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Forbidden points' in pregnancy: historical wisdom?
  1. Debra Betts1,
  2. Sarah Budd2
  1. 1Centre for Complementary Medicine Research, University of Western Sydney, Penrith, New South Wales, Australia
  2. 2Maternity Unit, Derriford Hospital, Plymouth, UK
  1. Correspondence to Mrs Debra Betts, Centre for Complementary Medicine Research, University of Western Sydney, Locked Bag 1797, Penrith, NSW 2751, Australia; debra.betts{at}rhizome.net.nz

Abstract

Within the acupuncture literature there is debate on the safety of using specific acupuncture points during pregnancy. Termed ‘forbidden’ or contraindicated, they refer to acupuncture points that can be used to induce labour but may also include points with no known inducing or labour-enhancing effects. Recommendations range from avoiding these acupuncture points at any time in pregnancy to statements that despite the warnings in the literature, these points are not contraindicated during a normal pregnancy. This discussion paper examines the historical use of contraindicated points, the physiology of the pregnant body and the effect of these points during research trials. It is hoped that this will encourage further discussion and provide a background for practitioners to make informed choices about how they use these points in clinical practice.

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Introduction

There is a growing interest from Western medicine practitioners in the use of acupuncture during pregnancy. Midwifery recommendations can now be found in the literature for nausea, breech presentation, pelvic girdle pain and induction of labour, as well as general pregnancy health problems such as insomnia, anxiety and stress responses.1,,3 A survey of 343 midwives in 2009 reported that 45% of Canadian and 55% of New Zealand midwives referred women for acupuncture treatment.4 Currently, specific acupuncture midwifery courses are offered in Denmark, Germany, Norway, Switzerland and New Zealand, with midwives then using these skills within midwifery practice. A survey within German obstetric clinics found that acupuncture was the most commonly used complementary therapy by midwives and was available in 97.3% of the 376 units that responded.5 In addition, support can be found within hospital management for specific acupuncture antenatal clinics operating within hospitals; currently, both authors are involved in such hospital-based clinics—one in the UK (SB) and one in New Zealand (DB).

Despite this interest from the medical community and the opportunities this offers acupuncturists to promote acupuncture treatment within mainstream medicine, some practitioners remain concerned about the possibility of treatment being associated with a subsequent spontaneous abortion or premature delivery.

This concern is understandable when practitioners are confronted by differing opinions within the acupuncture literature as to the safety of using acupuncture during pregnancy. A range of opinions can be found in modern texts, from it being preferable not to use any acupuncture or moxibustion at all, but if a practitioner does choose to do so, not to use the contraindicated points as this may lead to spontaneous abortion,6 through to acupuncture being a safe treatment and that the warnings in other texts about contraindicated points, such as SP6, can be dismissed.7

For practitioners to confidently to promote and provide safe treatment during pregnancy it is important that these contraindications are discussed. This paper examines the historical use of the forbidden points, their relevance to the physiology of a pregnant body and their use in research trials in the hope that this will contribute towards this discussion.

Historical texts

Historical references to acupuncture are overwhelmingly found in the context of difficult labour rather than treatment for pregnancy conditions. These references often involve stories of a doctor being called to a birth at the last moment, when all else has failed, and then heroically using acupuncture to deliver the child and/or save the life of the mother.8 Traditional acupuncture texts also list specific acupuncture points such as LI4, SP6, GB21, BL32, BL60 and BL67 for labour pain or difficult labour, with various needling techniques and point combinations recommended to enhance these effects.9 This portrays an impression of acupuncture as a potentially powerful and dangerous treatment during pregnancy—to be used only as a last resort to induce or stimulate labour. This concept is further reinforced when major textbooks omit to mention acupuncture when discussing pregnancy-related conditions. An example being the Fu Ke Xin Fa Yao Jue (The Golden Mirror of Orthodox Medicine—compiled in 1742 and used in the Qing Dynasty as a text for the Imperial School), a text where only herbal formulas are mentioned for treatment during pregnancy.10

From these writings it is understandable how acupuncture treatment that was seen to have the effect of stimulating labour, or acupuncture points that lay directly over the uterus, were regarded as contraindicated in pregnancy and have remained referenced as such in modern textbooks.9 However, the source of some recommendations now seen in the acupuncture literature is unknown. These recommendations include refraining from using acupuncture points such as the Hua Tuo Jai Ji points11 or the opening points of the Directing vessel (LU7 and KID6).12 Simply stating these points, together with others that can be found (often given as lists to students through acupuncture colleges), as unsuitable, with no further explanations as to why they may be of concern, creates a mythical aspect around the use of acupuncture in pregnancy and understandable uncertainty for practitioners. We suggest that when points are termed contraindicated in pregnancy for unknown reasons that are not consistent with the induction of labour, their use becomes a matter of practitioner choice.

In addition to historical writings, further information for treatment considerations can be gathered by examining the physiology of the pregnant body and the use of acupuncture in research studies on women during pregnancy.

Physiology during pregnancy

Midwifery texts state several considerations that we consider important for acupuncturists. Three of these, in particular, relate to the potential for acupuncture to be associated with subsequent spontaneous abortion or premature labour. First, in early pregnancy the developing fetus requires a low oxygen environment for optimal development, changing to high-level oxygen requirements after 10–12 weeks.13 This raises the possibility that acupuncture treatments increasing oxygenation to the uterus may have a detrimental effect immediately after implantation and during early pregnancy. Second, there is a dependence on maternal progesterone levels until the placenta takes over production at 10–12 weeks,14 suggesting that acupuncture treatments capable of influencing hormonal levels might produce different effects before 12 weeks than after this stage of pregnancy. Finally, it is known that significant changes occur with uterine contractions as the pregnancy progresses. While contractions are present as early as 7 weeks, the intensity and frequency of these contractions changes as the pregnancy progresses. As women approach 36 weeks, oxytocin and prostaglandins are released, uterine receptors react to these hormonal changes—promoting contractions until peak levels are reached with the onset of labour.15 These changes raise the possibility that acupuncture points influencing contractions may have different effects in the final weeks of pregnancy than in the mid-trimester.

