Hypnotherapy for Labor and Birth. Kathleen R. Beebe

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2 NE Hypnotherapy for Labor and Birth Kathleen R. Beebe

3 Objectives Upon completion of this activity, the learner will be able to: 1. Defi ne and describe hypnosis and hypnotherapy, and describe different types of hypnosis. 2. Describe research fi ndings on hypnotherapy for labor and birth. 3. List and describe actions nurses can take when preparing to care for women who wish to use hypnotherapy during labor and birth. Continuing Nursing Education (CNE) Credit A total of 1 contact hour may be earned as CNE credit for reading Hypnotherapy for Labor and Birth and for completing an online post-test and participant feedback form. To take the test and complete the participant feedback form, please visit awhonn.org. Certifi cates of completion will be issued on receipt of the completed participant feedback form and processing fees. Association of Women s Health, Obstetric and Neonatal Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. Accredited status does not imply endorsement by AWHONN or ANCC of any commercial products displayed or discussed in conjunction with an educational activity. AWHONN is approved by the California Board of Registered Nursing, provider #CEP580. INTRODUCTION There is no published estimate of the numbers of women currently using hypnosis for childbirth; however, it is likely to be a small minority in the United States. The reasons for this are unknown, but are possibly owing to a combination of poor access to perinatal hypnosis training, lack of knowledge about its utility and negative attitudes toward the practice. Detailed demographic data for women selecting hypnosis are also limited. Systematic analyses on the efficacy of hypnotherapy for applications in maternity care conclude that there may be benefits, but contradictory findings prevail. This article will describe the features of hypnosis and hypnotherapy. Background literature on the effectiveness of this technique during childbirth will be reviewed along with implications for nursing practice. Barriers to hypnotherapy in the clinical setting along with strategies for overcoming them will also be addressed. Box 1 provides a case example of labor and birth with hypnotherapy. DEFINITIONS Hypnosis is a procedure during which a person experiences suggested changes in sensation, perception, thought or behavior (Kirsch, 1994, p. 142). It is a condition of intense inner absorption, concentration and focus (American Society of Clinical Hypnosis, 2010), wherein the person experiencing it is fully conscious. Hypnosis is likened to states such as daydreaming or fascination with a riveting movie. In these circumstances, the individual chooses to tune-out or to reappraise certain stimuli in order to focus more completely on the object of attention. Theoretically, this entrancement permits an activation of the subconscious mind, allowing it to override prior habitual or patterned behavior governed by conscious thought (Hypnosis Motivation Institute, 2010). Hypnosis is a voluntary state, wherein one chooses to become receptive to entering the hypnotic state, whether or not a hypnotist is directly involved. At any time, the person could choose to disengage from that state and broaden his/ her sphere of awareness. Unfortunately, misconceptions about hypnosis as a form of mind control, which have Kathleen R. Beebe, PhD, RNC-OB, is an associate professor of nursing at Dominican University of California in San Rafael, CA. The author and planners of this activity report no conflicts of interest or relevant financial relationships. The author discloses that she is certified as a trainer by HypnoBirthing The Mongan Method, which is mentioned in this article, but that she has no financial stake in that organization. No commercial support was received for this learning activity. Address correspondence to: kathleen.beebe@dominican.edu. Abstract: Hypnotherapy is an integrative mind-body technique with therapeutic potential in various health care applications, including labor and birth. Evaluating the efficacy of this modality in controlled studies can be difficult, because of methodologic challenges, such as obtaining adequate sample sizes and standardizing experimental conditions. Women using hypnosis techniques for childbirth in hospital settings may face barriers related to caregiver resistance or institutional policies. The potential anxiolytic and analgesic effects of clinical hypnosis for childbirth merit further study. Nurses caring for women during labor and birth can increase their knowledge and skills with strategies for supporting hypnotherapeutic techniques. DOI: / X Keywords: childbirth HypnoBirthing hypnosis hypnotherapy intrapartum nursing care , AWHONN

4 been promoted by stage acts exemplifying involuntary and sometimes embarrassing behavior, tend to undermine the therapeutic potential of hypnosis by reinforcing a stigma that it holds some dangerous or magical power. Misperceptions have the consequence of breeding suspicion, apprehension and mistrust in hypnosis. Accurate beliefs about hypnosis contribute to more positive attitudes about its use and more effective results with the techniques (Capafons et al., 2008). Box 2 lists some common misconceptions about hypnosis. Hypnosis and hypnotherapy are terms that are often used interchangeably; however, there is an important distinction in that hypnotherapy uses hypnosis techniques with specific intent. Hypnotherapy or clinical hypnosis is an integrative mind-body technique using hypnotic suggestions for a specified, therapeutic purpose mutually identified between a hypnotherapist and a client. Medical and nonmedical indications for hypnosis are numerous and include a variety of applications, such as alleviating phobias, building better time management skills, medical and surgical analgesia, symptom management and many more (Montgomery, Schnur, & Kravits, 2012). A hypnotherapist is a trained mental health or medical professional who has expertise in the treatment condition as well as in hypnosis techniques. Although nearly anyone can be taught how to induce hypnosis, only trained health care professionals should be directing clinical hypnosis (hypnotherapy), as the ability for the techniques to be optimally safe and efficacious depends on the hypnotherapist s skill, experience, knowledge about the client, and the therapeutic objective. Given that there is little formal regulation of hypnosis practice in the United States (only three states require mandatory licensure), consumers need to carefully evaluate the qualifications and certifications of selected hypnotherapy programs and practitioners (Hypnotherapist s Union, Local 472, 2013). Hypnotizability (also known as hypnotic susceptibility or suggestibility) is defined as a trait-like ability, which determines how much an individual experiences or benefits from hypnosis, independent of attitudes or expectations (Barabasz & Perez, 2007). Most experts BOX 1 CHILDBIRTH USING HYPNOTHERAPY: A CASE STUDY Evidently Beth, the pregnant woman presenting at the admissions desk of the labor and delivery unit, was not in active labor. Despite reporting what she called uterine surges for the past several hours, she was calm, with a serene facial expression and body posture. She had a quiet demeanor and exhibited a subtle pattern of altered breathing. Because this was Beth s first pregnancy, her assigned nurse suspected that this was early labor, if it was labor at all. In the triage area, the nurse began taking a history. Beth s husband, Jack, answered most of the questions and provided a recounting of Beth s health history, which included an uncomplicated pregnancy with no identified medical risk factors, and comprehensive prenatal care. The nurse was curious about the fact that Jack did all the talking and she attempted to engage Beth in conversation directly. At this point, Jack explained that Beth was in a state of conditioned self-hypnosis and that he was advocating for her to focus on using her learned skills to complete the plan they had made for a safe and satisfying birth. He said that Beth was under hypnosis even when her eyes were open. Between surges (the term used in place of contractions or pains ), Beth verified Jack s role as her spokesperson, and helped answer questions when needed. The nurse then recalled that many women using hypnosis for birth presented to the hospital in advanced labor and without the usual affective signs noted in the active or transitional phases. After verifying a category 1 fetal heart rate pattern, the nurse removed the fetal monitor and used intermittent auscultation of the fetal heart rate (IA) for the duration of Beth s labor. Cervical examination revealed a dilation of 8 cm complete effacement, a bulging bag of water, and fetal descent to a +1 station. The certifi ed nurse-midwife was notifi ed, and the staff prepared for the birth. Meanwhile, using headphones Beth listened to a prerecorded hypnosis script while remaining focused and relaxed. Despite the need to quickly complete admission procedures and to comply with safe inpatient care standards for Beth and her baby, the nurse also ensured that Beth s request for a low-stimulation environment were accommodated wherever possible. She kept the couple informed about their progress and encouraged their efforts. Jack provided Beth with continual reassurances, verbal prompts for deepening hypnosis, and light-touch massage. Beth declined intravenous fluids, and preferred to labor in a semi-recumbent position. Both Beth and Jack expressed a desire to be kept informed about any necessary invasive procedures during birthing, and to have as few interruptions as possible. When Beth entered the second stage of labor soon afterward, she modifi ed her breathing technique to breathe the baby to birth, using an open-glottis bearing down technique that she and Jack had learned during the particular hypnosis training program they had chosen (Mongan, 2005). The term pushing was not mentioned by the couple, but rather, terms such as opening and breathing down were emphasized (Mongan, 2005). Two hours after admission, Beth and Jack became the proud parents of an 8 pound, 1 ounce, healthy baby boy. 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5 Hypnosis and hypnotherapy are terms that are often used interchangeably; however, there is an important distinction in that hypnotherapy uses hypnosis techniques with specifi c intent contend that there are degrees of suggestibility (e.g., low, medium and high), and that various therapeutic approaches exist to enable hypnotizability along this continuum in all but a very few cases (Barrett, 2010; Dienes & Hutton, 2013; Jaret & Martin, 2004). One study (Alexander, Turnbull, & Cyna, 2009) suggests that women become more hypnotizable during pregnancy, leading to the hypothesis that pregnancy represents a potentially sensitive period of receptivity to the practice. Pregnant women might, therefore, be uniquely suited to benefit from the therapeutic effects of hypnotic suggestion. COMPONENTS OF HYPNOSIS FOR LABOR AND BIRTH Implementation of hypnosis during childbirth usually involves three components: (1) preparation and conditioning in the prenatal period, (2) inducing, deepening and sustaining hypnosis during labor and birth, and (3) the presence of a supportive advocate throughout the experience. Preparation and Conditioning in the Prenatal Period The first component often involves a reframing of the birthing process from one that is necessarily painful, long, difficult and dangerous to one that can be safe, easy and satisfying. This component includes education that uses different terminology applied to the mechanics of birth, often softening traditional, medicalized and sometimes frightening language. For