Ice Massage for the Reduction of Labor Pain

Bette L. Waters, CNM, RN, and Jeanne Raisler, CNM, DrPH, FACNM
The current study investigated the use of ice massage of the acupressure energy meridian point large intestine
4 (LI4) to reduce labor pain during contractions. LI4 is located on the medial midpoint of the first metacarpal,
within 3 to 4 mm of the web of skin between the thumb and forefinger. A one-group, pretest, posttest design
was chosen, which used 100-mm Visual Analog Scales (VAS) and the McGill Pain Questionnaire (MPQ)
ranked numerically and verbally to measure pain levels; the pretest served as the control. Study participants
were Hispanic and white Medicaid recipients who received prenatal care at a womens clinic staffed by
certified nurse-midwives and obstetricians. Participants noted a pain reduction mean on the VAS of 28.22
mm on the left hand and 11.93 mm on the right hand. The postdelivery ranked MPQ dropped from number
3 (distressing) to number 2 (discomforting). The study results suggest that ice massage is a safe, noninvasive,
nonpharmacological method of reducing labor pain. J Midwifery Womens Health 2003;48:317321 2003
by the American College of Nurse-Midwives.
keywords: labor, first stage, pain relief, acupressure, ice massage

A womans experience of labor pain is influenced by many

elements including her past experiences of pain, her coping
abilities, the birth environment, and psychosocial factors.
The definition of pain as an unpleasant and emotional
experience resulting from actual or potential tissue damage
has powered the scientific study and management of pain in
recent decades. Labor pain differs from other forms of pain
in that no actual trauma or tissue damage occurs. Chapman1
describes labor pain as stimuli of receptive neurons arising
from contractions of the uterine muscles, which is referred
to as the visceral, pelvic, and lumbar-sacral areas. To date,
labor pain management studies have focused on use of
drugs that affect sensory awareness of pain, which may
have the additional effect of impeding womens active
participation in giving birth.
McCafferys definition, Pain is whatever the experiencing person says it is, and happens whenever the experiencing person says it does,2 reflects the midwifery approach to
labor management. This philosophy supports management
options that include diverse methods for decreasing pain
while not eliminating the source.
Even though there has been enormous growth in complementary alternative medicine (CAM) research in the past
decade, few well-designed studies on the use of CAM in
pregnancy or childbirth have been conducted. Some of the
most interesting of the studies are those based in traditional
Chinese medicine, which is a complex ancient system of
healing that includes the use of acupuncture, acupressure
(acupuncture without needles), moxibustion (stimulation of
acupuncture points with heat from a burning herb), massage, diet, herbs, and exercise to promote health and treat
disease. Within the framework of traditional Chinese medicine, the stimulation of acupuncture points by these treatments is a way of initiating, controlling, or accelerating

Address correspondence to Bette L. Waters, CNM, RN, 1504 South Silver

Street, Deming, NM 88030.
Statistical analysis was funded by a grant from Memorial Medical Center
Foundation, 1675 South Don Rosser Street, Las Cruces, NM 88011.

Journal of Midwifery & Womens Health www.jmwh.org

2003 by the American College of Nurse-Midwives
Issued by Elsevier Inc.

body functions by stimulating energy channels (meridians)

