Content uploaded by Véronique Waisblat
Author content
All content in this area was uploaded by Véronique Waisblat on Jan 09, 2017
Content may be subject to copyright.
1
Impact of a Hypnotically-based Intervention on Pain and Fear in
Women Undergoing Labor
Running Head: HYPNOTICALLY-BASED INTERVENTION DURING LABOR
Véronique Waisblat,a * Bryan Langholz,b ° Franck J. Bernard,c * Monique Arnould,a * Aurélien
Benassi,d * François Ginsbourger,e * Nicolas Guillou,c * Karine Hamelin,c * Philippe Houssel,c *
Pierre Hugot,c * Sylvie Martel-Jacob,f * Moustapha Moufouki,f * Hervé Musellec,c * Said Nid
Mansour,a * Daniel Ogagna,a * Xavier Paqueron,g * Sihem Zerguine,a * Patrice Cavagna,a *
Sébastien Bloc,h* Mark P. Jensen,i α Gilles Dhonneur.j δ
aDepartment of Anesthesiology, GHI Le Raincy Montfermeil France, bDivision of
biostatistics, University of Southern California USA, cDepartment of Anesthesiology, CHP
Saint Grégoire, France, dDepartment of Anesthesiology, Jean Verdier University Hospital,
Bondy, France, eDepartment of Anesthesiology, Clinique Mutualiste La Sagesse, Rennes
France, f Department of Anesthesiology and Intensive Care Medicine, Antoine-Béclère
University Hospital, Clamart France, gDepartment of Anesthesiology, Centre clinical, Soyaux
France, hDepartment of Anesthesiology, Hôpital privé Claude Galien, Quincy-sous-Sénart
France, iDepartment of Rehabilitation Medicine, University of Washington Seattle,
jDepartment of Anesthesiology and Intensive Care Medicine, Henri Mondor University
Hospital, Créteil, France.
•Staff Anesthesiology; ° Professor of Biostatistics; α Professor of Psychology; δ Professor of
Anesthesiology, Head of Department
HYPNOTICALLY-BASED INTERVENTION DURING LABOR
3
Abstract
The purpose of this study was to evaluate the effects of a hypnotically-based
intervention on pain and fear in women undergoing labor who are about to receive an epidural
catheter. 155 women received interventions that included either (1) patient rocking, gentle
touching, and hypnotic communication or (2) patient rocking, gentle touching, and standard
communication. We found that the intervention that included hypnotic communication was
more effective than the intervention that included standard communication for reducing both
pain intensity and fear. The results support the use of hypnotic communication just before
and during epidural placement for women who are in labor, and also indicate that additional
research to evaluate the benefits and mechanism of this treatment is warranted.
Key words: Labor; Clinical hypnosis; Pain; Fear; Epidural analgesia
4
Impact of a Hypnotically-based Intervention on Pain and Fear in
Women Undergoing Labor
Neuraxial (epidural) analgesia is considered as the gold standard for achieving pain
relief during labor (Gizzo et al., 2014). Although epidural analgesia during labor is generally
easily performed and often well tolerated by women, it can also be accompanied by
significant fear, which can increase pain and make the placement of the epidural catheter
difficult (Cyna, 2012; Clark et al., 2015). The availability of treatments and procedures that
anesthesiologists could easily use to reduce both the fear related to epidural placement and the
pain associated with uterine contractions could benefit many of the women who undergo
epidural analgesia. To address this important issue, we developed and here evaluate the
effects of such an easily administered treatment procedure that has three components: (1)
patient rocking, (2) gentle touch, and (3) hypnotic communication.
The first component, patient rocking, was included because it is very easy for patients
to do and previous research has shown that inviting patients to engage in a rocking motion
reduces uterine contraction-related pain intensity (Waisblat et al., 2010). The second
component of the intervention, gentle touching (of the neck) was included in the procedure
for a number of reasons. First, gentle touching of the neck or upper back is often used to
facilitate the placement of the epidural catheter, so it is a natural component of epidural
procedures. Second, and importantly for the aims of this study, gentle touching can
communicate and provide an element of emotional support easily provided to women during
childbirth (Hodnett, Gates & Hofmeyr, 2013). Gentle touching is also a common component
of general medical care—for example in emergency situations (Airosa, Andersson &
Falkenberg, 2011)—because of the emotional comfort it can provide. Moreover, there is
4
HYPNOTICALLY-BASED INTERVENTION DURING LABOR
5
evidence indicating that gentle touch can itself have some analgesic effects (Herrington &
Chiodo, 2014; Mancini, Nash, Iannetti et al., 2014).
The third component of the intervention evaluated here was hypnotic communication
(Coldrey & Cyna, 2004). This component was added because evidence indicates that the
words that clinicians use can result in either pain relief (Lang et al., 2006; 2008) or more pain
(Richter, Eck, Straube, 2010), depending on the specific words chosen. Importantly, hypnosis
and the use of hypnotic communication can enhance the beneficial or negative effects of
words (Derbyshire, Whalley, & Oakley, 2009; Lang et al., 2006; 2008). In the current study,
we compared hypnotic communication (communication designed to focus the patient’s
awareness towards sensations and images that would elicit relaxation and comfort; Coldrey &
Cyna, 2004) to standard communication (the provision of information and command
statements typically made during medical procedures; Slater, Sellors & Cyna, 2011).
