The Safety and Effectiveness of Electroacupuncture for Labor Pain Relief: a Systematic Review and Meta-Analysis

Article information

Perspect Integr Med. 2025;4(1):6-15

Publication date (electronic) : 2025 February 28

doi : https://doi.org/10.56986/pim.2025.02.002

Hyein Jeong ¹^,^†

, Jiwon Heo ²^,^†

, Hyunsuk Park ³

, Kyeong Han Kim ⁴^,

¹Department of Preventive Medicine, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea

²College of Korean Medicine, Woosuk University, Jeonju, Republic of Korea

³Department of Korean Medicine Rehabilitation, Bucheon Jaseng Hospital of Korean Medicine, Bucheon, Republic of Korea

⁴Department of Preventive Medicine, College of Korean Medicine, Woosuk University, Jeonju, Republic of Korea

^*Corresponding author: Kyeong Han Kim, Department of Preventive Medicine, College of Korean Medicine, Woosuk University, Jeonju 54986, Republic of Korea, Email: solip922@hanmail.net

†The authors contributed equally.

Received 2024 December 16; Revised 2025 February 3; Accepted 2025 February 6.

Abstract

Background

Labor pain is among the most intense forms of pain, significantly impacting physical and psychological well-being. Although epidural anesthesia is effective, it has side effects and limited accessibility. Electroacupuncture (EA) offers a low-risk alternative. This systematic review and meta-analysis assessed the safety and effectiveness of EA in relieving labor pain and duration.

Methods

Randomized controlled trials comparing EA with standard treatments, including epidural anesthesia, were identified through database searches up to August 2024. The primary outcome was pain reduction (assessed using the visual analog scale), and the secondary outcomes were labor duration (1^st and 2^nd stages), Apgar scores, and adverse effects.

Results

In the analysis there were 10 randomized controlled trials (involving 1,498 women in labor) included in this review. EA statistically significantly improved both the level of pain and reduced labor duration compared with those women who received standard treatments (p < 0.001). Apgar scores were assessed in 3 studies and determined that the physical condition of the delivered babies was not statistically significantly different between EA and standard treatment for labor pain. Study protocol indicated the recording of adverse effects in one of the ten studies. Adverse events in that study recorded mild localized discomfort (1.89%, n = 1).

Conclusion

EA reduced labor pain and duration, and demonstrated its potential as an alternative to the conventional approaches for managing labor pain. The limited data suggest EA is likely safe, but further research is needed to confirm its safety profile.

Keywords: electroacupuncture; epidural anesthesia; labor pain; meta-analysis; systematic review

Visual abstract

Introduction

Labor pain is universally recognized as one of the most intense and challenging forms of pain experienced by women, and the physical, psychological, and emotional components of labor often contribute significantly to stress and anxiety [1]. This multifaceted pain experience can influence the course of labor, the mother’s ability to cope, and the overall childbirth experience. Effective labor pain management is therefore critical, not only for the physical comfort of the mother but, also for her psychological well-being and the smooth progression of labor.

Conventional labor pain relief methods including epidural analgesia (EDA) are widely utilized in clinical settings. Moreover, such techniques are considered highly effective [2]. However, EDA has certain drawbacks. The modality carries the risks of hypotension, prolonged labor, increased likelihood of instrumental delivery, and a potential impact on the newborn’s condition [3]. Additionally, the invasiveness of the procedure and the requirement for skilled medical personnel restrict its accessibility, particularly in resource-limited settings. For instance, in Saudi Arabia, 52.5% of women decline EDA due to insufficient explanation from medical staff and potential concerns about side effects [4]. In India, many obstetricians have reported limited training in labor analgesia during residency, further reducing the accessibility of EDA [5].

Globally, there was approximately 140 million births annually [6], and substantial disparities in the methods used for managing severe labor pain. In a World Health Organization recommendation in 2018, the importance of woman-centered care was highlighted (with the recommendation to improve the experience of labor and childbirth), and a global model of intrapartum care was introduced [6]. EDA utilization varies widely from rates as low as 20% in some regions of the world to over 70% in developed countries [6]. These disparities reflect differences in healthcare infrastructure, availability of trained personnel, and cultural attitudes toward pain management [7].