example, substitution of the terms uterine surges or waves for labor pains or contractions may reframe the experience for women and reinforce the physiologic and nonthreatening nature of progressive labor sensations. Should the necessity arise for increased medical surveillance or intervention during birthing, the woman is conditioned to remain in hypnosis and to use the turn in conditions (a term to describe an unexpected event or complication) as a signal to further relax and trust in her body and in the process of birth (Mongan, 2005). The choice of words in medical care is thought to contribute to patient perceptions and responses. A recent study of word selection in the management of pain after cesarean birth compared positive and negative language use by caregivers in two experimental patient groups. The findings suggested that the use of negative words to assess pain may magnify the perception, appraisal and incidence of pain reporting (Chooi, Nerlekar, Raju, & Cyna, 2011). Likewise, persistent media representations of birthing as dramatically dangerous and agonizingly painful offer vicarious exposure to examples that reinforce distorted representations of women s capacity for birthing (Morris & McInerney, 2010). Positive effects of conditioned hypnosis for birthing support the mid-range nursing theory of symptom management, which maintains that altering one s perception or appraisal of a physical, psychological or environmental condition influences one s reaction or response to that condition (Dodd et al., 2001). Part of the conditioning component in the prenatal period includes developing body awareness as well as awareness and attachment to the developing baby. This level of preparation is designed to empower women to respect their innate ability to birth. Additionally, the focus on connecting with the fetus fosters a link that provides purpose and motivation for the process of labor and birth (Mongan, 2005). This element takes the form of education about pregnancy, labor and birth processes, as well as exercises fostering introspection, visualization and BOX 2 COMMON MISCONCEPTIONS ABOUT HYPNOSIS MISCONCEPTION Hypnosis is a state of unconsciousness Hypnosis is mind-control and forces one to behave against her will Those who can be hypnotized have weak minds Hypnosis doesn t really work ACCURATE STATEMENT Hypnosis is a state of hyper-consciousness Hypnosis is a voluntary activity; hypnotic suggestions can be refused, because those undergoing hypnosis are fully conscious Hypnotizability is not a negative personality trait; most people can be hypnotized to some degree, if they so choose Many studies over the last century support the effi cacy of hypnosis in various applications 52 Nursing for Women s Health Volume 18 Issue 1

6 self-affirmation. Coupled with hypnotherapy for birth preparation, these interventions can become powerful forces for reducing anxiety and counteracting fearful messages about the birth process. When labor begins, activating a preconditioned response of calm relaxation may reduce catecholamine release and enhance uterine contractility and labor progress. Inducing, Deepening and Sustaining The second component of hypnotherapy for birthing continues to emphasize the positive aspects of the birthing experience as it unfolds, while expanding to include deepening techniques, which permit varying degrees of hypnoanalgesia (American Psychological Association, 2004). Alterations in physical sensations are enabled through practice and conditioning over time before onset of labor. Some laboring women are able to achieve a high level of analgesia through subconscious rendering of birth sensations into other sensations (such as numbness). One method of accomplishing this under hypnosis is training the mind to make a part of the body become insensible, and then using that part of the body (usually a hand or arm) to transfer or extend its insensibility to another body area. Other women can attenuate nociception (pain sensation) through a combination of focused reappraisal and altered sensation. An example of focused reappraisal is reconditioning one s belief that uterine contractions are painful by offering an alternative positive consideration that the contraction of other muscles (such as the biceps) are not painful, and that the uterine muscle fibers are acting in concert to help achieve the desired goal of birthing the anticipated baby. One hypothetical explanation for analgesic hypnotic effects is that a reduction in labor pain simply results from the natural release of endorphins accompanying any unmedicated birth. However, this theory does not adequately explain the phenomenon, since hypnoanalgesia has been successfully reported in other patient populations undergoing acute medical or dental treatment (Barrett, 2010). A Supportive Advocate The final component of hypnosis for birthing involves the active presence of a prepared and trusted other to participate through activities such as reinforcement, encouragement and advocacy. Because the hypnotic state does not necessarily announce itself outwardly, the partner often serves as one who holds space for the woman to feel safe and sustain her hypnotic entrancement, thereby maximizing its efficacy. This person remains present with the hypnotized woman throughout labor and birth, and contributes to her sense of security. She is assured that she can remain under hypnosis while her primary support person pronounces and protects the plans she has for birthing. The support person may be an intimate partner, other family member, friend or a trained doula. The choice of primary support person rests with the woman, but it is someone who has trained along with her in techniques of self-hypnosis. In addition, this person has learned strategies for deepening and sustaining the hypnotic state, such as light-touch massage, specific relaxation scripting and breathing pattern reinforcement. After