Vidya Bhagat1*, Sheila Menon2
1Faculty of Medicine Universiti Sultan Zainal Abidin Terengganu, Malaysia,
2Faculty of London College of Clinical Hypnosis Asia
*Corresponding Author E-mail: 55vidya42@fiver

ABSTRACT:
Hypnosis has a long history as a treatment method to reduce pain during labor. The purpose of this literature review is to scope the evidences on interventions for decreasing patient anxiousness during the perioperative care and in particular for obstetrics and gynecology patients. It was hypothesized that techniques, which reduce anxiety, will have a beneficial impact on pain reduction. The current study seeks also to provide a design to conceptualize the benefits of introducing psych-education and hypnotherapy as an adjunct to perioperative care. This literature review was completed using electronic databases such as PubMed, CINAHL, EMBASE, and TRIP. The current study analyzed 40 articles from the year 1970 to 2019. The reviewed articles selected identified the effectiveness of hypnosis as a treatment option for obstetrics and gynecology patients, specifically for pain management in laboring women. The study concluded that the addition of hypnosis showed success in controlling pain among laboring women. The current study identified that when nursing staff are provided with information and or training in hypnosis and self-hypnosis laboring women receive broader treatment options for anxiety and pain management. Routine education programs on hypnosis and self-hypnosis designed to reduce the discomfort and pain of women during labor may also provide benefit. The current study reviewed the benefit of psycho-education and hypnotherapy for pain management offered to obstetrics and gynecology patients when nurses and or patients or both are provided with this information.

KEYWORDS: Hypnosis, obstetrics and gynecology, laboring women, pain management.

INTRODUCTION:
Hypnosis is a prehistorically observed method of treatment, characterized by an enhanced focus of attention together with an elevated susceptibility to suggestion. It has been observed as a non-pharmacological pain management treatment option for over 100 years. In the past few decades, researchers have revisited the use of hypnosis to ease labor pain. In the studies reviewed hypnosis sessions were conducted by trained caregivers, midwives, physicians or hypnotherapy operators. Analysis of the literature reveals that the use of hypnosis is evidenced as efficacious; though, some studies have shown controversial results. Analysis of the literature shows the effect of hypnosis among obstetrics and gynecology patients to be successful1. The technique hypnosis produces both a fixated attention and a mental state similar to daydream2. To enter into a hypnotic state, the person needs to be a willing participant. There is no clear differentiation between hypnosis and self-hypnosis. Persons who learn self-hypnosis retrospectively concentrate on a suggested signal during practice sessions. This signal redirects their focus to positive thoughts creating an altered state of consciousness, which is subsequently used to induce anesthesia by hindering painful sensations. Previous literature reveals that pain relief during hypnosis is gained through inhibition of cortical centers that are functionally analytical and alteration to cerebral blood flow during hypnosis3.

Hypnosis in obstetrics and gynecology:
In recent decades many obstetrics and gynecology patients express curiosity about the role of self-hypnosis to achieve pain relief during labor. Nurses have very little or no knowledge of hypnosis or self-hypnosis. Clinical experience evidenced in the literature indicates that when nurses have appropriate training in self-hypnosis they contribute effectively to reducing pain during labor. These findings encourage nurses to get trained for hypnotherapy in order to help laboring women preparing for childbirth. This is particularly relevant with self-hypnosis since there is no side effect4. One of the studies reviewed reveals the significance of outcome when nurses are trained in self-hypnosis, as they can train patients willing to use self-hypnosis in childbirth. It is important to understand that person cannot be hypnotized by force. Nurses are seen as support staff by patients so they are well placed to offer this option to the willing participant. Engagement and cooperation from the patient is essential. The patient must positively engage with the process whether they are learning to use self-hypnosis or being inducted with hypnosis. One literature study states that the significance of outcome is improved when certified practitioners teach hypnosis to women. This further reinforces that collaboration is essential between the patient and operator4. Self-hypnosis provides the patient with a sense of control. It also helps the patient manage anxiety and physical discomfort by allowing them to enter an altered state of consciousness. Self-hypnosis offers the patient with the option to use hypnosis without the presence of an operator or therapist being present during labor5.