In response to the limitations of conventional pain relief methods, alternative approaches, such as electroacupuncture (EA), have garnered significant attention [8]. EA is a modern adaptation of traditional acupuncture that involves the application of electrical current to needles inserted at specific body points. This technique stimulates the nervous system to trigger the release of endogenous opioids and other neurochemicals that modulate pain perception [9]. Unlike EDA, EA less invasive, does not require an anesthesiologist (requires an EA practitioner), and is associated with a reduced risk of adverse effects [10].

Despite the potential of EA, effectiveness, safety, and acceptability of EA for labor pain management remains under debate. One study suggested that EA applied to SP6 can reduce pain intensity, reduce the active phase of labor, and improve the quality of delivery [11]. By contrast, another study reported that acupuncture, whether using manual or EA, did not significantly reduce labor pain, however, only a few women opted for EA, indicating a potential underestimation of EA’s benefits [12]. These conflicting findings highlight the need for comprehensive evaluation.

This systematic review synthesized evidence from 10 randomized controlled trials (RCTs) to assess the role of EA in labor safety, pain management, and reduced time in labor. By consolidating the available data, this review aimed to inform clinical practice and guide future research on alternative pain-relief methods for childbirth.

Materials and Methods

1. Study design

This systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 statement. The protocol was registered in PROSPERO (registration no.: CRD42024559269).

2. Search strategy

A comprehensive search was conducted across several electronic databases (PubMed, Cochrane Library, Embase, KISS, RISS, ScienceON, OASIS, and CNKI). The search strategy included both keywords and Medical Subject Headings terms related to EA and labor pain. The search terms consisted of variations such as “electroacupuncture,” “labor pain,” “labour pain,” “childbirth pain,” and “delivery pain,” along with their synonyms. Boolean operators such as “AND” and “OR” were employed to refine the search results. Additionally, forward and backward citation tracking was utilized. No restrictions were imposed on language or publication dates during the search process.

3. Inclusion and exclusion criteria

3.1. Inclusion criteria

This review exclusively included RCTs to provide robust evidence on the effectiveness of EA in managing labor pain. Studies were deemed eligible if they involved pregnant women in labor, regardless of age, ethnicity, or gestational stage. The intervention specifically involved EA aimed at reducing labor pain. The included studies also had to have a comparison group, which could consist of conventional care (e.g., usual pain management practices without EA), placebo (e.g., sham EA), or no intervention.

3.2. Exclusion criteria

Non-randomized studies, observational studies, case reports, and qualitative studies were excluded. In addition, studies involving women with conditions that significantly altered their labor experience such as high-risk pregnancies requiring medical interventions unrelated to pain management were also excluded. Research focusing on traditional acupuncture without electrical stimulation or employing EA for purposes other than labor pain relief was not considered. Furthermore, studies comparing EA with non-analgesic interventions, or those lacking a relevant comparator group were also excluded.

3.3. Study selection and data extraction

Two independent reviewers screened titles and abstracts for eligibility. Full-text reviews were performed for studies that met the inclusion criteria or for which eligibility was unclear. Disagreements between reviewers were resolved through discussion with a 3^rd reviewer. Data was systematically extracted using a standardized form capturing details of the study characteristics, laboring women demographics, intervention specifics, outcomes, and adverse effects. Where necessary, the study authors were contacted for additional information or clarification.

3.4. Risk of bias assessment

The risk of bias (ROB) in the included studies was assessed using the Cochrane Risk of Bias tool (RoB-2). This tool evaluates potential biases across several domains including selection, performance, detection, attrition, and reporting. Each domain was rated as “low risk,” “high risk,” or “some concerns,” and the overall ROB was considered when interpreting the results.

4. Data synthesis

A narrative synthesis of the included studies was performed to summarize the key findings related to the effectiveness of EA for labor pain relief. Where possible, a meta-analysis was conducted using a fixed-effects model to pool data from studies that reported comparable outcomes. Heterogeneity was interpreted based on the following categories: (1) values ranging from 0%–40% were considered unimportant; (2) 30%–60% indicated moderate heterogeneity; (3) 50%–90% reflected substantial heterogeneity; and (4) 75%–100% represented considerable heterogeneity.

