and total labor durations in the SP6 group. Additionally, Arunita et al. (2023) concluded in a literature review that acupressure reduced the first stage of labor by 1–2 hr, with SP6 and GB21 “Gallbladder” 21points being particularly effective. Devi and Lepcha (2021) also highlighted labor-shortening effects. Gönenç and Terzioǧlu (2020) found shorter active and total labor durations in the SP6 group, though not statistically significant.

Regarding the second stage of labor, Najafi et al. (2018) reported significantly shorter durations in the acupressure group, whereas Çelik and Okumuş (2019) found no significant difference, the latter possibly due to increased obstetric interventions to expedite delivery.

For oxytocin administration, the results of this study are consistent with previous literature suggesting that SP6 acupressure may contribute to a reduced need for labor augmentation. Similar outcomes were reported by Arunita et al. (2023), highlighting its potential to promote spontaneous labor progression. Meanwhile, variations in oxytocin use observed in other studies—such as those by Gönenç and Terzioǧlu (2020), and Mafetoni and Shimo (2015)—underscore the influence of contextual factors like sample size distribution and institutional protocols on intervention outcomes.

With regard to fetal and neonatal safety, the current results agree with existing literature indicating that SP6 acupressure does not adversely affect fetal heart rate patterns or Apgar scores. Mafetoni and Shimo (2016) similarly reported no significant differences in neonatal outcomes. Furthermore, the systematic review by Raana and Fan (2020) supports the overall safety of acupressure during labor, reinforcing its use as a non-pharmacological intervention with minimal risk to fetal well-being.

So from the hopeful effect of acupressure on SP6 point on labor, the major participants have reported satisfaction toward SP6 acupressure reflects its perceived value as a supportive measure during labor that confirms and accepts the third hypothesis. While literature exploring maternal satisfaction with this specific intervention remains limited, prior studies have noted its potential psychological benefits. Gönenç and Terzioǧlu (2020) observed improvements in emotional responses, self-control, and overall childbirth experience associated with acupressure. Although Türkmen and Çeber Turfan (2020) reported a higher satisfaction rate among women receiving SP6 acupressure, the difference did not achieve statistical significance, underscoring the need for further investigation into the psychosocial dimensions of this technique.

Strengths and Limitations

This study provides significant contributions to the understanding of SP6 acupressure as a non-pharmacological intervention for labor pain management. A notable strength of the study is the relatively large sample size, which enhances the statistical power and robustness of the findings. Additionally, the rigorous statistical analysis, including paired t-tests and marginal homogeneity tests, ensures the reliability of the results in demonstrating the effectiveness of SP6 acupressure. The careful methodology, including well-defined inclusion criteria and precise outcome measures, adds to the overall validity of the study.

A potential limitation of this study is the absence of a sham group, which is commonly used in intervention studies to control for placebo effects. While this study design strengthens the focus on real-world applications of SP6 acupressure, we acknowledge that the lack of a sham group may limit the ability to fully exclude the psychological impact of the intervention. Despite this, the findings remain robust, with statistically significant reductions in pain severity observed across all stages of labor, which reinforces the clinical value of SP6 acupressure. Additionally, the sample population in this study was relatively homogeneous, with a significant proportion of primiparous women and those residing in urban areas. This limited diversity could affect the generalizability of the findings to broader populations, such as multiparous women or those from rural areas. Future studies should aim to include a more diverse sample to enhance the external validity of the results. Moreover, including a sham group in future studies would further isolate the physiological effects of acupressure from placebo effects and improve the interpretability of the findings.

Implications for Practice

Apply Sp6 acupressure as one of non-pharmacological pain relief measures could reduce the severity of pain associated with labor, faster the cervical dilation, and short the duration of labor. So, implement acupressure during the intrapartum care could have a positive effect on childbirth experience.