The primary aim of the current study was to evaluate and compare the effects of each
of the components of the interventions on both (1) fear of epidural placement and (2) pain
associated with contractions, in a sample of women in labor who were scheduled to receive an
epidural. Each component of the two interventions – rocking, touching and communication –
was introduced successively. All of the participants received the same rocking and touching
components. However, we used a quasi-experimental design to evaluate the potentially
additional benefits of hypnotic communication by using as study clinicians anesthesiologist
who either (1) had no experience or training in hypnotic communication and who therefore
provided standard communication (i.e., they provided the study participants with the usual
information and commands before and during the epidural procedure) and (2) had training
and experience in the use of hypnotic communication (i.e., they made suggestions to increase
relaxation and comfort before and during the epidural). We hypothesized that significant
improvements (decreases) in both fear and pain would occur following the rocking
6
component in the patients of both groups of anesthesiologists, but that the patients of the
anesthesiologists who provided hypnotic communication would report significantly more
reductions in fear and pain than the patients of the anesthesiologists who provided standard
communication following the communication component of the intervention.
Methods
Study design
Because we had already demonstrated that rocking alone is effective for reducing pain
(Waisblat et al., 2010), we did not plan to compare rocking with a control condition; rather,
we were interested first in replicating our previous finding of a pain reduction with rocking,
and then in determining if touching combined hypnotic communication had an additional
beneficial effect over and above the effects of rocking. Given that the benefits of hypnotic
communication have not yet been evaluated in women about to undergo an epidural injection,
a second goal was to compare the reductions in the pain and fear ratings in a group of women
who received hypnotic communication with a group who received standard communication.
To address these aims, we used a longitudinal repeated measures quasi-experimental design,
where all participants were first instructed to rock for five minutes and who then received one
of two conditions (as a function of the training of their treating anesthesiologist; i.e., not as a
function of random assignment).
Patient participants
We enrolled women in labor who had requested epidural analgesia to assist with their
delivery. All of the patient participants provided informed consent. The women did not
receive any information regarding medical hypnosis and were not aware if the
anesthesiologist caring for them was skilled in clinical hypnosis, or not. In addition, the
anesthesiologist enrolling patients in the present trial were informed of the importance the
consenting women remained blinded to the group they were allocated. Inclusion criterion
6
HYPNOTICALLY-BASED INTERVENTION DURING LABOR
7
were (1) no clinical or biological contraindications to epidural analgesia placement and (2)
rating the pain of uterine contractions as ≥ 4/10 on a 0-10 Numerical Rating Scale (NRS) of
pain intensity (Jensen & Karoly, 1986). Study exclusion criterion were (1) being unable to
understand or speak French and (2) being unable to understand the study design or rate pain
and fear of the epidural puncture using the NRS, with 0 = “No pain [fear]” and 10 = “Worst
imaginable pain [fear]”.
Anesthesiologist selection and education
After the institutional ethical review board approved the study, 16 senior
anesthesiologists working in both public and private obstetric institutions agreed to recruit
laboring women for the purpose of this clinical trial. In order to be able to evaluate the added
benefits of hypnotic communication, we recruited a subset of physicians who had training and
experience in the use of hypnosis. Specifically, we identified half (n = 8) of the participating
physicians as physicians with no to minimal experience with hypnosis and half (n = 8) with a
high degree of experience in the use of hypnotic communication. Before enrolling the
laboring women, all of the participating physicians were taught the use of the rocking and
touching using video recordings. When comfortable with the treatment components and were
determined to be competent in each by a supervisor (VW), each participating physician was
then asked to enroll 10 consecutive laboring women.
As indicated previously, physicians naïve to clinical hypnosis were recruited to
provide treatment to the Standard communication Group (Group S) participants. They were
instructed to behave normally and “do their best” to comfort the patients before and during
the epidural procedure. They were not otherwise given any instructions regarding what to say
or how they might say it – that is, they were given no instructions in hypnotic communication.
Commonly used verbal communications by anesthesiologists include information and
command statements such as “Put your chin down onto your chest”. They often also use of
8
negative words or phrases such as “sting,” “burn,” “hurt,” “bad,” “pain” and “…it will feel
like a bee sting” when explaining the procedure (Häuser, Hansen & Enck, 2012; Slater et al.,
2011; Varelmann, Pancaro, Cappiello et al., 2010). However, the Group S physicians were
not specifically instructed to use these words.
The study anesthesiologists who were experienced in clinical hypnosis were given
additional instruction to standardize the words they expressed before and during the epidural
procedures for the Hypnotic communication group patients (Group H). Specifically they were
given instruction in the use of positive suggestive communication strategies (Varga, 2013).