hospital admission, it is often the primary support person who wishes to interact with providers, in order to permit the laboring woman to remain under hypnosis undisturbed. AUTO-HYPNOSIS AND SELF-HYPNOSIS Two schools of thought exist on the efficacy of auto-hypnosis (self-induced) versus hetero-hypnosis (that which is hypnotistmediated). Hypnosis, as a voluntary state of mind, is subject to the mindfulness and willing participation of the individual. This would seem to make the argument for all hypnosis having a selfgenerated component (Mongan, 2005). However, some authors maintain that a sense of involuntariness, or the perception that one is guided through their hypnosis experience by a trained other, is an essential component of hypnotherapeutic effectiveness (Burkhard, 2009; Wegner & Erskine, 2003). Women using hypnotic techniques for childbirth can Substitution of the terms uterine surges or waves for labor pains or contractions may reframe the experience for women and reinforce the physiologic and nonthreatening nature of progressive labor sensations opt for hypnotist-mediated techniques, self-taught and selfconditioned hypnosis preparation, or a blended program of mediated sessions coupled with at-home conditioning. Studies suggest that, although all methods can be beneficial, clinical hypnosis is more effective when conducted live with a hypnotherapist compared to methods using audio-taped scripts (Montgomery, David, Winkel, Silverstein, & Bovbjerg, 2002). It is likely that the effectiveness of self-hypnosis for childbirth is influenced by the amount and consistency of conditioning and practice. The research on self-hypnosis for birthing is lacking in measures of adherence to practice sessions; therefore, the ability to evaluate its overall effectiveness is limited. Typically, training programs for birthing-hypnosis begin in the late second trimester with several hetero-hypnosis sessions, and include concurrent in-home auto-hypnosis practice sessions. Thereafter, the auto-hypnosis sessions are continued daily through birth using an audiotaped script to condition the patient to entering and deepening the hypnotic state. This mixed method approach of hetero- and auto-hypnosis sessions is likely the most practical and cost-effective for pregnancy and birthing applications. CNE February March 2014 Nursing for Women s Health 53

7 HYPNOTHERAPY IN CLINICAL AND RESEARCH SETTINGS Hypnotherapeutic treatment for such health indications as smoking cessation, weight management, sleep disorders, anxiety, depression, nausea and pain have been used in the general population and in particular subpopulations, including childbearing women (Khianman, Pattanittum, Thinkhamrop, & Lumbiganon, 2012; Ng & Lee, 2008). In addition, hypnosis has been evaluated for its effectiveness in addressing childbearingrelated conditions such as hyperemesis, pregnancy termination, preterm labor, fetal movement, external breech version, post-date pregnancies, breastfeeding difficulties, postpartum depression and infertility (Dufresne et al., 2010; James, 2009; Reinhard, Huesken-Janßen, Hatzmann, & Schiermeier, 2009; Typically, training programs for birthinghypnosis begin in the late second trimester with several hetero-hypnosis sessions, and include concurrent in-home auto-hypnosis practice sessions Reinhard et al., 2012; Shah, Thakkar, & Vyas, 2011). A number of investigations into perinatal hypnosis have focused on labor and birth variables, particularly with respect to the variable of pain control, but also include related outcomes such as labor duration, anxiety levels, neonatal Apgar scores, incidence of cesarean surgical birth, analgesia use, oxytocin use and childbirth satisfaction (Cyna, McAuliffe, & Andrew, 2004; Cyna, Andrew, & McAuliffe, 2006; Cyna, et al., 2006; Werner, Uldbjerg, Zachariae, Rosen, & Nohr, 2012). While many of these investigations show positive effects of hypnosis on the outcomes studied, there are conflicting findings in others showing no statistically significant benefit. RESEARCH RESULTS ON EFFICACY Four systematic reviews on hypnosis for birthing have been completed, with contradictory findings (Cyna et al., 2004; Landolt & Milling, 2011; Jones et al., 2012; Madden, Middleton, Cyna, Matthewson, & Jones, 2012). Interpretation of the findings regarding hypnosis for childbirth are complicated by the variations in study design. These methodologic factors include the doses and types of hypnosis regimens, sample sizes, selection and definition of outcome variables, randomization procedures, measures of participant adherence and inclusion of appropriate control groups. It is no surprise that the overarching conclusion of systematic analyses of hypnosis for childbirth pain control show some, none or only modest beneficial effects (Cyna et al., 2004; Simkin & Bolding, 2004; Landolt & Milling, 2011; Jones et al., 2012; Madden et al., 2012). This apples and oranges comparison of studies complicates a clear determination of the degree to which hypnosis in maternity care is beneficial. METHODOLOGIC CHALLENGES Two of the consistent critique points made by authors who have attempted to draw conclusions from published research on the value of hypnosis for childbirth are (1) lack of standardization of the treatment conditions and (2) small, nonrepresentative sample sizes. Prior work contains variations in number of hypnosis training sessions, duration of those sessions, qualifications of the hypnotherapists, quality of the hypnosis sessions themselves, and between-session practice times required of and performed by the participants (Landolt & Milling, 2011; Ng & Lee, 2008). These factors account for differences in the effectiveness of the treatment. For example, a recent randomized controlled trial in Denmark evaluating the effect of self-hypnosis on labor pain and epidural use showed no significant improvement compared to controls, while an earlier published study