Results

1. Study selection

A total of 154 studies were identified based on the search strategy. After removing 51 duplicate records, 103 studies were included in the analysis. These studies were screened based on their title and abstract. Of these, 36 were assessed for eligibility through a full-text review. During this process, 26 studies were excluded for the following reasons: (1) improper interventions, such as transcutaneous electrical nerve stimulation or acupuncture without electrical stimulation (8 studies); (2) non-RCTs, including reviews, guidelines, or clinical trials without randomization (16 studies); (3) inability to obtain the full text (1 study); and (4) follow-up study (1 study). Ultimately, 10 studies were included in this review, with a subset selected for meta-analysis (Figure 1).

Figure 1

Preferred Reporting Items for Systematic reviews and Meta-Analyses flow diagram.

*PubMed, Cochrane Library, Embase, KISS, RISS, ScienceON, OASIS, and CNKI.

RCT = randomized controlled trial.

2. Characteristics of the included studies

There were 10 full-text articles identified that met the inclusion criteria (Table 1 [12–21]). The 1^st RCT on EA for labor pain was published in 2007. Between 2007 and 2023, the number of trials conducted each year ranged from 0 to 3. Notably, no clinical trials were conducted during 2008–2010, 2012–2013, 2016–2018, or 2021–2022 (Figure 2).

Table 1

Characteristics of Published RCTs

Figure 2

Trends in the number of clinical studies on electroacupuncture for labor pain management (2007–2023).

3. Treatment groups and sample characteristics

An analysis of the 10 included studies identified four main groups: EA, sham EA, manual therapy, and control. Most studies focused on comparing EA with control groups, whereas some incorporated multiple EA groups to evaluate variations in EA interventions.

The sample size per group varied across studies, ranging from 18 to 100 laboring women [13,14]. Collectively, this review included data from 10 studies with approximately 1,498 women, providing a broad representation for assessing the effects of EA on labor pain management. The women’s ages predominantly ranged between 25 and 33 years, with comparable age distributions observed across the EA, sham EA, manual therapy, and control groups, ensuring a balanced demographic representation across the study arms.

The gestational age was primarily between 37 and 41 weeks, corresponding to full-term pregnancies. A few studies have reported mean gestational ages closer to 40 weeks [14–16].

4. Treatments utilized in studies

Among the included studies, SP6 was the most frequently used acupoint, featured in nine studies [13–21], followed by LI4 in five studies, and ST36 in three studies [17,18,20,21]. Additional acupoints, including BL60, BL67, PC6, EX-B2, and ear points, were used in each included study (Figure 3).

Figure 3

Frequency of acupoints used in clinical studies on electroacupuncture for labor pain management.

The control conditions varied across studies. Some studies employed usual conventional care (including patient-controlled EDA) as a control measure, whereas others utilized sham EA involving placebo needles applied to non-acupoints without skin penetration or electrical stimulation [14,15,17,19–21]. In certain cases, laboring women were allowed to select additional non-acupuncture-based pain relief methods in collaboration with the midwives [20].

5. Outcome measures

In total, seven types of outcomes were assessed across the 10 clinical studies. Each outcome was categorized as either “statistically improved” or “not significant.” The visual analog scale (VAS) score was the most commonly employed measure for evaluating the severity of labor pain, with 10 studies (90%) demonstrating a statistically significant improvement in pain relief following EA application compared with sham EA, sham manual and EA, and control groups [13–21]. Only one study reported a non-significant result [12]. Results are shown in Figure 4.

Figure 4

Outcome measures assessed in clinical studies on electroacupuncture for labor pain management.

VAS = visual analog scale.

Labor duration following EA was statistically significantly improved in four studies compared with control groups, including routine obstetric care and epidural analgesia [14,17,18,21]. EDA usage was assessed in two studies and was not statistically significantly different to EA in terms of labor duration [12,16].

Other outcomes included serum β-endorphin levels, amount of bleeding, and analgesic usage which were each assessed in two to three studies [13,15,17,19]. These outcomes demonstrated positive changes in a small subset of studies.

6. ROB assessment

The details of the ROB for each RCT are summarized in Figure 5.

Figure 5

Risk of bias assessment.