Positive suggestive communication includes elements such as attentive listening, provision of
the perception of control (“Let us know, at any time, what we can do for you”),
encouragement, use of emotionally neutral descriptors (e.g., “This is the local anesthetic”
instead of “You will feel a sting and a burn”), and use of positive suggestions (e.g., “I am
putting an antiseptic on your back. How does it feel?” – Cold – “Did you know that coldness
may help you and numb the skin?”). The Group H anesthesiologists were also instructed in
the use of positive imagery, including suggestions for experiencing oneself being in a
safe/favorite place or a safe/favorite time (e.g., “And now, you might imagine yourself in a
safe and comfortable place...”). In addition to being given a standardized training program in
the form of the video training, the Group H anesthesiologists were encouraged to tailor the
hypnotic communication provided to the needs and responses to each individual patient,
varying these as a function of the patients’ behavior and on their judgment of patients’ needs.
Such communication style has been previously shown to reduce both pain and stress during
invasive procedures (Dutt-Gupta, Bown, & Cyna, 2007; McMurtry, Chambers & McGrath,
2010).
8
HYPNOTICALLY-BASED INTERVENTION DURING LABOR
9
Description of the interventions
During the first component (Rocking), all women were asked to sit up and rock gently
back and forth. Rocking could be ongoing or intermittent depending on the participant’s
preference. The participants were also free to choose the amplitude and rate of the rocking
motions. The anesthesiologist caring for the patient was asked to encourage and to assist
rocking for approximately 5 minutes.
The second component that all of the women were given (Touching) began after 5 min
of rocking. During this component, the anesthesiologist’s assistant faced the woman and
gently touched the nape of the woman’s flexed neck with one hand to facilitate relaxation and
communicate support. As the assisting nurse continued to touch the neck of the participant,
the physician began the third component (Communication). Depending on the
anesthesiologist, the physician provided either standard (Group S) or hypnotic (Group H)
communication. The touching and the communication component lasted about 7 min, until
the beginning of the epidural procedure.
Assessment Procedures
Pain and fear were first assessed at baseline in the delivery ward, while the laboring
women were lying on a birthing table. Women reporting initial pain intensity ratings of ≥
4/10 and who expressed an interest in participating in the study were enrolled at this time
(baseline), if they were eligible. The participants were then asked to sit up and the rocking
motion was initiated. During the rocking component, a sterile field for the epidural was
prepared. After 5 min of rocking, the study outcomes (pain intensity and fear) were measured
again (post-rocking). This was followed by the touching and communicating components;
rocking was maintained, however, while a local anesthetic was applied. After about 7 min of
the touching and communicating components, pain intensity and fear were assessed for a third
and final time (post-communication). Following this, the rocking motion was maintained or
10
stopped during epidural catheter placement, depending upon what the anesthesiologist
thought best.
Data analysis
The study was powered to detect both (1) the hypothesized reductions in pain with
rocking alone (baseline to post-rocking) and (2) the hypothesized between-group (i.e.,
standard versus hypnotic communication) differences in reductions in pain following the
touching and communication components (post-rocking to post-communication). In a
previous study (Waisblat, 2010), we found a significant mean (SD) reduction of pain intensity
from 8.1 (1.8) to 6.6 (1.9) with rocking alone. In the current study, we hypothesized that the
participants would report similar same levels of pain reduction following rocking alone, and
also that the participants who received touching and hypnotic communication (Group H)
would report this amount of further reductions in pain, relative to the participants who
received touching and standard communication (Group S). Using an alpha level of 0.05 and a
power of 0.9, we determined that 140 participants (70 per group) should be enrolled in the
study to be able to detect these effects.
We first compute descriptive statistics (means, standard deviations, rates, and
percentages) of the demographic and obstetrical variables of the study clinicians and
participants to describe the sample, and compared the Group S and Group H study clinicians
and participants on these variables to determine if they were equivalent at baseline. Next to
test the study hypotheses, we performed a pair of repeated measures analyses of variance with
the pain and fear ratings as the dependent variable and time (baseline, post-rocking, post-
communication) and treatment condition (Group S, Group H) as the dependent variables.
Support for the first study hypothesis would emerge if a significant time effect emerged, with
subsequent univariate analyses indicating a significant decrease in pain and fear from baseline
to post-rocking for both treatment groups, combined. Support for the second study hypothesis
10
HYPNOTICALLY-BASED INTERVENTION DURING LABOR
11
would emerge if a significant Time X Treatment Group interaction emerged, with subsequent
univariate analyses indicating significantly greater reductions in pain and fear in Group H
than Group S. All analyses were conducted using the SAS software package (SAS Institute,
Cary, NC).
Results
Subject and anesthesiologist characteristics
The chronological age (Group S: 44.3 years [SD, 13.3]; Group H: 46.3 years [SD,
7.1]; t (14) = -0.44, p = 0.67) and duration of professional activity (Group S: 13.3 years [SD,
3.9]; Group H: 15.1 years [SD, 3.2]; t (14) = -0.37, p = 0.72) of the Group S and H study
clinicians were similar. The study clinicians approached a total of 172 potential participants,
of whom 6 were not able to understand how to use the NRS rating scales, and 11 declined
participation. This left a total of 155 laboring women in the study. One study clinician
enrolled 12 patients, one enrolled 11, eleven enrolled 10, two enrolled 8, and one enrolled 6.
Baseline and post-rocking pain intensity ratings were missing for two participants and one
participant did not provide baseline fear ratings. These patients were excluded from analyses
that used any of the missing variables. As illustrated in the flow chart (see Figure 1), there
were 76 patients enrolled in Group S and 79 in Group H. The obstetrical characteristics of the
study sample are provided in Table 1. There were no statistically significant differences
between the two groups regarding the characteristics of the enrolled women.