showed significant improvements when hypnotherapy was used (Cyna, Andrew, & McAuliffe, 2006; Werner et al., 2012). Each study used a different number of class sessions and protocols for their hypnosis intervention. One solution to this limitation is to launch comparative investigations using standardized protocols for hypnotherapy interventions across studies. There are a number of established programs using hypnosis for childbirth such as Hypnobabies, the LeClaire Hypnobirthing Method and HypnoBirthing : The Mongan Method. The Mongan Method has been implemented internationally, which permits application in research studies abroad. Using one of these types of programs as a consistent interventional package upon which to design future large-scale studies may offer better control over the treatment conditions, and hence, more interpretable and comparable results. To date, the best dose of hypnotherapy for childbirth has not been determined. The HypnoBirthing website has published its statistics collected from 2,001 women between 2005 and 2010 (Dolce, 2010). The women voluntarily self-reported on their birth outcomes after using hypnosis for childbirth. These data were compared to the data from the Center for Disease Control and Prevention s (CDC) 2007 Birth Statistics report (a national database of birth outcomes from all recorded births in the United States in 2007) and the Listening to Mothers II survey (a national telephone or online survey of the birth experiences 1,573 women who delivered in 2005) (Declercq, Sakala, Corry, & Applebaum, 2006; Martin et al., 2010). Women in the hypnosis group reported higher levels of birth over 37 weeks gestation, fewer low birth weight infants and 54 Nursing for Women s Health Volume 18 Issue 1

8 fewer cesarean births (17 percent vs percent) compared to U.S. statistics at the time of data collection (Dolce, 2010). In addition, these women reported fewer medical interventions such as pharmacologic analgesia/anesthesia, oxytocin use, continuous fetal monitoring, artificial rupture of membranes, and perineal suturing than those polled in the Listening to Mothers II survey (Dolce, 2010). These data are limited by the voluntary and anonymous nature of online reporting and may not be representative of the experience of all women using hypnosis for birthing. There are few data on the demographic characteristics of women selecting hypnosis (and none reported in the Dolce 2010 report), and it is possible that this group may be more homogenous, and therefore not representative of the birthing population in general. One study on the impact of hypnosis on reducing preterm birth showed a positive effect, but the researchers did not randomly allocate their participants into the treatment and control groups. The self-selected hypnosis participants were more advantaged socioeconomically, reducing the comparability of the groups and weakening the validity of the findings (Reinhard et al., 2009). The few randomized studies that control for these factors continue to demonstrate mixed results. ADVERSE EFFECTS Despite variances in the findings on the effectiveness of hypnotherapy to achieve its intended goals in statistical analyses, it is considered to be an integrative intervention that has a consistently low-risk index along with a generally high level of acceptability by participating women. No recent published studies were found noting medical or psychological complications resulting from the use of hypnosis for childbirth preparation. However, there have been reports of unintended negative effects resulting from hypnosis (Gruzelier, 2000). These are usually minor and of short duration, including, headache, anxiety and/or amnesia. There are increased risks for severe side effects among those with existing psychopathology, including an exacerbation of psychoses; therefore, the use of hypnosis use among groups of women with certain preexisting mental health conditions may require the consultation with a mental health professional, or be contraindicated. A LESS INVASIVE OPTION Because of its less invasive nature, hypnosis offers birthing women an alternative to pharmacologic interventions, which they may need to, or wish to, avoid. The reappraisal of the birthing process in a wellness paradigm, which emphasizes women s capabilities to use the mind-body connection to its best advantage, may have the potential to improve obstetric outcomes when used as a replacement for or an adjunct to increasingly common interventions such as intravenous narcotics, oxytocin use or epidural anesthesia. More well-designed and controlled studies are needed to examine these effects. OPPORTUNITIES AND BARRIERS FOR HYPNOTHERAPY DURING LABOR AND BIRTH Individualized Nursing Care and Institutional Policies Hypnotherapy is an attractive and empowering modality for some women. But what is less certain is the level of acceptability by physicians, nurses and other clinicians, upon whom the future potential of hypnotherapy utilization, at least in the inpatient setting, may rest. Institutional barriers to using hypnosis for childbirth may include protocols that require even low-risk birthing women to be interrupted by continuous electronic fetal monitoring, routine IV placement, activity restrictions, inflexible vital sign measurement intervals and regular requests to rate their pain. All of these distract from a woman s ability to remain in a focused state within her birthing body. Low-technology nursing care suggestions for low-risk birthing women using hypnosis include offering oral fluids as tolerated during labor, intermittently auscultating the fetal heart rate, encouraging freedom of movement, minimizing cervical exams and utilizing ratings of comfort levels rather than pain levels (Romano & Lothian, 2008). Box 3 describes some nursing approaches that may be most effective in working with hypnosis-trained women and their support persons. Resolving Confl