6.1. Bias arising from the randomization process

The ROB due to the randomization process was rated as “low” in 6 studies [12–15,20,21]. However, in 4 studies, the concealment of the allocation sequence remained unclear, and thus resulting in a rating of “concern” [16–19].

6.2. Bias due to deviations from intended interventions

Nine studies were rated as having a “low” ROB due to deviations from intended interventions [13–21]. In 1 study, the context of the clinical trial made it unclear whether deviations had occurred, resulting in a rating of “concern” for ROB [12].

6.3. Bias due to missing outcome data

The ROB from missing outcome data was regarded as “low” in 6 studies with no missing data [13–15,18,20,21]. In 3 studies, the missing data were unlikely to be dependent on true values, leading to a rating of “some concerns” for ROB [12,16,17]. One study lacked sufficient information to determine dependencies, which led to a “high” ROB [19].

6.4. Bias in outcome measurement

Three studies were rated as having a “low” ROB as the outcome assessors were blinded [13,20,21]. In the remaining 7 studies, the blinding status of the outcome assessors remained unclear, raising the possibility of bias due to awareness of the intervention. Consequently, these studies were rated as having “some concerns” [12,14–19].

6.5. Bias in the selection of the reported results

One study had a “low” ROB in the selection of reported results [13]. In 9 studies, whether the analyses followed pre-specified plans or if data were analyzed prior to unblinding was unclear, resulting in a rating of “some concerns” [12,14–21].

7. Meta-analysis

Various assessment tools were used by the 10 studies. However, due to the lack of necessary data for quantitative synthesis, such as missing mean and SD values, only a limited number of studies were included in the final meta-analysis. Control group duplication in Dong et al [18] was resolved by halving the control sample size to prevent overestimation. All meta-analysis figures can be found in Supplementary Material 1.

7.1. VAS score 30 minutes post-intervention

Three studies assessed the effect of EA on VAS scores 30 minutes post-intervention. The meta-analysis demonstrated a significant reduction in pain in the EA group compared with the control group. There was with a mean difference of −1.12 [95% confidence interval (CI): −1.43 to −0.80, p < 0.001], and no substantial heterogeneity (I² = 0%, Chi² = 0.76, p = 0.68).

7.2. VAS score 60 minutes post-intervention

Two studies evaluated VAS scores 60 minutes post-intervention and reported significant pain reduction in the EA group compared with the control group. There was a mean difference of −2.07 (95% CI: −2.42 to −1.72, p < 0.00001). In addition, moderate heterogeneity was also observed (I² = 45%, Chi² = 1.82, p = 0.18).

7.3. Labor duration (Stage 1)

Four studies investigated the effect of EA on the duration of the 1^st stage of labor and demonstrated a statistically significant reduction of −31.10 minutes (95% CI: −37.56 to −24.65, p < 0.00001) for the EA group compared with routine care, standard care, and epidural analgesia. Additionally, significant heterogeneity was also noted (I² = 85%, Chi² = 19.60, p = 0.0002).

7.4. Labor duration (Stage 2)

In the 2^nd stage of labor, based on the findings of four studies, EA significantly reduced labor duration by −7.49 minutes compared with routine care and epidural analgesia (95% CI: −10.73 to −4.26, p < 0.00001). Considerable heterogeneity was observed (I² = 87%, Chi² = 22.91, p < 0.00001).

8. Adverse events

Adverse effects were rare. Only one study recorded adverse events according to their protocol, reporting mild discomfort in one patient. In this study by Jin et al [15], patients were randomized after surgery to receive 2-Hz electroacupuncture treatment (n = 53), and 1.89% of them experienced mild adverse effects, including localized discomfort. Adverse events were not reported in the remaining nine studies. Apgar scores were evaluated in three studies, but none demonstrated statistically significant differences between EA and control groups, including sham EA, standard care, and epidural analgesia [17,19,21]. The lack of comprehensive and consistent reporting on adverse effects prevents robust conclusions from being made.