12
Table 1. Descriptive and obstetrical data for the participants in the two experimental groups.
Group S
n = 76
Group H
n = 79
Age in years (SD) 30.4 (5.9) 29.6 (4.5)
Number of births (%)
1 29 (39%) 42 (53%)
2 25 (33%) 24 (30%)
>3 21 (28%) 13 (16%)
Cervical dilatation at T0 (%)
<3cm
3-4 cm
>4 cm
17 (23%)
28 (38%)
29 (39%)
18 (23%)
32 (41%)
29 (37%)
Note: Group S: Rocking + Touching + Standard Communication group; Group H: Rocking +
Touching + Hypnotic Communication group. Values are mean (SD) or number (%). No
significant between-group differences emerged in the descriptive or obstetrical variables.
12
HYPNOTICALLY-BASED INTERVENTION DURING LABOR
13
Baseline to post-rocking changes in pain and fear ratings
A statistically significant baseline to post-rocking decrease in pain intensity occurred
in both groups (Table 2). When pooling the data of both groups, baseline to post-rocking pain
ratings decreased from 7.3 to 5.9, respectively, for a mean decrease of 1.4 [95% CI: -1.7-1.2]
(p < .0001). Furthermore, 74% (113/152) of patients reported lower pain ratings following
Rocking (p < .0001). As seen in Figure 2a, report of a decrease in Pain score was not
dependent on the initial (baseline) score; that is, mean pain ratings decreased after Rocking
independent of the baseline pain ratings and other factors. However, the benefits of Rocking
were greater for participants who was birthing for the first or second time, and for participants
who had less (<4 cm) cervical dilation in labor. However, there was no evidence of variation
in results due to Rocking across physicians.
Table 2. Means and standard deviations of the pain and fear ratings at each assessment point.
-----------------------------------------------------------------------------------------------------------------
------------
Post- F for the F for the
Outcome Baseline Post-rocking communication time Time X
Group
14
variables Mean (SD) mean (SD) Mean (SD) main effect
interaction
-----------------------------------------------------------------------------------------------------------------
-------------
Pain intensity
Group S 7.25a (1.95) 5.95b (2.19) 5.78b (2.17) 153.96***
11.00***
Group H 7.43a (1.62) 5.83b (1.60) 4.87c (1.55)
Fear
Group S 5.47a (3.20) 4.76b (2.98) 4.59b (2.97) 67.39*** 5.84**
Group H 4.75a (2.81) 3.72b (2.55) 3.21c (2.28)
-----------------------------------------------------------------------------------------------------------------
-------------
Note: Group S received standard communication after the rocking component, and Group H
received hypnotic communication after the rocking component. Means with different
subscripts are significantly different from one another.
*p < .05, **p < .01, ***p < .001
Similarly, a reduction in fear was observed from before to after rocking to the same
extent in both groups. When pooling the data from both groups (Figure 2b), the baseline to
post-rocking fear ratings decreased from 5.1 and 4.2, for a mean decrease of 0.8 [95% CI:
-1.1, -0.62]; (p < .0001). However, fewer participants (48%, or 74/154) reported decreases in
fear following rocking than reported decreases in pain (p = .63). In addition, the women who
experienced the largest decreases in fear were those who endorsed the most fear at baseline.
Differences in pain and fear as a function of physician type
Figures 3 and 4 illustrate post-rocking to post-communication changes in the pain and
fear ratings, respectively. As predicted, we found statistically significant Time X Group
interactions for both outcomes (see Table 2). The univariate analyses performed to explain
these interactions indicated that participants treated by Group S (standard communication)
14
HYPNOTICALLY-BASED INTERVENTION DURING LABOR
15
physicians did not evidence significant changes in fear or pain. On the other hand,
participants treated by the Group H (hypnosis communication) physicians reported significant
post-rocking to post-communication reductions in both pain and fear. The mean post-
communication pain rating [95% CI] in the Group H participants was 4.9 [4.5-5.2], which was
statistically than the mean post-communication pain rating in the Group S participants (5.8
[5.3-6.3], p = .004). Similarly, the mean fear ratings [95% CI] in the Group H participants
was 3.2 [2.7-3.7], significantly lower than that of the Group S participants (4.6 [3.9-5.3], p = .
001).
Following the Communication component of the intervention, the epidural catheter
was inserted. Despite the fact the anesthesiologists were allowed to stop patient’s movements
16
at this point, the epidural catheter was inserted while Rocking in 29/76 (38%) of the cases in
Group S, and 70/79 (89%) in Group H. No patients in either group had any epidural catheter
placement complications.
Discussion
The results of this study indicate that a simple process involving two nonverbal
interactions (rocking and touching) and hypnotic communication resulted in significantly
more reductions in both uterine contraction pain and fear of epidural analgesia than a
procedure that involved the two nonverbal interactions and standard communication. The
findings have important implications for how anesthesiologists might facilitate greater
comfort in laboring women.