We suggest that acupuncturists should consider that during the first 10–12 weeks and final 4 weeks of a pregnancy, women are more susceptible to acupuncture treatments that increase blood flow to the uterus, influence hormonal responses and stimulate uterine contractions.

Traditionally, specific acupuncture points were found to have an effect in stimulating labour. It would therefore be prudent to consider the possibility that underlying physiological responses may be responsible for these effects, and plan treatment accordingly. While these same points may be useful to prepare women's bodies for labour in later pregnancy, they still require appropriate use and caution. Pregnant bodies are not all physiologically identical, with different process required depending on the obstetric assessment. For example, acupuncture may be used to assist in cervical ripening for a women expecting her first child, but may not be appropriate for a woman preparing for the birth of a subsequent baby.

Research findings

Although research on the safety of treating pregnancy-related conditions with acupuncture is limited, data collected to date on its safety for nausea, back pain, moxibustion, breech presentation, induction of labour and pain relief during labour report no adverse effects on fetal or maternal outcomes.16

However, when the acupuncture points used within research studies are examined, it is found that there is limited use of points traditionally termed contraindicated in pregnancy. These points are avoided in an early pregnancy study of nausea and vomiting where safety outcomes were monitored.17 They are also avoided in research and case histories examining the effect of acupuncture in halting premature labour.18 19 Where these points are used—for example, LI4, BL32 and BL60 for pelvic girdle pain20 and LI4 for heartburn,21 they are used on women after 12 and before 36 gestational weeks. In view of the physiology of pregnancy, as discussed above, it may be that the actions of these acupuncture points are not as activating at these times as potentially they may be in the early and late stages of a pregnancy.

It may also be that varying levels of stimulation are required among individual women to initiate any potential labour-inducing reactions. The number of women receiving acupuncture in these studies (125 for pelvic girdle pain and 20 for heartburn), may not be sufficient to detect detrimental effects. In view of the number of acupuncture points practitioners have at their disposal to treat heartburn and back pain effectively during pregnancy, we do not consider that omitting these points places practitioners at a disadvantage.

It is noteworthy that the literature from China reports the success rate of abortion by acupuncture as being 75.46% for early pregnancy and 30.9% in the middle trimester,22 suggesting that acupuncture can be used to stimulate labour successfully before term and that similar treatment may have different effects during the different trimesters of a pregnancy.

In one study that involved the acupuncture induction of seven women between 15 and 23 weeks' gestation (using the acupuncture points LI4 and SP6) the induction was unsuccessful, with all women requiring further medical intervention. However, although these points did not induce labour, all women demonstrated the onset of recordable contractions, with some becoming regular and of high amplitude.18 In a clinical context one author (DB) has used LI4 for conditions such as toothache and sinus pain during mid-trimester, but discontinued this practice after several women reported the onset of contractions the night after treatment. While these contractions did not progress to labour, their onset did induce unnecessary anxiety.

Discussion

Although there are a variety of points contraindicated or termed as forbidden points in acupuncture literature, not all of these stem from traditional literature promoting the stimulation of labour. It is our view that the acupuncture points LI4, SP6, GB21, BL32, BL60 and BL67 have historical authority as valuable points for use in difficult or painful labour and as such may promote or enhance labour. These points may have physiological actions on a pregnant body and it is possible that the actions of these points may be time dependent on the gestational age of the pregnancy. Thus these points should be used with caution and specific intention during pregnancy, rather than routinely added to point prescriptions.

Although points such as BL60, BL67, CV4 and SP6 can be used to prepare women for an efficient labour when used for specific rationale, such as positioning the baby into an anterior position and cervical ripening,7 23 these points require individualisation for the treatment required. It is also logical from an acupuncture theory perspective that consideration is given to using different needling techniques, points in combination and different treatment modalities such as moxibustion and electroacupuncture. It is assumed that practitioners consider acupuncture points that lie directly over the uterus as requiring caution and when used, require different needling techniques than in a non-pregnant body.

Although some research has used acupuncture points such as LI4, BL32 and BL60 to treat back pain and heartburn in pregnancy, the results have been limited to a small number of women between 12 and 36 gestational weeks and therefore do not demonstrate that these points are safe to use routinely in pregnancy.

Conclusion

The challenge for acupuncturists today is to continue to explore the benefits of offering acupuncture treatment during pregnancy in an environment that is safe but does not restrict practice owing to unjustified concerns that such treatment may be unsafe. With research suggesting that acupuncture is safe to use in the treatment of specific pregnancy-related conditions and the interest demonstrated by some Western medicine practitioners, the potential for the expanding use of acupuncture during pregnancy appears promising.

With this in mind we suggest that there is historical wisdom in acupuncture texts from the past advising that acupuncture points associated with the induction or stimulation of labour be used with caution. Best practice would suggest that until more is known about the specific effects of acupuncture points such LI4, SP6, GB21, BL32, CV4, SP6, BL60 and BL67, caution is recommended, especially in early and late pregnancy.

It is hoped that this prudent approach, alongside further discussion of clinical experience and examination of these effects within research projects, will lead to further understanding of the use of these points traditionally forbidden during pregnancy.

References

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Footnotes

  • Competing interests None.

  • Provenance and peer review Commissioned; not externally peer reviewed.

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