One study indicates that the role of hypnosis as a treatment option in the field of health care regarding genital system is a system of sex organs can be extended with specific application for sexual dysfunction, chronic pelvic pain, hyperemesis gravid arum, urinary incontinence, and pain relief in labor and delivery2. Other research emphasized the importance of educating nurses in the use of self-hypnosis during childbirth, so that they can offer patients the dual benefits of entering the deep hypnotic state and producing an analgesic effect to reduce pain. Self-hypnosis is described as a type of hypnosis induced by one’s own self after receiving appropriate training from a certified practitioner. The patient achieves the ability to enter the altered state of consciousness at will. Using self-hypnosis for childbirth pain provides women with a sense of control to manage both their anxiety levels and the normal discomfort of labor. Since several decades before the use of pharmaceuticals use for pain management, hypnosis was one of the predominantly used pain relief methods for labor pain6. The emergence of new pain relief interventions in the last century has meant that less attention was given to hypnotherapy methods. Most of the deliveries were conducted in the non-hospital setting, the hospital nurses have little or no knowledge about hypnosis and its techniques, and there is limited information regarding hypnosis and self-hypnosis in the literature. The importance of hypnosis is that it offers benefits without any side effects. Nurses who are on hand at the laboring woman’s bedside are ideally placed to offer knowledge of self-hypnosis and to provide pregnant women with a full range of pain control options, both drug and non-drug related. This study suggests that women will have been access and choice to include hypnosis as a treatment option6. The previous literature states that the time period before childbirth is the best time for the patient to learn hypnosis for reducing labor pain4.

Practice and training time enables the woman time to become confident and familiar with the technique. This improves the patient’s sense of control and active engagement in the process and ensures that she gets the maximum benefit from the pain relief during childbirth. Nurses who expressed their interest in learning self-hypnosis techniques, should refer to the accepted protocols used before to teach women self-hypnosis for childbirth7. It is usual practice in hypnosis training for operators to use suggestions of images or to reduce the pain experience. These commonly include replacing the pain sensation with other sensations such as tingling, coolness, or warmth. Other suggestions include floating or numbness in order to change the perception of pain8. Braxton Hick’s contractions are normal contractions that may occur prior to childbirth. Teaching women how to manage these contractions through self-hypnosis is useful in decreasing anxiety associated in laboring women9. Women are provided with that beforehand knowledge, to focus on contractions and use this as a cue to deepen relaxation while recognizing the mild sensations. Early preparation reduces the anxiety response and the hypnotic method provides a sense of being in control, of knowing how to respond and for a reduced intensity of the sensation9. Literature studies refer to the importance of making training on self-hypnosis available for obstetrics and gynecology nurses who interested in trained as certified hypnosis practitioners. When these nurses’ recommends about self-hypnosis, this can significantly encourage a laboring woman to use these methods to reduce their laboring pain. Previous studies evidence the effectiveness of hypnosis regarding pain control for laboring women is provided only after screening for hypnotic suitability and set by a trained specialist10. Certified hypnosis practitioners commonly use techniques, which include the client’s preference. The woman may request a specific suggestion for comfort of safety which her support person or nurse can use to cue the self-hypnosis or pain management during labor. This enables the woman to feel in control and can help ensure a sense of calm and balanced emotions11.

The presence of the nurse at the patient’s bedside provides the additional benefit of perceiving and supporting the laboring woman her spouse and her family at their time of need. The nurse can interjects positive hypnotic suggestions provided between contractions, which can strengthen the woman’s confidence and enhance the ability to give birth. Using music in the technique hypnosis suggestion also help the woman remain focused, calm, and increase her self-control. Nurses who work with laboring women using self-hypnosis must be trained not to interrupt women whilst they are focused on the hypnotic suggestion at the time of contraction. Commonly during the contractions, women may open their eyes, change position, and breathe deeply so that they have ended their focused state of hypnosis. Here the nursing staff can quietly communicate about, what/she is expected to do and request the woman’s participation. Appropriate training is essential as Morgan’s study showed that self-hypnosis may not demonstrate the classic signs of active labor observed by the nurses in other women who have not received hypnosis12.

Reappearance of hypnosis Childbirth preparation of patients:
One of the literature studies identifies that the hypnotic techniques have been used in obstetrics to control labor pain for more than a century13. Studies also revealed that the overview of chemo-anesthesia and inhalation anesthesia led to a decline in hypnosis practice used in obstetrics pain management in the nineteenth century14. The current study analyzed the reappearance of hypnosis practice in obstetric works in the literature in the 1960s, which reported a variety of applications in obstetrics15. Rehearsal of the entire surgical procedure with the patient in the deep hypnotic state appears to “block” the neurophysiological pathways involved in the transmission of pain impulses16. One previous literature study that explored hypnosis intervention in a number of complicated deliveries, surgical procedures, and length of hospital stay and found the inclusion to be beneficial17.A previous studies on the use of hypnosis in obstetrics revealed 21 newborns delivered with the assistance of hypnosis were studied clinically and biochemically and compared with newborns born under various types of analgesia and anesthesia. 20 of the 21 babies were in excellent clinical condition at birth. The study confirmed that there is no significantly deferred incidence found in a regional anesthesia group18. It was evidenced in serial determinations of the acid-base status during the first hour of life that the hypnosis group babies showed a significantly greater ability to recover from the asphyxia of birth than the non-hypnosis infants including a non-medicated regional anesthesia group18. Hypnosis has been used in the field of medicine, since the time of Mesmer in the 17th century and by physicians and surgeons such as Braid, Freud, Elliotson and so on. Despite this early success it later became an ignored part of medicine19.