icts in Care Philosophies Health care providers may not understand or accept the utilization of hypnotherapy in the birth setting, and may disapprove of or undermine its use. Conversely, women and Because of its less invasive nature, hypnosis offers birthing women an alternative to pharmacologic interventions, which they may need to, or wish to, avoid their partners may take a hard line in refusing medicallyindicated interventions if they are perceived as unnecessary or intrusive to the desired birthing experience. In these cases, the shared goal between health care providers and birthing women for a safe and satisfying outcome can be thwarted by this intersection of competing priorities, expectations and demands. Areas of conflict in this regard need to be carefully scrutinized with regard to examining standards of practice for safe, effective and ethical nursing care. When routine or recommended interventions are questioned for their necessity during an uncomplicated birth, the potential for power struggles between patients, their partners and hospital staff arises. Hypnosis-trained and prepared CNE February March 2014 Nursing for Women s Health 55

9 Disadvantages of hypnosis for childbirth are few, but further barriers exist. Although prices for hypnosis training and audiotaped scripts vary among programs and practitioners, the fees for these services and materials are in the typical range of $250 to $500 (Hypnosis for Change, 2011; Your Birthing Journey, 2013). Costs may limit access for low-income women. Likemothers-to-be are conditioned and oriented toward normalcy in birthing, and may require explanation and justification for staff-recommended interventions. It is no surprise, then, that a larger proportion of women who desire birth using hypnosis also seek to birth outside of the hospital setting (1 percent for the general U.S. population vs. 13 percent for HypnoBirthing women), thereby avoiding the potential for these conflicts (Dolce, 2010). Interestingly, however, this same report showed that most women (86 percent) who used hypnosis for birthing in the hospital or in a free-standing birth center reported a high degree of satisfaction with the level of support they received from the nursing staff. This could imply that nurses are aware of The role of nurses in reinforcing or inhibiting hypnosis techniques during pregnancy and birth has not been studied. Open communication between women, their partners and their nurses about needs and expectations will improve understanding and the ability for all parties to collaborative effectively the need to accommodate women s birthing preferences while balancing the requirement to meet institutional standards, reinforcing the natural partnership between patients and their nurses. Further investigation is needed to explore hypnosis awareness and advocacy from a nurse s perspective. The role of nurses in reinforcing or inhibiting hypnosis techniques during pregnancy and birth has not been studied. Open communication between women, their partners and their nurses about needs and expectations will improve understanding and the ability for all parties to collaborative effectively (see Box 3). Non-judgmental approaches by nurses and other health care providers makes women feel able to honestly and clearly state their needs, and simultaneously builds rapport and trust. Also, active listening provides women and their nurses the chance to negotiate creative solutions to meet needs for safe and effective care while honoring patient preferences. For example, if a woman does not want to be asked to rate her pain each hour during active labor, she and her nurse might agree on different language to elicit this information or, perhaps the woman would agree to this assessment, but less frequently. Respecting patient autonomy and supporting patient rights to approve of and participate in their plan of care is a central precept of ethical nursing practice (American Nurses Association, 2010). BOX 3 NURSING ACTIONS TO SUPPORT FAMILIES USING HYPNOTHERAPY FOR CHILDBIRTH Maintain a low-stimulation environment. Provide high-touch, low-tech interventions for labor and birth (e.g., intermittent auscultation) based on risk status and patient preference. Anticipate a woman s reduced desire for activity and repositioning during active labor. Prepare to answer questions and entertain challenges to medical/institutional protocols in an open and nonjudgmental fashion. Explain rationale for invasive interventions (e.g., prophylactic antibiotic therapy) and respect woman s autonomy in decision-making. Include the woman s primary support person in caregiving activities. Remain open to using creative strategies for enabling hypnosis-mediated birthing. Advocate for the woman s birth preferences with other providers. Assess for objective indicators of advancing labor (e.g., bloody show, spontanteous rupture of membranes and/or open-glottis bearing down), because typical affective cues of labor progress may not be apparent. Be prepared for unexpected progression in cervical dilation and fetal descent. Encourage the use of complementary hypnosis techniques if pharmacologic and/or surgical intervention become necessary. Emulate the language used by the patient to refer to the various components of the birthing process. Reinforce the use of hypnotherapy techniques into the postpartum period. Seek ongoing educational and practice opportunities to expand one s nursing skill set to include hypnotherapeutic techniques. Access to Services 56 Nursing for Women s Health Volume 18 Issue 1