Hypnotic procedures are thought to alter the subject’s “state of consciousness” in such
a way as to make them more open to responding to suggestions, whether those suggestions are
helpful (e.g., “The coolness of the antiseptic may help you and numb the skin”) or less than
helpful (e.g., “Here comes the bee sting!”; Elkins, Barabasz, Council et al., 2015). The
concept of consciousness, of course, is complex. Human consciousness and experiences of
the bodily self, is thought to be the result of a multimodal integration of bodily information,
originating mostly from vestibular, tactile, proprioceptive, visual information and pain (Ferrè,
Lopez & Haggard, 2014; Ionta, Gassert & Blanke, 2011; Lenggenhager, & Lopez, 2015;
Pfeiffer et al., 2013; Schwabe & Blanke, 2008). It is possible that in the context of giving
birth, the Rocking, Touching and Hypnotic Communication techniques examined here may
have affected one or more of these multisensory integration systems; that is, they may have
facilitated a hypnotic state (Elkins et al., 2015).
The reduction of uterine contraction pain intensity during rocking has been noted in a
previous study (Waisblat et al., 2010). Importantly, simply being in a seated position (or not)
had little influence on labor pain intensity – it was the rocking motion that influenced pain. In
16
HYPNOTICALLY-BASED INTERVENTION DURING LABOR
17
the current study, we observed in both groups a similar reduction of 20% in pain and fear
ratings following the Rocking component. We speculate that the observed decrease in pain
and fear may have been the result from a direct effect of the rocking movements on reducing
nociception and anxiety. Indeed, repetitive back and forth head movements have been shown
to induce intense vestibular stimulation (Angelaki & Cullen, 2008; Lopez, & Blanke, 2011)
which is known to alter multisensory integration (Carmona, Holland & Harrison, 2009;
Lopez, Schreyer, Preuss et al., 2012; Viaud-Delmon, Venault & Chapouthier, 2011) and
depress nociception (Ferrè, Bottini & Iannetti, 2013; McGeoch, Williams & Lee, 2008). In
addition, repetitive rocking of the upper body may promote proprioceptive stimulation and
also influence multisensory integration and awareness of the body (Proske & Gandevia, 2012;
Salomon, Lim, Herbelin et al., 2013). Thus, the combination of vestibular and proprioceptive
stimulation during rocking may have blurred the nociceptive message (Mathai, Natrajan &
Rajalakshmi, 2006) and possibly alter the processing of sensory input, resulting in the reduced
intensity of uterine contraction pain and less epidural analgesia fear (Grabherr, L., Macauda,
G., & Lenggenhager, B., 2015). It is also possible that the repetitive and rhythmic movement
(of rocking) may have facilitated a hypnotic state, which then could have increased the
participants’ responsivity to the implicit suggestion that the procedure would reduce both pain
and fear. While research would be needed to better understand the mechanisms of the
beneficial effects of rocking, the fact remains that this simple procedure results in significant
and meaningful decreases in pain and fear.
A large number of studies support the beneficial impact of hypnotic communication
and positive suggestions in pain (e.g. Coldrey & Cyna, 2004; Cyna, Andrew & Tan, 2009;
Faymonville et al., 1997; 2000; Kekecs & Varga, 2013; Lang & Laser, 2009; Lang, 2012;
Rainville, Carrier, Hofbauer et al., 1999; Uman et al., 2013; Valentini, Betti, Hu et al., 2013;
Varga & Kekecs, 2014; Yip, Middleton, Cyna et al., 2009). Our findings are consistent with
18
this body of research. What is particularly important about the results of this study, in our
view, is the finding that these effects were achieved so easily, with no added time or cost to
the procedure.
However, it is also important to keep in mind that this was not a randomized clinical
trial, so it is possible that some (unknown) differences between participants in the two
treatment conditions might explain the effects. Although we did not find any systematic
differences between the participants in the two conditions at baseline, additional research
using a randomized clinical trial design is needed to help establish the reliability of the results.
Another limitation of the current study, shared by all studies evaluating psychosocial
interventions, is that the study clinicians were not blind to treatment assignment. Moreover,
although efforts were made to blind the participants to treatment condition as much as
possible, it is possible that they might have accurately guessed that they received hypnosis (or
not). Thus, the participants in the hypnotic language condition may have demonstrated more
benefits because of the expectations of the clinicians that the hypnotic language was more
effective or by the expectations in the patients engendered by this language, and not by the
specific effects of the suggestions provided. Although the possible nonspecific effects
associated with patient or clinician expectations may have been minimized somewhat by the
fact that the patients did not know that their clinician was particularly skilled in or had
received any special training in hypnosis, it would have been useful to assess patient and
clinician outcome expectancies, in order to be able to evaluate the potential impact of these
variables on outcome.
Despite the facts that we used a quasi-experimental and not a randomized control
design, as well as the lack of treatment blinding that is a limitation of any psychosocial pain
clinical trial, the findings add important new information to the small body of research
assessing the efficacy of hypnosis during labor and childbirth (Jones et al., 2012; Madden,
18
HYPNOTICALLY-BASED INTERVENTION DURING LABOR
19
Middleton, Cyna, et al., 2012; Marc et al., 2011). We found that a very simple procedure that
could easily be used by anesthesiologists during epidurals without adding any time to the
procedures results in important reductions in both pain and fear in laboring women. The
procedure is fully adaptable to daily clinical practice of anesthesiology in obstetric units.