Discussion

This systematic review and meta-analysis of 10 RCTs conducted between 2007 and 2023, evaluated the safety and effectiveness of EA in managing labor pain and duration. Most studies focused on acupoints, such as SP6, LI4, and ST36, which are closely associated with pain management. These findings indicated that EA significantly reduced pain intensity during labor (as demonstrated by improvements in VAS scores across most studies). Furthermore, EA reduced the duration of the 1^st and 2^nd stages of labor. Reports of adverse effects were minimal in the 1 study that reported adverse events; mild localized discomfort in 1.89% of laboring women receiving 2-Hz EA. The remaining 9 studies did not report adverse events as part of the study protocol, highlighting a significant gap in AE reporting. While the limited data suggest that EA is likely safe, further research with systematic AE reporting is required to confirm its safety.

Previous studies on labor pain management have explored various approaches including traditional acupuncture, acupuncture combined with massage, and acupressure [22,23]. This review focused exclusively on EA which enabled the observation of its effects on labor pain by excluding other treatment methods.

EA is emerging as an effective alternative to EDA for managing labor pain [19,21] In addition, in the management of postoperative pain following a cesarean delivery, combining EA with patient-controlled intravenous analgesia (PCIA) has been reported to be effective in terms of reduced requirement for PCIA [15]. This suggests that EA can also provide analgesic effects when used in conjunction with conventional pain management methods. Specifically, the combination of EA and PCIA contributed to reduced analgesic consumption and improved patient satisfaction, highlighting EA’s potential not only as a standalone treatment but also as an integrative medicine, a complementary tool to optimize pain management.

EDA is a sophisticated medical procedure requiring skilled anesthesiologists and specialized equipment. Financial constraints, inadequate healthcare infrastructure, and a shortage of trained personnel pose significant barriers to healthcare services in low- and middle-income countries, making it challenging to implement advanced medical services like EDA [24]. In contrast, EA is less invasive, and requires minimal equipment, it requires technical expertise but can be effectively implemented even in resource-limited settings. EA safely and effectively alleviates labor pain and shortens the labor process even in resource-constrained environments [14]. These findings suggest that EA can serve as an alternative to EDA in settings with limited resources or as an integrative medicine, complementary tool to existing pain management methods in more resource-abundant settings.

EA appears to effectively manage labor pain, by targeting specific acupoints that influence physiological functions related to pain perception and uterine activity, labor pain is lessened. Acupoint SP6, the most commonly used acupoint, has been reported to reduce labor pain, regulate uterine muscle contractions, and shorten labor duration [25,26]. LI4, another key acupoint, has broad analgesic effects and is commonly used to alleviate labor pain [27]. ST36 is associated with analgesic effects mediated by the serotonergic system and contributes to pain relief and overall well-being [28].

In an animal model, stimulation of ST36 has been reported to regulate a non-selective cation channel that detects pain and temperature changes (transient receptor potential vanilloid 1) and decrease expression of a kinase (phosphorylated extracellular signal-regulated kinase) involved in critical pain-modulating regions such as the somatosensory cortex, amygdala, and thalamus. In a pain and depression comorbidity animal model, combined stimulation of ST36 and SP6 improved pain and depressive behaviors by regulating serotonin (5-HT) in the dorsal raphe nucleus [29].

Other acupoints including BL60, BL67, those on the ear, PC6, and EX-B2 were utilized in each of the 10 studies. BL60 has been linked to sensory pain inhibition and anxiety reduction [30], while BL67 is recognized for relief of labor pain [31] PC6 and LI4 are significant acupoints in meridian theory that increase pain thresholds, alleviate microvascular spasms, and modulate pain by involving the prefrontal cortex and ventrolateral thalamus. A previous study has also highlighted the importance of LI4 and PC6 in relieving pain from thoracic surgery which demonstrates their versatility as analgesic acupoints [32].

The meta-analysis in this study demonstrated significant reductions in VAS scores measured at 30 and 60 minutes after the intervention. It has been reported that prolonged EA application enhanced analgesic outcomes [33,34]. EA also reduced the duration of the 1^st and 2^nd stages of labor, although the high heterogeneity across the 10 studies emphasized the need for standardized intervention protocols. Despite these promising results, many of the included studies had an overall ROB rated as “some concerns” or “high,” ROB particularly due to missing outcome data and performance bias stemming from the lack of blinding. This highlights the need for caution in interpreting these findings. The less invasive nature of EA compared with EDA, and its minimal resource requirements render the approach a practical and effective alternative to invasive pain management techniques, particularly in settings with limited resources.