Conclusion

Based on the study's findings, we can conclude that SP6 acupressure appears to significantly alleviate labor pain and may improve the efficiency of labor progression. Specifically, the reduction in pain scores at different stages of cervical dilation and the observed improvements in cervical dilation rates, along with a decrease in the need for oxytocin, suggest that SP6 acupressure could serve as an effective non-pharmacological intervention for pain relief and labor augmentation. Additionally, the favorable neonatal outcomes and high levels of maternal satisfaction indicate that SP6 acupressure is a safe and well-tolerated intervention. However, the study's design limits our ability to make definitive conclusions regarding its impact on labor duration, and further research with a more robust methodological approach is warranted.

Recommendations

Based on the findings of this study, it is recommended that future research further explore the effects of SP6 acupressure on labor pain and progression through randomized controlled trials with larger sample sizes and the inclusion of a placebo or sham acupressure group to enhance the validity and generalizability of the results. Additionally, investigations into the long-term effects of SP6 acupressure on maternal and neonatal outcomes, as well as its potential combination with other non-pharmacological methods, would provide valuable insights. Further studies should also consider variations in the timing and duration of acupressure application to identify the most effective protocols for different stages of labor.

Footnotes

Acknowledgments

The authors would like to express their great appreciation for all parturient women who agreed to participate in this study.

ORCID iD

Shimaa Ibrahim Salama

Ethical Consideration

An ethical approval was obtained from the Scientific Research Ethical Committee of the Faculty of Nursing at Ain Shams University (Study Approval Number: 24.12.448). Additionally,an official permission was gained from the director of hospital where the study was conducted. Written informed consent was obtained from each participant after clarifying the aim of study through using supportive media regarding the SP6 acupressure. Anonymity,confidentiality,and the right to accept,refuse,and withdraw at any phase were assured.

Author Contribution

All authors had contributed in selecting the research title and design the tools of data collection. The first author was responsible for collecting the data and writing the methodology and discussion while the fourth author had formulated the introduction. The second and third authors had participated through providing a critical revision and editing for this manuscript.

Funding

The authors received no financial support for the research,authorship,and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research,authorship,and/or publication of this article.

References

Altınayak

S. Ö.

Özkan

(2022). The effects of conventional, warm and cold acupressure on the pain perceptions and beta-endorphin plasma levels of primiparous women in labor: A randomized controlled trial. Explore (New York, NY), 18(5), 545–550. https://doi.org/10.1016/j.explore.2022.02.004

American Academy of Pediatrics Committee on Fetus and Newborn. (2015). The Apgar score. Pediatrics, 136(4), 819–822. https://doi.org/10.1542/peds.2015-2651

Arunita

A. V.

Rahayu

H. S. E.

Wijayanti

, et al. (2023). The effect of acupressure on length of labor: A literature review4th Borobudur International Symposium on Humanities and Social Science 2022 (BIS-HSS 2022) (Vol. 778, pp. 679–691). Advances in Social Science, Education and Humanities Research. https://doi.org/10.2991/978-2-38476-118-0_79

Beyable

A. A.

Bayable

S. D.

Ashebir

Y. G.

(2022). Pharmacologic and non-pharmacologic labor pain management techniques in a resource-limited setting: A systematic review. Annals of Medicine and Surgery, 74(103312). https://doi.org/10.1016/j.amsu.2022.103312

Çelik

HÖ

Okumuş

(2019). The effect of acupressure at the Sanyinjiao point on labor pain relief and duration of labor in Turkish nulliparous women. Journal of Experimental and Clinical Medicine, 36(3), 73–80. https://doi.org/10.5835/jecm.omu.36.03.002

Couper

M. P.

Tourangeau

Conrad

F. G.

Singer

(2006). Evaluating the effectiveness of visual analog scales: A web experiment. Social Science Computer Review, 24(2), 227–245. https://doi.org/10.1177/0894439305281503