In conclusion, here we evaluated the potential benefits of a series of procedures that
included nonverbal interactions and hypnotic communication designed to reduce the pain and
fear in women who are about to receive epidural analgesia. The procedure we proposed to
parturients is probably very similar to the “original hypnotic experience” many most humans
have experienced during childhood when their mother or father sang in swaying them in their
crib (Zelinka, Cojan & Desseilles, 2014). By analogy with our protocol, rocking could be the
induction tool and the language voiced by the anesthesiologist, the suggestion part of
hypnosis. We speculate that the cue and mechanisms installed in early may be reactivated at
the time when women give birth. We have shown that a process combining body rocking
motion, gentle nape touching, and hypnotic communication using positive suggestions may be
an effective non-pharmacological means of reducing pain and fear in laboring women up to
epidural obstetrical analgesia administration. Future research to confirm these findings in
additional samples is warranted.
Acknowledgments: We would like to thank Noah Langholz an exchange student who brought
together the French and the American research teams; Professor Alain Berthoz for his long-
term support; Christophe Lopez PhD for its constructive evaluation of our discussion; and
Allan Cyna FANZCA, PhD for his helpful review of the draft manuscript.
Financial support and sponsorship: None
Conflicts of interest: None
Presentation: Preliminary data for this study were presented as a poster presentation at the
Société Française d’Anesthésie et Réanimation (SFAR) 19-22 September 2012, at the
20
American Society of Anesthesiology (ASA) Anesthesiology, 13–17 October 2012,
Washington, DC, USA; and at the European Society of Hypnosis (ESH) 22-25 October
2014, Sorrento, Italy.
20
HYPNOTICALLY-BASED INTERVENTION DURING LABOR
21
References
Airosa, F., Andersson, S. K., Falkenberg, T., Forsberg C., Nordby-Hörnell E., Ohlén G.,
Sundberg T. (2011). Tactile massage and hypnosis as a health promotion for nurses in
emergency care—a qualitative study, BMC Complement Altern Med, 11, 83-91. doi:
10.1186/1472-6882-11-83.
Angelaki, D. E. & Cullen, K. E. (2008). Vestibular system: the many facets of a multimodal
sense. Annu Rev Neurosci, 31:125-50. doi: 10.1146/annurev.neuro.31.060407.125555.
Carmona, J. E., Holland, A. K. & Harrison, D. W. (2009). Extending the functional cerebral
systems theory of emotion to the vestibular modality: a systematic and integrative
approach. Psychol Bull. 135:286-302. doi: 10.1037/a0014825.
Clark, A., Holck, G., Mahoney, B., Farber, M. K., Liu, X. & Tsen, L. C. (2015), Differences
between anticipated and perceived difficulty and insertion duration of labor epidural
techniques among anesthesiologists, nurses and patients. Int J Obstet Anesth.
May;24:111-6. doi: 10.1016/j.ijoa.2014.12.004.
Coldrey, J. C. & Cyna, A. M. (2004). Suggestion, hypnosis and hypnotherapy: a survey of
use, knowledge and attitudes of anaesthetists. Anaesth Intensive Care. Oct;32:676-80.
Cyna, A. M. (2012), Managing the placement of an epidural catheter when the woman is
anxious and/or having painful uterine contractions using suggestion and the
communication structure ‘LAURS’ In Sia A, Chan YK, Gatt SP, Obstetric Anesthesia
and Analgesia: Practical Issues p. 60-73 Red Cells Series Malaysian University Press.
Cyna, A. M., Andrew, M. I. & Tan, S. G. (2009). Communication skills for the anaesthetist.
Anaesthesia. 64:658-65. doi: 10.1111/j.1365-2044.2009.05887.x.
Derbyshire, S. W., Whalley, M. G. & Oakley D. A. (2009). Fibromyalgia pain and its
modulation by hypnotic and non-hypnotic suggestion: an fMRI analysis. Eur J Pain.
May;13(5):542-50. doi: 10.1016/j.ejpain.2008.06.010.
HYPNOTICALLY-BASED INTERVENTION DURING LABOR
22
Dutt-Gupta, J., Bown, T. & Cyna, A. M. (2007). Effect of communication on pain during
intravenous cannulation: a randomized controlled trial. Br J Anaesth. Dec;99:871-5.
Elkins, G. R., Barabasz, A. F., Council, J. R. & Spiegel, D. (2015). Advancing research and
practice: the revised APA Division 30 definition of hypnosis. Int J Clin Exp Hypn.
63:1-9.
Faymonville, M. E., Laureys, S., Degueldre, C., DelFiore, G., Luxen, A., Franck, G,…
Maquet, P. (2000) Neural mechanisms of antinociceptive effects of hypnosis.
Anesthesiology. 92:1257-67.
Faymonville, M. E., Mambourg, P. H., Joris, J., Vrijens, B., Fissette, J., Albert, A. & Lamy,
M. (1997). Psychological approaches during conscious sedation. Hypnosis versus
stress reducing strategies: a prospective randomized study. Pain. 73:361-7.