Evidence suggests that autogenic training based on the hypothesis training on focal attention facilitates cortico-diencephalic alterations, which enables normal forces to establish without restricting the capacity for self-regulatory normalization20. The evidence also finds that laboring woman coping with symptoms of, pain, fear, and anxiety the represents a uniquely restricted situation for more extensive clinical exploration and research into the adjunctive role of hypnosis for facilitating relief of stress in perioperative care. Studies have also revealed that pregnant woman undergoing a fleeting spell of insignificant vomiting or more significantly malicious vomiting. Psychotherapy, hypnotherapy, and behavior therapy are useful in the treatment of patients with pregnancy complication that is characterized by severe nausea, vomiting, dehydration and weight loss21. The most evidential studies observed are in the area of labor and delivery in the management of pain and ease the delivery. Administering hypnotic susceptibility scales on Hungarian women favored the hypnosis method of preparation for childbirth and psychological pain relief22.

Analysis of previous literature identifies an evidenced detailed procedure; the hypnoreflexogenous process prepares women for childbirth, the method teaches how to enter a hypnotic state, which prepares women for labor and delivery in this hypnotic state23. This method provides a trained reflex effect that produces a favorable outcome for labor and delivery by enhancing the sense of readiness and control in laboring women24. Further, the observations evidenced that the using hypnosis lead to less problems, higher incidence of normal deliveries, and positive postpartum improvement. The advantageous to the cost-effectiveness for the method used25.

Hypnotherapy in the birth process:
Evidence emphasizes the importance of introducing hypnosis or hypnotherapy to the patient before the labor process begins so that a collaborative relationship has developed. This ensures the rapport between patients and physician and the readiness of the patient to respond to the hypnotherapy suggestions5. Educating and preparing patients regarding the process reduces anxiety. Patients typically require less medication during and after the procedure and healing is faster and fewer complications occur13. Santiago Roig-Garcia (1961) coined the term “Hypnoreflexogenous method” to describe the method that combines the concept of conditioned reflex and hypnosis and its application to obstetrics. In this method the patient is first taught self-hypnosis, and then prepared in hypnosis for the upcoming labor and delivery. Preparing patients with self-hypnosis sessions provides a “conditioned reflex” effect conducive to normal, healthy labor and delivery26. Previous studies that examine the self-hypnosis method advocate managing labor and delivery in this state of wakefulness without pain or fear. In this method the conditioning of the reflexes is obtained almost solely through suggestion. Verbal suggestions are delivered during deep hypnosis to provide better impact and better penetration. Roig Garcia (1961) maintained that suggestion is the simplest and most typical basis of the conditioned reflex in man26.

Grantley Dick Read identified the fear, tension, and pain and pain, tension, and fear reverberatory circuit. When this reflex pattern is changed or modified, even in part, the stage is set for normal uterine contractions that are painless, just as other physiological processes are normally free of pain27, 28. Previous studies suggest that training in relaxation and emotional calm reduced unpleasant tensions and fears associated with delivery. This facilitates a natural response towards a natural physiological function for which the woman can be adequately psychologically prepared29. The Hypnoreflexogenous, HR, method, places emphasis on explaining the muscular constitution of the uterus. This is important because any normal muscular contraction should not create undue discomfort. Laboring mothers naturally have a curiosity about terms that are used in their presence, such as membranes, amniotic fluid, rupture of the bag of water, and various positions and presentations. Education about the function of the cervix and the way it must be relaxed and dilated during labor to permit the baby to pass through is another important part of the training. Providing this information recognize the mother’s right to be regarded as the principal participant on the obstetrical team rather than the patient14.

Patients receive training session to provide them with alternate ways to produce hypo-analgesia and hypno-anesthesia. Self-suggestion can be used at any time during labor or delivery, when the patient experiences a contraction that creates significant discomfort. These methods induce spontaneous deep hypnotic states in laboring women and can enable them to remain in this state when they have contraction. When the contraction ends, the woman will be completely relaxed and contended again. In a case of extended labor, the woman is ideal to remain in the hypnotic state to complete numerous contractions through the residual of labor and delivery30. The current study, explores the use of active imagery techniques from previous literature whereby the patients are trained to mechanism to maintain a satisfying depth of hypnosis and use any time during prenatal, labor, delivery and postnatal period. The emphasis of self-hypnosis training during labor is focused on performing a normal physiological act and not on undergoing surgery.