This study had several limitations. Firstly, the number of included RCTs was limited and most studies were performed in China, potentially limiting the generalizability of the findings to other populations and healthcare settings. Secondly, adverse effects were not reported as part of the RCT protocol in the included studies (with the exception of 1 RCT). This lack of data hinders the ability to draw definitive conclusions about the safety of EA. Thirdly, methodological issues, such as the lack of blinding in some studies, may have introduced performance bias, particularly for subjective outcomes such as pain scores. Variability in EA protocols, including acupoint selection and stimulation parameters, further contribute to the heterogeneity. Finally, the small sample sizes in some studies reduced the robustness of the findings of this systematic review and meta-analysis.

Future research is required whereby large, multicenter, well-designed RCTs (with standardized EA protocols) will improve the reliability of the findings, and work on diverse populations and healthcare settings would enhance generalizability. Longterm studies examining EA safety profiles are required to identify potential adverse effects over time. Additionally, exploring the combined effects of EA and conventional methods of pain relief during labor could reveal synergies for optimizing labor pain management strategies.

Conclusion

EA demonstrates promise as a safe and effective method for managing labor pain. By targeting acupoints such as SP6, LI4, and ST36, EA significantly reduced pain intensity and enhanced maternal comfort during labor. The less invasive nature of the technique compared with EDA and its minimal resource requirements make it a particularly attractive option in resource-limited settings. However, the results of this review can only be applied to study setting and methodological inconsistencies indicate that further high-quality research is essential to support these findings and broaden their applicability.

Supplementary Materials

Supplementary materials are available at doi: https://doi.org/10.56986/pim.2025.02.002.

pim-2025-02-002-Supplementary-Material-1.docx

Notes

Conflicts of Interest

The authors have no conflicts of interest to declare

Funding

None

Ethical Statement

Not applicable

Data Availability

The data that support the findings of this study are available on request from the corresponding author.