Ferrè, E. R., Bottini, G., Iannetti, G. D. & Haggard, P. (2013). The balance of feelings:
vestibular modulation of bodily sensations. Cortex. 49:748-58. doi:
10.1016/j.cortex.2012.01.012.
Ferrè, E. R., Lopez, C. & Haggard, P. (2014). Anchoring the self to the body: vestibular
contribution to the sense of self. Psychol Sci. Nov;25:2106-8.
Gizzo, S., Noventa, M., Fagherazzi, S., Lamparelli, L., Ancona, E., Di Gangi, S., …&
Nardelli, G.B. (2014). Update on best available options in obstetrics anaesthesia:
perinatal outcomes, side effects and maternal satisfaction. Fifteen years systematic
literature review. Arch Gynecol Obstet. Jul;290:21-34.
doi:10.1177/0956797614547917
Grabherr, L., Macauda, G., & Lenggenhager, B. (2015), The Moving History of Vestibular
Stimulation as a Therapeutic Intervention, Multisensory Research. doi:
10.1163/22134808-00002495
HYPNOTICALLY-BASED INTERVENTION DURING LABOR
23
Häuser, W., Hansen, E. & Enck, P. (2012). Nocebo phenomena in medicine: their relevance in
everyday clinical practice. Dtsch Arztebl Int . Jun;109:459-65. doi:
10.3238/arztebl.2012.0459
Herrington, C. J. & Chiodo, L. M. (2014). Human touch effectively and safely reduces pain in
the newborn intensive care unit. Pain Manag Nurs. Mar;15:107-15. doi:
10.1016/j.pmn.2012.06.007
Hodnett, E. D., Gates, S., Hofmeyr, G. J. & Sakala, C. (2013). Continuous support for women
during childbirth. Cochrane Database Syst Rev. Jul 15;7: CD003766.
Ionta, S., Gassert, R. & Blanke, O. (2011). Multi-sensory and sensorimotor foundation of
bodily self-consciousness - an interdisciplinary approach. Front Psychol. 2:383. doi:
10.3389/fpsyg.2011.00383. eCollection 2011.
Jensen, M. P. & Karoly, P. (1986). Self-report scales and procedures for assessing pain in
adults, in Handbook of Pain Assessment, Edited by Dennis C. Turk and Ronald
Melzack, The Guilford Press.
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 Syst Rev. doi: 10.1002/14651858.CD009234.pub2.
Kekecs, Z. & Varga, K. (2013). Positive suggestion techniques in somatic medicine: A review
of the empirical studies. Interv Med Appl Sci. Sep;5:101-11. doi:
10.1556/IMAS.5.2013.3.2.
Lang, E. & Laser, E. (2009). Patient Sedation Without Medication: Rapid Rapport and Quick
Hypnotic Techniques: A Resource Guide for Doctors, Nurses, and Technologists. USA
& Canada: Trafford Publishing.
Lang, E. V., Berbaum, K. S., Faintuch, S., Hatsiopoulou, O., Halsey, N., Li, X., … Baum, J.
(2006). Adjunctive self-hypnotic relaxation for outpatient medical procedures: a
HYPNOTICALLY-BASED INTERVENTION DURING LABOR
24
prospective randomized trial with women undergoing large core breast biopsy. Pain.
Dec 15;126:155-64.
Lang, E. V., Berbaum, K. S., Pauker, S. G., Faintuch S, Salazar GM, Lutgendorf S, Spiegel D.
(2008). Beneficial effects of hypnosis and adverse effects of empathic attention
during percutaneous tumor treatment: when being nice does not suffice. J Vasc Interv
Radiol. Jun;19:897-905. doi: 10.1016/j.jvir.2008.01.027.
Lang, E. V. (2012). A Better Patient Experience Through Better Communication. J Radiol
Nurs. Dec 1;31:114-119.
Lenggenhager, B. & Lopez C. (2015).Vestibular contributions to the sense of body, self and
others. In: Metzinger T. & Windt J. (Eds.). Open MIND. MIND Group, Frankfurt am
Main, p. 1-38. http://open-mind.net/papers/vestibular-contributions-to-the-sense-of-
body-self-and-others
Lopez, C., Schreyer, H. M., Preuss, N. & Mast F. W. (2012). Vestibular stimulation modifies
the body schema. Neuropsychologia. 50:1830-7. doi:
10.1016/j.neuropsychologia.2012.04.008.
Lopez, C. & Blanke, O. (2011). The thalamocortical vestibular system in animals and
humans. Brain Res Rev. 24;67:119-46. doi: 10.1016/j.brainresrev.2010.12.002.
Madden, K., Middleton, P., Cyna, A. M. Matthewson, M. & Jones, L. (2012). Hypnosis for
pain management during labour and childbirth. Cochrane Database Syst Rev. doi:
10.1002/14651858.CD009356.pub2.
Mancini, F., Nash, T., Iannetti, G. D. & Haggard, P. (2014). Pain relief by touch: a quantitative
approach. Pain. Mar;155:635-42.
Marc, I., Toureche, N., Ernst, E., Hodnett, E.D., Blanchet, C., Dodin, S. & Njoya, M.M.
(2011). Mind-body interventions during pregnancy for preventing or treating women’s
anxiety. Cochrane Database Syst Rev. doi: 10.1002/14651858.CD007559.pub2.