beneath the skins surface and rebalancing the bodys
energy (Qi) to restore health.3 Shiatsua Japanese healing
modality based on acupuncture uses massage to stimulate
the energy pathways.
Despite the exponential growth of research on traditional
Chinese medicine in the past decade, the mechanisms of
action of acupuncture, acupressure, and moxibustion are
still largely unexplained in the Western scientific model.
Western research on the use of traditional Chinese medicine
in obstetrics has focused on the effect of acupuncture/
acupressure on nausea and vomiting during pregnancy4,5
and on the use of moxibustion for breech version.6 In the
1970s and 1980s, studies on the use of acupuncture for
labor induction and labor analgesia were carried out, but
there were problems with the study methods, including
small sample sizes, the variety of methods for assessing
pain, and in some studies, the lack of a control group.
However, many effective CAM therapies, including massage, therapeutic touch, hydrotherapy, music, heat, and
cold, are used by midwives to reduce labor pain.7
The purpose of this study was to evaluate the effectiveness of the use of ice massage of the energy meridian point,
large intestine 4 (LI4), during contractions to reduce the
womans perception of labor pain. The energy meridian
pathway is bilateral. The LI4 point is located on both the
right and the left hands. Ice massage was performed on both
hands, and any differences in pain sensation were measured
and compared.
BACKGROUND
Cooling Temperatures to Reduce Pain
Ice or cooling applied to an injured body part is used as
standard treatment of trauma, bleeding, swelling, and soft
tissue injuries.8 Ice is commonly used to reduce pain of
perineal lacerations or episiotomy in the postpartum period.
The early work of Denny-Brown et al.9 showed that cold
temperature effectively blocks nerve conduction in sensory
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1526-9523/03/$30.00 doi:10.1053/S1526-9523(03)00277-0

fibers. Grant10 advocated massage with ice for the treatment

of musculoskeletal pain and named his technique cryokinetics. Marshall11 published a study using ice cube massage
for the relief of chronic pain of herpes of the eye.
Melzack et al.12,13 found that intense sensory input
produced by ice massage of the web between the thumb and
forefinger resulted in a 50% reduction in acute dental pain.
The researchers hypothesized that the efficacy of ice
massage was due to engaging the gate control pain system
rather than eliminating the source of the pain.14 They
hypothesized that the positive and negative effects of the
different impulses counteracted each other at the gate
level in the spine. When impulses reaching the spine
pathway to the brain are stimulated by techniques such as
vibration, scratching, or ice massage, the gate closes,
resulting in a decrease in the sensation of pain. In addition,
Melzack and his colleagues connected their work to acupuncture relying on the correlation between trigger points
used in Western medicine that corresponded to acupuncture
points used in traditional Chinese medicine.15
Large Intestine Energy Meridian
The large intestine energy meridian point that Melzack used
in his study on ice massage for dental pain reduction is
referred to as LI4 or Hoku. The energy meridian pathway is
bilateral and begins in the surface of the skin at the root of
the index fingernail. It courses on the external part of the
arm. The outward end of the shoulder blade is crossed.
Then the meridian leaves the skin surface to connect with
the lower part of the lung and transverse colon. It then
returns to the skin surface at a point under the chin. From
that point, the meridian is again buried deep within the area
referred to as the double chin. It follows the lower row of
dental roots, passing then to the upper line of teeth roots,
crossing the front of the mouth to emerge on the skin surface
and the facial point next to the nostrils16 (Figure 1).
Shiatsu practitioners17 describe LI4 (also referred to as
Hoku) as being located on the inner lateral midpoint of the
first metacarpal. The area between the thumb and forefinger
is within 3 to 4 mm of the location of an LI4 (Figure 2).
A pilot study was developed on the basis of Dr. Melzacks use of ice massage of LI4 to reduce dental pain after
discovering that Aleda Erskine18 linked dental pain, childbirth pain, and myocardial infarction under the category of
acute clinical pain. Acupuncture or acupressure points

Bette L. Waters, CNM, RN, is the author of Vaginal Politics: A Midwifes

Story, Bluwaters Press, Deming, NM, 2003, and Massage During Pregnancy,
3rd Edition, Sundance Press, Inc, El Paso, TX, 1998. She is also a Sexual
Assault Nurse Examiner (SANE) for the SANE Project, LaPinon Rape
Recovery Center, Las Cruces, NM.
Jeanne Raisler, CNM, DrPH, FACNM, is an Assistant Professor at the
University of Michigan, Ann Arbor, MI, where she teaches Midwifery and
Complementary and Alternative Medicine. She is a consultant to the Global
AIDS Program of the Health Resources and Services Administration and
Chair of the American College of Nurse-Midwives Division of Research.