10 wise, availability for non-english-speaking women, those with sensory deficits, those with limited support systems and/or those of low literacy may also be limited. These barriers could be overcome if hypnosis programs were developed specifically to target these populations. CONCLUSION Beth and Jack, the couple whose experience is described in Box 1, were able to receive supportive care from an experienced nurse who matched her assessment and care activities to their individual wishes. After listening to the couples needs and preferences, the nurse minimized distractions and reduced the use of technological interventions where possible. This included the use of intermittent auscultation, oral rather than intravenous fluids and low lighting and sound levels. The nurse met safe standards of practice while simultaneously individualizing care, building a therapeutic relationship with the couple and giving Beth the space to utilize her hypnosis techniques effectively. This successful partnership may have been influenced by the culture of the birthing unit as well as by the knowledge, expertise and flexibility of the nurse. Cultivating these qualities across groups of nursing providers and perinatal units may improve the ability for low-risk women to make use of integrative techniques that promote physiologic labor and birth. Beth s birth story illustrates an exception to the rule we have come to recognize as the somatic and affective progression of so many labors and births (fear, tension, pain), while also posing the proposition that hypnotherapy could be an underutilized resource for better childbirth preparation and management one that could improve comfort and satisfaction during this significant life event Expanding opportunities for women to access and utilize hypnosis for childbirth will give clinicians and scientists more chances to evaluate its effects. Nurses are well-positioned to develop their knowledge and skill toward becoming more deliberate, and hence, effective participants in hypnotherapies. In observing nurses who work with birthing women, an intriguing prospect arises could the gentle stroking massages, the soothing, low-pitched, repetitive affirmations murmured to patients, the deliberately calming movements, and the encouraging suggestions that the baby is nearly here actually be generating some unintentional, but nonetheless beneficial, hypnotherapeutic effects? This possibility calls for further investigation into the mechanisms of mind-body interventions during labor and birth, as well as the role of nurses in facilitating any beneficial effects. As maternity nurses rise to the challenge of operating in both a high-tech and a high-touch environment, developing a working knowledge of ways to support women and their partners in achieving their goal of using clinical hypnosis for birthing strengthens the therapeutic relationships formed between nurses and the women they care for. Developing skills in utilizing integrative techniques increases perinatal nurses breadth of expertise and augments their collection of available strategies to meet women s needs during the experience of childbirth. NWH REFERENCES Alexander, B., Turnbull, D., & Cyna, A. (2009). The effect of pregnancy on hypnotizability. American Journal of Clinical Hypnosis, 52, American Nurses Association. (2010). The nurse s role in ethics and human rights: Protecting and promoting individual worth, dignity and human rights in practice settings. Silver Spring, MD: Author. 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Contemporary Hypnosis, 25, doi: /ch.359 Chooi, C. S., Nerlekar, R., Raju, A., & Cyna, A. M. (2011). The effects of positive or negative words when assessing postoperative pain. Anesthesia and Intensive Care, 39(1), Cyna, A. M., McAuliffe, G. L., & Andrew, M. I. (2004). Hypnosis for pain relief in labour and childbirth: A systematic review. British Journal of Anaesthesia, 93, Cyna, A., Andrew, M. I., Robinson, J. S., Crowther, C. A., Baghurst, P., Turnbull, D., Whittle, C. (2006). Hypnosis antenatal training for childbirth (HATCh): A randomized controlled trial. BioMed Central Pregnancy and Childbirth, 6, doi: / Cyna, A. M., Andrew, M. I., & McAuliffe, G. L. (2006). Antenatal self-hypnosis for labour and childbirth: A pilot study. Anaesthesia Intensive Care, 34, Declercq, E. R., Sakala, C., Corry, M. P., & Applebaum, S. (2006). Listening to Mothers II: Report of the second national U. S. survey on women s childbearing experiences. New York: Childbirth Connection. Retrieved from org/pdfs/ltmii_report.pdf Dienes, Z., & Hutton, S. (2013). Understanding hypnosis metacognitively: rtms applied to left DLPFC increases hypnotic suggestibility. Cortex, 49, doi: /j.cortex CNE February March 2014 Nursing for Women s Health 57

11 Dodd, M., Janson, S., Facione, N., Faucett, J., Froelicher, E. S., Humphreys, J.,... & Taylor, D. (2001). Advancing the science of symptom management. Journal of Advanced Nursing, 33, Dolce, K. (2010). HypnoBirthing outcomes United States, Pembroke, NH: HypnoBirthing Institute. Retrieved from Dufresne, A., Rainville, P., Dodin, S., Barré, P., Masse, B., Verreault, R., & Marc, I. (2010). Hypnotizability and opinions about hypnosis in a clinical trial for the hypnotic control of pain and anxiety during pregnancy termination. International Journal of Clinical and Experimental Hypnosis, 58, doi: / Gruzelier, J. (2000). Unwanted effects of hypnosis: A review of the evidence and its implications. Contemporary Hypnosis, 17, doi: /ch.207 Hypnosis for Change. (2011). Fees. Glendale, WI: Author. Retrieved from hypnobirthing-class-fees/ Hypnosis Motivation Institute. (2010). Foundations in hypnotherapy. Tarzana, CA: Author. Retrieved from hypnosis.edu/distance/foundations/workbook/v1.pdf Hypnotherapist s Union Local 472. (2013). Summary of state laws regarding hypnosis. Beverly Hills, CA: Author. Retrieved from James, U. (2009). Practical uses of clinical hypnosis in enhancing fertility, health pregnancy and childbirth. Complementary Therapies in Clinical Practice, 15, doi: /j. ctcp Jaret, P., & Martin, A. (2004). Hypnosis can help you heal really. Health, 18, 41. Jones, L., Othman, M., Dowswell, T., Alfirevic, Z., Gates, S., Newburn, M.,... & Neilson, J. P. (2012). Pain management for women in labour: An