HYPNOTICALLY-BASED INTERVENTION DURING LABOR
25
Mathai, S., Natrajan, N. & Rajalakshmi, N. R. (2006). A comparative study of
nonpharmacological methods to reduce pain in neonates. Indian Pediatr. 43:1070-5.
McGeoch, P. D., Williams, L. E., Lee, R. R. & Ramachandran V. S. (2008). Behavioural
evidence for vestibular stimulation as a treatment for central post-stroke pain. J
Neurol Neurosurg Psychiatry. 79:1298-301. doi: 10.1136/jnnp.2008.146738.
McMurtry, C. M., Chambers, C. T., McGrath, P. J. & Asp, E. (2010). When “don’t worry”
communicates fear: Children’s perceptions of parental reassurance and distraction
during a painful medical procedure. Pain. Jul;150:52-8. doi:
10.1016/j.pain.2010.02.021.
Pfeiffer, C., Lopez, C., Schmutz, V., Duenas, J. A., Martuzzi, R. & Blanke, O. (2013).
Multisensory origin of the subjective first-person perspective: visual, tactile, and
vestibular mechanisms. PLoS One. 22;8:e61751. doi: 10.1371/journal.pone.0061751.
Proske, U. & Gandevia, S. C. (2012). The proprioceptive senses: their roles in signaling body
shape, body position and movement, and muscle force. Physiol Rev. Oct;92:1651-97.
doi: 10.1152/physrev.00048.2011.
Rainville, P., Carrier, B., Hofbauer, R. K., Bushnell, M. C. & Duncan, G. H. (1999).
Dissociation of sensory and affective dimensions of pain using hypnotic modulation.
Pain. 82:159-71.
Richter, M., Eck, J., Straube, T., Miltner, W.H. & Weiss, T. (2010). Do words hurt? Brain
activation during the processing of pain-related words. Pain.;148:198-205. doi:
10.1016/j.pain.2009.08.009.
Salomon, R., Lim, M., Herbelin, B., Hesselmann, G. & Blanke, O. (2013). Posing for
awareness: proprioception modulates access to visual consciousness in a continuous
flash suppression task. J Vis.13:2. doi: 10.1167/13.7.2.
HYPNOTICALLY-BASED INTERVENTION DURING LABOR
26
Schwabe, L. & Blanke, O. (2008). The vestibular component in out-of-body experiences: a
computational approach. Front Hum Neurosci. 3;2:17. doi:
10.3389/neuro.09.017.2008.
Slater, P., Sellors, J. & Cyna, A. M. (2011). Communications during epidural catheter
placement for labour analgesia, Anaesthesia. 66:1006-11. doi: 10.1111/j.1365-
2044.2011.06852.x.
Uman, L. S., Birnie, K. A., Noel, M., Parker, J.A., Chambers, C.T., McGrath, P.J. & Kisely,
S.R. (2013) Psychological interventions for needle-related procedural pain and distress
in children and adolescents. Cochrane Database Syst Rev. 10. doi:
10.1002/14651858.CD005179.pub3.
Valentini, E., Betti, V., Hu, L. & Aglioti, S. M. (2013). Hypnotic modulation of pain
perception and of brain activity triggered by nociceptive laser stimuli. Cortex. 49:446-
62. doi: 10.1016/j.cortex.2012.02.005
Varelmann, D., Pancaro, C., Cappiello, E. C. & Camann, W. R. (2010). Nocebo-induced
hyperalgesia during local anesthetic injection. Anesth Analg. Mar 1;110:868-70. doi:
10.1213/ANE.0b013e3181cc5727.
Varga, K. & Kekecs, Z. (2014). Oxytocin and cortisol in the hypnotic interaction. Int J Clin
Exp Hypn. 62(1):111-28. doi: 10.1080/00207144.2013.841494.
Varga, K. (2013). Suggestive techniques connected to medical interventions. Interv Med Appl
Sci. Sep;5:95-100. doi: 10.1556/IMAS.5.2013.3.1.
Viaud-Delmon, I., Venault, P. & Chapouthier, G. (2011). Behavioral models for anxiety and
multisensory integration in animals and humans. Prog Neuropsychopharmacol Biol
Psychiatry. 35:1391-9. doi: 10.1016/j.pnpbp.2010.09.016.
HYPNOTICALLY-BASED INTERVENTION DURING LABOR
27
Waisblat, V., Mercier, F. J., Langholz, B., Berthoz, A., Cavagna, P. & Benhamou, D. (2010).
Effect of rocking motion on labour pain before epidural catheter insertion in the sitting
position Ann Fr Anesth Reanim. 29:616-20. doi: 10.1016/j.annfar.2010.04.004.
Yip, P., Middleton, P., Cyna, A. M. & Carlyle, A. V. (2009). Non-pharmacological
interventions for assisting the induction of anaesthesia in children. Cochrane
Database Syst Rev. Jul 8;(3):CD006447. doi: 10.1002/14651858.CD006447.pub2.
Zelinka, V., Cojan, Y. & Desseilles, M. (2014). Hypnosis, attachment, and oxytocin: an
integrative perspectve. Int J Clin Exp Hypn. 62:29-49 doi:
10.1080/00207144.2013.841473.