318

Figure 1. Large intestine energy meridian pathway.

used for the relief of a particular pain syndrome often lie

within or near the pain area, but many are located at a
distance. The large intestine pathway moves from the tip of
the forefinger up to the face and circles the teeth; it
bifurcates at the shoulder to move downward wrapping
around the entire colon. At term pregnancy, the colon
practically encircles the upper portion of the uterus. The
location of LI4 is a point where the energy flow of the
meridian is closest to the skin and can be easily stimulated
with pressure, needles, or extreme cold and pressure.
The pilot study using ice massage for reducing labor pain
was carried out by a researcher in 1992.19 Twenty women
were recruited to participate in this study on their admission
to the labor and delivery unit at Humana Hospital, Dade
City, FL. Ice massage of the energy meridian LI4 was
performed during each contraction and was carried out over
a 30-minute period. Data from the Visual Analog Scale

Figure 2. Large intestine energy point four, also known as LI4 and Hoku.
Reprinted with permission from Massage During Pregnancy, 1st
Edition, by Bette L. Waters, Research Triangle Publishing, FuquayVarina, NC, 1995.

Volume 48, No. 5, September/October 2003

(VAS) showed a mean reduction in pain of 25.15. The

reduction of pain was statistically significant despite the
small number of participants. The statistical standard was
matched pairs t test. The current study expands on this
previous work using a larger sample and tested efficacy of
right-hand ice massage versus left-hand.
METHODS
A one-group, pretest, posttest design was chosen.20 The
pretest was a 100-mm VAS. The VAS has been extensively
used and validated in pain research and is considered to be
a valid measure, especially in a one-time intervention
study.21,22 The pretest was used to measure labor pain
intensity before ice massage and served as the control.
Posttest 1 was a 100-mm VAS for both the right hand and
the left hand. It was used to measure pain intensity during
ice massage intervention and to compare pain intensity on
the right hand versus the left hand. Pretest and posttest 1
scores were compared by using standard analysis of variance, Statistical Analysis System, Version 8.00. Pain response differences were multiples that consisted of three
elements: pain before massage, pain during massage of the
left hand, and pain during massage of the right hand. These
differences were identified by using Duncans New Multiple Range test.23
Posttest 2 was the McGill Pain Questionnaire (MPQ)
Verbal Rating Scale. The MPQ is the most widely used
instrument in pain research and practice.24,25 It consists of
verbal pain descriptors designed to capture the intensity
continuum of pain ranging from mild to excruciating, and
ranked numerically from 1 to 5. The participant scored two
questions using the MPQ: (1) What was your pain before
you started the ice massage? (2) What was your pain while
using the ice massage? The MPQ was analyzed by using a
standard analysis of variance equivalent to a paired t test.26
If data collected in posttest 2 follows the pattern of posttest
1, it is regarded as a valuable corroboration of the data.
To reduce threats to the validity, posttest 1 was administered immediately after the intervention, 40 minutes or
less after scoring the pretest. This small window of time
between the pre- and posttest helped to eliminate intervening events that could alter the posttest scoring. Posttest 1
was presented to the study participants on a separate sheet
of paper so they could not see where they had marked on
the pretest VAS. VAS tool copies were made from a master
copy on the same copy machine. Posttest 2 was administered within 24 hours after the delivery. Postponing the
scoring of this test until after the woman, especially the
primigravida, had experienced the process of the labor and
birth with full knowledge of all its intensity strengthens any
corroborative data.
Study participants were a convenience sample of English-speaking Hispanic and white Medicaid recipients who
received prenatal and delivery care from a clinic team of
certified nurse-midwives and obstetricians at a 250-bed
Journal of Midwifery & Womens Health www.jmwh.org