Hypnoreflexogenous Technique prepare women for labor and delivery:
One of the literature studies described a precise protocol for the Hypnoreflexogenous method from the time the patient prepares for childbirth. The patients are trained for getting inn to hypnotic state before prepare them for delivery. The hypnoreflex is a conditioned reflex, is advantageous, that brings positive outcome by enhancing the patient’s readiness and control that pave up smooth labor and delivery31. In one of the earlier studies Werner et al. (1982) discusses the effectiveness of the Hypnoreflexogenous method that prepare patients for the delivery13. Inadequate preparation of patients causes anxiety, which may lead to misperceptions of the labor and delivery process and the occurrence of difficulties arising during labor and delivery. Werner et al. state that the Hypnoreflexogenous approach represents one of the most effective alternative approaches to childbirth preparation. In addition to the education and information provided, the patient has the opportunity to prepare for childbirth in the hypnotic state. The previous study states that higher focused concentration positively influences and enhances the learning outcome of the hypnotic suggestion32. Suggestion given during hypnosis would facilitate developing the intense focus in laboring women33. One previous study evidenced that the study group using hypnotic induction was much more relaxed and developed more of an espirit de corpa34

Studies in the past had conceptualized that the patient’s preparedness depends on the quality of suggestions given during posthypnotic stage. The focus in these studies was on providing suggestion/ expectation, which incorporated specific occurrences during labor and delivery. The literature on proven practice designates an individual’s undergoing anxiousness is contrariwise associated with their sense of directed locus of control. When the laboring women are unable to predict the happenings of the delivery period, they have misinterpreted expectations, which can lead to an externally directed locus of control distinctive to the hospital atmosphere and may result in anxiety that exacerbates the sense of distress leading to complications in delivery. Evidences supports that the hypnoreflex method helps women feel a sense of predictability through educational provided during preparation, also teaches them how to manage their anxiety. Self-hypnosis increases the individual’s sense of internalized control and reinforces their emotional resilience. Literature evidences that hypnotic preparation of patients positively contribute to better management with regard to anxiety, pain, and patient cooperation in medical treatment35. Studies have emphasized that the HR technique prepares the patient for delivery and does not require that they are in a hypnotic state during childbirth. The literature shows that the majority of patients prepared with the HR technique have a satisfying, complication-free delivery without entering a formal hypnotic state. HR preparation is accomplished with the patient in the hypnotic state and generally encompasses six training sessions of approximately 2 hours. The most efficient and effective method of training seems to be accomplished in groups of 10-12 participants. Evidence indicates that using hypnosis techniques for childbirth within hospital settings support laboring women to easily overcome hurdles associated with institutional policies and caregiver resistance36.

Comparing hypnosis with analgesics:
One study; a large randomized controlled trial of women provided with training in self-hypnosis to ease childbirth and reduce epidural pain experience, compared responses to another group who received analgesics, found that there was no differences across study groups. Hypnosis can be chosen in place of analgesics but not all patients are indicated for hypnosis37. Whilst studies evidenced the effectiveness and safe inclusion of hypnosis for pain management among laboring women during labor and childbirth, there have been reports that hypnosis used on women to reduce childbirth pain can leads to unintentional adverse effects38.

Past studies reveal that hypnosis used during childbirth may cause short-term headache, anxiety, and amnesia. Evidence also found women with existing psychopathology had an elevated risk of exacerbates psychoses when undergoing hypnosis to reduce their labor pain. This reinforces the necessity for providing appropriate training in the use of hypnosis. It is also advisable to seek consultation with a mental health professional when treating women with preexisting mental health conditions to avoid contraindications for hypnosis. The literature identified some unanticipated adverse behavior after inducing hypnosis39. The most common adverse reactions comprises of anxiety, headaches drowsiness, dizziness, and stiffness. On occasions some physiological symptoms were also observed. Besides these complications, hypnotherapy with laboring women demonstrated positive results in reducing labor pain40.

CONCLUSION:
Reviewing and analyzing the literature concludes that hypnosis is historically observed as a method of treatment, for which successful application is observed. Benefits include improved positive affect, enhanced receptiveness suggestion can benefits in both pain reduction and reduced anxiety when used by laboring women. The positive effect of hypnosis among obstetrics and gynecology patients demonstrates the success of hypnosis in pain management. The current study supports the recommendation that nurses and midwives

should receive training in this area in order to provide broader choices for managing pain to the laboring women. The current study suggests that conducting routine education programs on hypnosis and self-hypnosis for obstetrics and gynecology patients may be beneficial in reducing anxiety and the pain associated with childbirth. The study has identified the positive contribution of hypnotherapy as psycho-education and treatment method for obstetrics, and gynecology patients and one which reduces complications during labor and childbirth and enhaces the women’s sense of control and autonomy during the process. It identifies that both nurses and patients may benefit from further training and information on the benefits of hypnosis in childbirth and patient outcomes.

DISCLOSURE:
The authors report no conflicts of interest in this work.