Delgado

D. A.

Lambert

B. S.

Boutris

McCulloch

P. C.

Robbins

A. B.

Moreno

M. R.

Harris

J. D.

(2018). Validation of digital visual analog scale pain scoring with a traditional paper-based visual analog scale in adults. Journal of the American Academy of Orthopaedic Surgeons Global Research and Reviews, 2(3), e088. https://doi.org/10.5435/JAAOSGlobal-D-17-00088

Devi

Lepcha

(2021). Acupressure as a potentially effective strategy for reducing the intensity and length of labour pain. International Journal of Development Research, 11(11), 51704–51709. https://doi.org/10.37118/ijdr.23224.11.2021

Gönenç

I. M.

Terzioǧlu

(2020). Effects of massage and acupressure on relieving labor pain, reducing labor time, and increasing delivery satisfaction. Journal of Nursing Research, 28(1), 1–9. https://doi.org/10.1097/jnr.0000000000000344

10.

Karimi

Mahdavian

Makvandi

(2020). A systematic review and meta-analysis of the effect of acupressure on relieving the labor pain. Iranian Journal of Nursing and Midwifery Research, 25(6), 455–462. https://doi.org/10.4103/ijnmr.IJNMR_257_19

11.

Lin

J. G.

Kotha

Chen

Y. H.

(2022). Understandings of acupuncture application and mechanisms. American Journal of Translational Research, 14(3), 1469. www.ajtr.org /ISSN:1943-8141/AJTR0131272

12.

Mafetoni

R. R.

Shimo

A. K. K.

(2015). Effects of acupressure on progress of labor and cesarean section rate: Randomized clinical trial. Revista de Saude Publica, 49(1), 1–9. https://doi.org/10.1590/S0034-8910.2015049005407

13.

Mafetoni

R. R.

Shimo

A. K. K.

(2016). The effects of acupressure on labor pains during childbirth: A randomized clinical trial. Revista latino-americana de enfermagem, 24, e2738. https://doi.org/10.1590/1518-8345.0739.2738

14.

Maleki

S. M.-N.

Heydarpour

Nikrai

Heydarpour

(2024). The comparison of effectiveness of acupressure on Spleen 6 and Hugo points on the severity of postpartum pain: A randomized clinical trial. Health Science Reports, 7(7), e2265. https://doi.org/10.1002/hsr2.2265

15.

Mattacola

C. G.

Perrin

D. H.

Gansneder

B. M.

Allen

J. D.

Mickey

C. A.

(1997). A comparison of visual analog and graphic rating scales for assessing pain following delayed onset muscle soreness. Journal of Sport Rehabilitation, 6(1), 38–46. https://doi.org/10.1123/jsr.6.1.38

16.

Melzack

Wall

P. D.

(1996). Pain mechanisms: A new theory: A gate control system modulates sensory input from the skin before it evokes pain perception and response. Pain Forum, 5(1), 3–11. https://doi.org/10.1016/S1082-3174(96)80062-6

17.

Morgan Farahat Khatap

Ali Abd El-Hamid

Mohamed Abd Allah

Mahmoud Ali El-kosery

(2015). Effect of the Sanyinjiao Point (SP6) acupressure on reducing labor pain at Ismailia governmental hospitals. Egyptian Journal of Health Care, 6(3), 56–69. https://doi.org/10.21608/ejhc.2015.216954

18.

Najafi

Jaafarpour

Sayehmiri

Khajavikhan

(2018). An evaluation of acupressure on the Sanyinjiao (SP6) and Hugo (LI4) points on the pain severity and length of labor: A systematic review and meta-analysis study. Iranian Journal of Nursing and Midwifery Research, 23(1), 1–7. https://doi.org/10.4103/ijnmr.IJNMR_184_15

19.

Raana

H. N.

Fan

X. N.

(2020). The effect of acupressure on pain reduction during first stage of labour: A systematic review and meta-analysis. Complementary Therapies in Clinical Practice, 39, 101126. https://doi.org/10.1016/j.ctcp.2020.101126

20.