hospital in New Mexico. They were recruited for the study

on the basis of the availability of the investigator after being
evaluated and admitted to the hospital in labor by their
midwife or physician. The gestational age of the participants was determined to be between 37 and 41 weeks by an
early sonogram. All participants had a reactive fetal heart
rate monitoring strip and were having contractions at least
every 10 minutes with some cervical changes, either effacement or dilation. Women diagnosed with pre-eclampsia or
chorioamnionitis were excluded from the study. Women
whose labor was induced, those who had narcotics in the
past 8 hours, and women with an underlying disease that
precluded attendance by a nurse-midwife were excluded
from the study. In addition, women dilated more than 8 cm
were excluded. It was believed that the intensity of the
labor contractions during this transition could decrease
participants cognitive abilities and thus compromise the
data obtained. Previous research reported27 that women
found the VAS difficult to use when experiencing severe
labor pain. The use of women in the early stages of labor
eliminated the ethical issue of withholding pain medications they might want to use as labor progressed.
The sample size was not predetermined. The goal was to
recruit as many subjects as possible within a 12-month
period. Unlike many other studies28 of non-pharmacological methods of pain relief, these participants had no prior
commitment to giving birth without pain medication, and
most expected to receive either narcotic or epidural analgesia at some point in the labor.
The clinical investigation protocol and consent form
were approved and monitored by Memorial Medical Centers Institutional Review Board. After obtaining verbal and
written informed consent, the investigator presented the
pretest and explained to the subject how to mark her pain
intensity at the present moment on the VAS. Ice massage
was started at the initiation of the next contraction. Approximately one-third cup of crushed ice was placed in the
center of a soft, thin terry wash cloth, and the four corners
of the washcloth were lifted to the center and twisted to
make a small ice bag. The ice bag fit snugly between the
thumb and forefinger. To ensure that cold was applied only
to the skin of the palm, the ice bag was placed on the medial
(palm side) aspect of the hand (Figure 3).
The lateral aspect of the participants hand was supported
by the hand of the person performing the massage. The
massage was stopped when the contraction ended and
restarted when the next contraction began. The ice bag was
rocked back and forth over the area of the web of skin
between the thumb and the forefinger. The pressure of the
ice bag was comparable to light scratching and was
intended to mildly irritate the neuron endings in the skin
It should be noted that the exact point of LI4 is located
on the medial aspect of the first metacarpal. The skin or
epidermis located directly over this point is part of the outer
part of the hand and is thin. Ice massage over this area can
cause breakdown of skin integrity due to cold temperatures
319

Table 1. Pre- and Posttest 1

Mean pain response on VAS

Pretest

Posttest 1
Right Hand

Posttest 1
Left Hand

61.53

49.60

33.31

Visual Analog Scale (VAS) scores of pre- and posttest 1 and scores for left- versus
right-hand use.

Figure 3. Ice bag use at large intestine energy point 4 (LI4). Correct
positioning of small ice bag for massage stimulation of LI4.

and friction. However, the web of skin between the thumb

and forefinger shown in Figure 2 is part of the thick, hard,
and horny texture of the palm and can withstand the
intermittent friction and cold temperatures used in this
technique.29
The massage was carried out on one hand for 20 minutes
or throughout three or four contractions, whichever occurred first. It was then repeated in the same manner on the
other hand. The selection of right hand or left hand first was
based on what activity the study participant was engaged in
at the time the ice massage began. If she was in bed, the
choice was determined by which side of the bed the fetal
monitor was located. If she was walking in the halls or
soaking in the Jacuzzi, the investigator accepted the participants choice.
At the end of the massage period (40 minutes or less), the
subject was given VAS posttest 1 on a separate sheet of
paper. She marked on the VAS the amount of pain she
experienced while using the ice massage on the right hand
and the left hand. At the end of the intervention, the
investigator taught a family member how to continue the
ice massage if the study participant desired.
Posttest 2, the ranked MPQ designed to measure memory
of pain, was completed by the participant within 24 hours
after delivery.
RESULTS
Fifty-three participants were solicited for the study. Two
women were excluded because they had difficulty understanding the concept of the measurement tool, one dropped
out after reading the consent form, and one withdrew at her
own request, leaving 49 women who completed the study.
Twenty-nine were Hispanic and 20 were white. Their ages
ranged from 16 to 38 years. Fifteen were multigravidas and
34 were primigravidas. Forty-one were dilated 3 or more
centimeters; eight were completely effaced and 1 to 3 cm
dilated at the start of the intervention. None had received
any type of pain medication prior to entering the study.
320