overview of systematic reviews. Cochrane Database of Systematic Reviews, 2012(3). doi: / CD pub2 Khianman, B., Pattanittum, P., Thinkhamrop, J., & Lumbiganon, P. (2012). Relaxation therapy for preventing and treating preterm labour. Cochrane Database of Systematic Reviews, 2012(8). doi: / cd pub2 Kirsch, I. (1994). APA definition and description of hypnosis: Defining hypnosis for the public. Contemporary Hypnosis, 11, Landolt, A. S., & Milling, L. S. (2011). The efficacy of hypnosis as an intervention for labor and delivery pain: A comprehensive methodological review. Clinical Psychology Review, 31, doi: /j.cpr Martin, J. A., Hamilton, B. E., Suppon, P. D., Ventura, S. J., Mathews, T. J., Kirmeyer, S., & Osterman, M. J. (2010). Births: Final data for National Vital Statistics Report, 58, Madden, K., Middleton, P., Cyna, A. M., Matthewson, M., & Jones, L. (2012). Hypnosis for pain management during labour and childbirth. Cochrane Database of Systematic Reviews, 2012(11). doi: / cd pub2 Mongan, M. F. (2005). HypnoBirthing : The Mongan method (3 rd ed.). Deerfield Beach, FL: Health Communications, Inc. Montgomery, G. H., David, D., Winkel, G., Silverstein, J. H., & Bovbjerg, D. H. (2002). The effectiveness of adjunctive hypnosis with surgical patients: A meta-analysis. Anesthesia and Analgesia, 94, Montgomery, G. H., Schnur, J. B., & Kravits, K. (2013). Hypnosis for cancer care: Over 200 years young. CA: A Cancer Journal for Clinicians, 63(1), doi: /caac Morris, T., & McInerney, K. (2010). Media representations of pregnancy and childbirth: An analysis of reality television programs in the United States. Birth, 37, doi: / j x x Ng, B. Y., & Lee, T. S. (2008). Hypnotherapy for sleep disorders. Annals Academy of Medicine Singapore, 37(8), Reinhard, J. Heinrich, T. M., Reitter, A., Herrmann, E., Smart, W., & Louwen, F. (2012). Clinical hypnosis before external cephalic version. American Journal of Clinical Hypnosis, 55, Reinhard, J., Huesken- Janßen, H., Hatzmann, H., & Schiermeier, S. (2009). Preterm labour and clinical hypnosis. Contemporary Hypnosis, 26, doi: /ch.387 Romano, A. M., & Lothian, J. A. (2008). Promoting, protecting, and supporting normal birth: A look at the evidence. Journal of Obstetric, Gynecologic & Neonatal Nursing, 37, Shah, M. C., Thakkar, S. H., & Vyas, R. B. (2011). Hypnosis in pregnancy with intrauterine growth restriction and oligohydramnios: An innovative approach. American Journal of Clinical Hypnosis, 54, Simkin, P., & Bolding, A. (2004). Update on nonpharmacologic approaches to relieve labor pain and prevent suffering. Journal of Midwifery and Women s Health, 49, Wegner, D. M., & Erskine, J. A. (2003). Voluntary involuntariness: Thought suppression and the regulation of the experience of will. Consciousness and Cognition, 12, Werner, A., Uldbjerg, N., Zachariae, R., Rosen, G., & Nohr, E. A. (2013). Self-hypnosis for coping with labour pain: A randomised controlled trial. British Journal of Obstetrics and Gynecology, doi: / Your Birthing Journey. (2013). Fees & packages. Retrieved from PACKAGES. html 58 Nursing for Women s Health Volume 18 Issue 1

12 Post-Test Questions Instructions: To receive contact hours for this learning activity, please complete the online post-test and participant feedback form at CNE for this activity is available online only; written tests submitted to AWHONN will not be accepted. 1. Which of the following is true about hypnosis? a. It can only be achieved in the presence of a hypnotist. b. It is an involuntary state. c. It is a voluntary state. 2. Which of the following is a common misconception about hypnosis? a. Hypnosis is a state of hyper-consciousness. b. Hypnosis only works on people with weak minds. c. Hypnotic suggestions can be refused. 3. Which of the following is a therapeutic aspect of hypnosis during labor and birth? a. It ensures a shorter labor. b. It helps a woman reframe her perception of birth from diffi cult and scary to easy and satisfying. c. It makes pain analgesia unnecessary. 4. What is auto-hypnosis? a. Group-mediated hypnosis b. Hypnotist-mediated hypnosis c. Self-induced hypnosis 5. What is the current state of scientifi c evidence for hypnotherapy as a therapeutic intervention during labor and birth? a. Evidence clearly indicates benefi ts. b. Evidence clearly indicates harm. c. Evidence is mixed. 6. According to a report published by the HypnoBirthing Institute, birth outside the hospital setting is desired by what percentage of women who desire birth using hypnosis, compared to 1 percent of women in the general U.S. population. a. 7 percent b. 13 percent c. 20 percent 8. Which of the following is true of a woman s support person when she is using hypnotherapy during labor and birth? a. The support person is hypnotized during the birth. b. The support person lets the laboring woman do most of the talking during the history and exam. c. The support person provides verbal prompts to deepen the woman s hypnosis. 9. Which hypnosis method is considered the most practical and cost-effective for pregnancy and birthing applications? a. A combination of hypnotist-mediated hypnosis and self-induced hypnosis sessions. b. A series of one-on-one live hypnotist-mediated sessions. c. A series of sessions listening to a recording of a hypnotist. 10. Which of the following is something nurses can do when caring for a woman using hypnotherapy during labor and birth? a. Ask the woman to rate her pain every hour. b. Expect normal progression in cervical dilation and fetal descent. c. Provide a low-stimulation environment as much as possible. 11. Which nursing care practice during labor could be researched to explore the potential for its hypnotic-like effects? a. Aromatherapy b. Gentle massage c. Hydrotherapy CNE 7. What is a possible contraindication to hypnosis? a. Existing psychopathology b. History of anxiety c. History of a sleep disorder February March 2014 Nursing for Women s Health 59