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Table 1

Characteristics of Published RCTs

Author (y) [ref]	Treatment (n)	Age (y)	Pregnancy period (wk)	Group 1	Group 2	Group 3	Results
Dong (2015) [18]	EA1 (60) EA2 (60) Control (60)	EA1 29.40 ± 2.96 EA2 29.12 ± 2.88 Control 28.98 ± 2.64	-	EA on EX-B2	EA on SP6	Control (routine intrapartum care)	(EA1 vs control / EA2 vs control) 1. VAS Scores (positive b, positive b) 2. Active labor phase duration (positive b, positive a) 3. Neonatal outcomes (NS)
Jin (2023) [15]	EA1 (53 EA2 (53) Sham EA (52)	EA1 30.83 ± 3.59 EA2 30.13 ± 3.31 Sham EA 31.19 ± 3.37	37.96 ± 1.64 38.32 ± 1.45 38.19 ± 1.28	PCIA (patient-controlled intravenous analgesia) + 2 Hz EA on ST36, SP6	PCIA + 20/100 Hz EA on ST36, SP6	PCIA + Sham EA	(EA1 vs sham EA / EA2 vs sham EA) 1. NAPC (number of analgesic pump compressions) at 6, 12, 24, 48 h (positive c, positive c) 2. VAS Scores at 6, 12, 24, 48 h (positive c, positive c) 3. Fentanyl consumption at 6, 12, 24, 48h (positive c, positive b^† ) 4. time to first exhaust (NS, NS) 5. Serum IL-6, PCT at 12, 48 h (NS between three groups)
Li (2020) [19]	EA (37) Sham EA (36) Control (31)	EA 30.3 ± 4.2 Sham EA 30.5 ± 5.3 Control 30.8 ± 4.7	278.4 ± 7.3 277.1 ± 7.9 278.0 ± 7.6	EA on SP6, LI4	Sham EA on SP6, LI4	Control (epidural block)	1. VAS Scores (positive a) 2. Serum β-EP levels (positive a) 3. Sufentanil/Ropivacaine usage (positive a) 4. Bleeding amount (positive a) 5. Oxytocin secretion period (NS) 6. Apgar score (NS)
Ma (2011) [14]	EA (92) Sham EA (94) Control (100)	EA 26.15 ± 2.83 Sham EA 26.39 ± 2.96 Control 25.55 ± 3.00	38–41 wk	EA on SP6	Sham EA on SP6	Control (regular parturient in labor)	1. VAS Scores 1-1. Needle retention (30 min) (positive a) 1-2. 2 h, 4 h after needle withdrawal (positive a)
Mackenzie (2011) [20]	EA (26) Manual (26) Sham manual & EA (27) Control (26)	EA 31.0 ± 4.4 Manual 32.5 ± 5.1 Sham manual & EA 30.5 ± 5.1 Control 31.1 ± 5.1	37–41 wk	EA & manual on LI4, SP6, BL60, BL67	Sham EA on LI4, SP6, BL60, BL67	Control (standard care)	1. Analgesia (epidural, parenteral) (NS ^‡) 2. Clinical and neonatal outcome (NS ^‡ )
Li (2019) [16]	EA (37) Sham EA (36) Control (31)	EA 30.4 ± 4.8 Sham EA 30.3 ± 5.2 Epidural block 30.4 ± 4.8	EA 278.5 ± 7.3 / Sham EA 277.1 ± 7.9 / Epidural block 278.0 ± 7.7	EA on SP6, LI4	Sham EA on SP6, LI4	-	1. VAS Scores (positive a) 2. ACTH levels (positive a) 3. COR levels (positive a) 4. PCEA use (positive a)
Qu (2007) [13]	EA (18) Control (18)	EA 28.7 ± 3.1 Control 28.9 ± 2.9	EA 39.6 ± 1.1 Control 39.9 ± 0.9	EA on LI4, SP6	Control (Natural vaginal delivery without pain relief)	-	1. VAS Score (positive a) 2. VAS (Relaxation) Score (positive a) 3. b-EP level (positive a) 4. 5-HT levels (positive a)
Sun (2019) [17]	EA (76) Control (76)	EA 27.82 ± 3.14 Control 27.63 ± 3.62	EA 39.41 ± 0.34 Control 39.27 ± 0.31	EA on ear acupuncture (uterus, shen men point), SP6, LI4	Control (standard obstetric care without acupuncture or EA)	-	1. VAS Scores (positive a) 2. Labor duration (positive a) 3. Blood loss (positive a) 4. Delivery method (spontaneous) (positive a) 5. Fetal distress (positive a) 6. Apgar score (NS)
Vixner (2014) [12]	MA (83) EA (87) Control (83)	MA 26.5 ± 4.8 EA 27.6 ± 4.6 SC 28.3 ± 5.0	MA 40 EA 39 SC 40	MA and EA Groups were treated with 13–21 needles, at 3 bilateral distal points and 4–8 bilateral local points,	EA	Control (Swedish clinical practice)	1. Vas Score (NS) 2. Epidural analgesia use (positive^§)
Xiao (2019) [21]	EA (60) Control (60)	EA 27.62 ± 2.86 Control 27.72 ± 2.60	EA 274.55 ± 7.77 Control 275.60 ± 7.59	CSEA + PCEA + EA on LI4, PC6, ST36, SP6	Control (CSEA + PCEA)	-	1. VAS scores (positive a) 2. Complications 2-1. Fever, Urinary retention (positive c) 2-2. Skin itch, Rests (NS) 3. Use of oxytocin (positive c) 4. Instrumental delivery (NS) 5. Cesarean section (NS) 6. Duration and neonatal outcome 6-1. Duration (positive) Cer 3–10 cm positive c / second stage NS / Third stage positive a 6-2. Cord blood pH (NS) 6-3. Apgar score (NS)

6 h positive bx.

^†

12 h positive c.

^‡

Manual + EA vs sham/control.

^§

EA vs SC: odds ratio [OR] 0.35; [95% CI] 0.19–0.67.

ACTH = adrenocorticotropic hormone; β-EP = beta-endorphin; CSEA = combined spinal-epidural analgesia; CI = confidence interval; COR = cortisol; EA = electroacupuncture; IL-6 = interleukin 6; MA = manual acupuncture; NAPC = number of analgesic pump compressions; NS = not significant; OR = odds ratio; PCIA = patient-controlled intravenous analgesia; PCEA = patient-controlled epidural analgesia; PCT = procalcitonin; RCT = randomized controlled trial; VAS = visual analogue scale; 5-HT = serotonin.