The range of pain intensity on the VAS pretest was 10.0

to 86.0 mm, and the mean value of initial pain intensity was
61.53 mm. After ice massage, the right-hand mean value
was lower (49.60 mm), and left-hand mean value was even
lower than the right-hand (33.31 mm) (Table 1).
In a post hoc test of these multiples using Duncans New
Multiple Range test, it was concluded that the three means
were detectably different. Although ice massage on either
hand provided pain reduction, 46 participants felt less pain
with left hand massage, and six felt less pain with the right.
The principal question addressed on posttest 2 was
whether the memory of pain intensity, before and during ice
massage, was different. Standard analysis was equivalent to
a paired t test. The analysis of variance indicated a
detectable difference in pain scores before and during ice
massage. The mean pain unpleasantness before ice massage
was 3.27, and mean pain unpleasantness after ice massage
was 2.33. The verbal description of pain dropped from
distressing to discomforting (Table 2).
DISCUSSION
The study intervention ended on the completion of posttest
1. No attempt was made to monitor the participants
continued use of the ice massage or to change their minds
about using medication. None of the participants viewed
the technique as a tool to replace the use of narcotic or
epidural pain relief. Three of the participants had cesarean
birth, and several had labor augmentation with intravenous
(IV) oxytocin following the ice massage. One participant
had IV analgesia and continued to use ice massage administered by family members for 12 more hours until she was
completely dilated. All of the study participants had good
outcomes with normal Apgar scores.
Whatever intervention one uses, labor pains grow
closer together and more intense. It should be noted that

Table 2. Memory of Pain Intensity Scale

Mild
1

Discomforting

Distressing

2
3
2.33
4
3.27
After ice
Before ice
massage
massage

Horrible

Excruciating

Scores for posttest 2 for memory of pain intensity.

Volume 48, No. 5, September/October 2003

the ice massage was performed in the early hours of

labor, and the effects may not be generalized to pain
control later in labor. The convenience sample also
restricts the studys generalizability. Other limitations
are that the study was not randomized and the protocol
precluded interobserver comparisons. Finally, interventions from another healing tradition (e.g., Shiatsu-based
ice massage) can seem culturally foreign to Americans
who may be uncomfortable using them. In this study, the
application of ice massage to the Shiatsu energy meridian point, LI4, was a noninvasive, effective tool to help
reduce the intensity and unpleasantness of pain from
early labor contractions. It was more effective on the left
hand for most of the women.
Over the years, the search for answers to controlling
labor pain has focused on drugs that alter mental and
sensory awareness of pain with noxious side effects of the
partial paralysis of epidurals, the confusion of opiates, and
the total absence of memory in the use of scopolamine.
Midwife deliveries take place in homes, birthing centers,
and in hospital settings where women may choose from
multiple pain control methods. Dr. Reynolds30 most astutely notes that most women in the world in remote and
rural areas and Third World countries do not have access to
medical procedures and drugs. Therefore, any technique
that provides safe, effective pain reduction without serious
side effects and that can be given by any health care
professional is a definite advance. The results of this
preliminary study suggest that ice massage of the LI4 may
be in this category and can safely be added to the many
other tools used by midwives, nurses, and physicians.
Further research about this technique is warranted.
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