Ropero Peláez

F. J.

Taniguchi

(2016). The gate theory of pain revisited: Modeling different pain conditions with a parsimonious neurocomputational model. Neural Plasticity, 2016, 4131395. https://doi.org/10.1155/2016/4131395

21.

Sharma

Jain

Sharma

(2022). The clinical evaluation of course of labour using modified WHO partograph. International Journal of Clinical Obstetrics and Gynaecology, 6(3), 45–51. https://doi.org/10.33545/gynae.2022.v6.i3a.1182

22.

Souza

M. R. T. D.

Carneiro

J. L.

Farias

L. M. V. C.

Costa

C. C. D.

Vasconcelos

C. M.

Lima

M. O. P.

Damasceno

A. K. D. C.

(2024). Neuroaxial analgesia in labor: Effects on maternal and neonatal outcomes. Acta Paulista de Enfermagem, 37, eAPE02103. https://doi.org/10.37689/acta-ape/2024AO00021033

23.

Tanjung

W. W.

Misbah

Nasution

E. Y.

(2023). Effect of SP6 acupressure on first-period labor pain. International Journal of Public Health Excellence (IJPHE), 3(1), 116–119. https://doi.org/10.55299/ijphe.v3i1.503

24.

Türkmen

Çeber Turfan

(2020). The effect of acupressure on labor pain and the duration of labor when applied to the SP6 point: Randomized clinical trial. Japan Journal of Nursing Science: JJNS, 17(1), Article e12256. https://doi.org/10.1111/jjns.12256

25.

World Health Organization. (1985). Appropriate technology for birth. The Lancet, 2(8452), 436–437.

26.

World Health Organization. (1994). The partograph: The application of the WHO partograph in the management of labour: Report of a WHO multicentre study, 1990–1991. World Health Organization. https://iris.who.int/handle/10665/58589

27.

World Health Organization. (2017). Managing complications in pregnancy and childbirth: A guide for midwives and doctors (2nd ed.). World Health Organization. https://iris.who.int/handle/10665/255760

28.

World Health Organization. (2018). WHO recommendations on intrapartum care for a positive childbirth experience. World Health Organization. https://www.who.int/publications/i/item/9789241550215

29.

World Health Organization. (2021). Caesarean section rates continue to rise, amid growing inequalities in access. World Health Organization. https://www.who.int/news/item/16-06-2021-caesarean-section-rates-continue-to-rise-amid-growing-inequalities-in-access

30.

Yang

Gao

Chen

Ren

Zhang

Chen

Liang

(2015). Application of acupoints and meridians for the treatment of primary dysmenorrhea: A data mining-based literature study. Evidence-Based Complementary and Alternative Medicine: eCAM, 2013, 752194. https://doi.org/10.1155/2015/752194

31.

Zhang

Wang

Zhou

Song

(2025). The role of acupressure in labor pain management: A comprehensive analysis of efficacy and maternal outcomes. Clin Exp Obstet Gynecol., 52(2), 33517. https://doi.org/10.31083/CEOG33517

32.

Zuarez-Easton

Erez

Zafran

Carmeli

Garmi

Salim

(2023). Pharmacological and non-pharmacological options for pain relief during labor: An expert review. American Journal of Obstetrics and Gynecology, 228(5), S1246–S1259. https://doi.org/10.1016/j.ajog.2023.03.003

Effect of Spleen 6 Point Acupressure on Severity of Labor Pain,Duration of Labor,and Women’s Satisfaction

Abstract

Introduction

Objectives

Methods

Results

Conclusion

Keywords

Introduction

Review of Literature

Methods

Study Design and Setting

Research Hypotheses

Population and Sample

Inclusion and Exclusion Criteria

Research Instruments

The Procedure

Ethical Consideration

Statistical Analysis

Results

Discussion

Strengths and Limitations

Implications for Practice

Conclusion

Recommendations

Footnotes

Acknowledgments

ORCID iD

Ethical Consideration

Author Contribution

Funding

Declaration of Conflicting Interests

References