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Impact of a Hypnotically-Based Intervention on Pain and Fear in Women Undergoing Labor

  • Le Raincy Montfermeil Hospital, France


The purpose of this study was to evaluate the effects of a hypnotically-based intervention for pain and fear in women undergoing labor who are about to receive an epidural catheter. A group of 155 women received interventions that included either (a) patient rocking, gentle touching, and hypnotic communication or (b) patient rocking, gentle touching, and standard communication. The authors found that the hypnotic communication intervention was more effective than the standard communication intervention 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. Copyright
Impact of a Hypnotically-based Intervention on Pain and Fear in
Women Undergoing 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
Corresponding Author: Véronique Waisblat, Department of Anesthesiology, GHI Le Raincy
Montfermeil, 10 rue du GL Leclerc, 93370 France, Telephone number
+33 6 89 14 78 04
This manuscript has not been published or submitted elsewhere.
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
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
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
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.
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
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
negative words or phrases such as “sting,” “burn,” “hurt,” “bad,” “pain” and “…it will feel
like a bee stingwhen 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,
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
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
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).
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.
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 (%)
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.
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
variables Mean (SD) mean (SD) Mean (SD) main effect
Pain intensity
Group S 7.25a (1.95) 5.95b (2.19) 5.78b (2.17) 153.96***
Group H 7.43a (1.62) 5.83b (1.60) 4.87c (1.55)
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)
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 = .
Following the Communication component of the intervention, the epidural catheter
was inserted. Despite the fact the anesthesiologists were allowed to stop patient’s movements
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.
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
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
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,
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
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.
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... The remaining nine studies (56%) used a passive comparison group (treatment as usual; TAU). Of these 16 studies, four (25%) evaluated the effects of a hypnosis intervention during childbirth (Kurnaesih et al., 2021;Rock et al., 1969;Uludağ & Mete, 2020;Waisblat et al., 2017), 11 (69%) evaluated the effects of an antenatal hypnosis training program (Atis & Rathfisch, 2018;Beevi et al., 2016Beevi et al., , 2017Beevi et al., , 2019Brann & Guzvica, 1987;Cyna et al., 2013;Downe et al., 2015;Guse et al., 2006;Harmon et al., 1990;Letts et al., 1993;Mehl-Madrona, 2004;Vasra & Murdiningsih, 2020;Werner et al., 2012;Werner, Uldbjerg, Zachariae, Wu et al., 2013;Werner et al., 2020), and one study (6%) combined both approaches (Davidson, 1962). ...
... Similarly, six studies assessed pain using visual or numerical self-reported assessment scales. Of these, five studies (83%), including three RCTs, showed significantly lower pain levels in hypnosis-trained participants (Atis & Rathfisch, 2018;Beevi et al., 2017;Rock et al., 1969;Uludağ & Mete, 2020;Waisblat et al., 2017). Effect sizes could be calculated from three of these previous studies, revealing medium to large effects (d = 0.48 to 2.04; Beevi et al., 2017;Uludağ & Mete, 2020;Waisblat et al., 2017). ...
... Of these, five studies (83%), including three RCTs, showed significantly lower pain levels in hypnosis-trained participants (Atis & Rathfisch, 2018;Beevi et al., 2017;Rock et al., 1969;Uludağ & Mete, 2020;Waisblat et al., 2017). Effect sizes could be calculated from three of these previous studies, revealing medium to large effects (d = 0.48 to 2.04; Beevi et al., 2017;Uludağ & Mete, 2020;Waisblat et al., 2017). One study (17%) failed to observe significant differences (Werner et al., 2012). ...
This systematic review aims to identify current protocols involving the use of hypnosis during the perinatal period and to examine its effects on mothers' well-being. Seven electronic databases were searched for articles published from 1960 to April 1, 2021, that assessed the effectiveness of hypnosis during the perinatal period. All published randomized, controlled trials and nonrandomized, controlled trials studies assessing the effectiveness of hypnosis used during the perinatal period with healthy adult women were included. The quality of the included studies was assessed using the Risk of Bias in Nonrandomized Studies of Interventions or the Revised Cochrane risk-of-bias tool for randomized trials. Article screening, methodological-quality assessment, and data extraction were performed by 2 independent reviewers. Twenty-one articles, corresponding to 16 studies met inclusion criteria. Apart from 2 studies, all included studies reported the benefits of implementing a hypnosis intervention during the perinatal period. However, methodological limitations relative to intervention implementation and assessment methods might have led to the observed variability in results across studies. Future studies should consider a more standardized methodology.
... Two studies used the NPS scale as a unit of measurement, and the remaining 59 studies used the VAS scale. Among the analyzed studies the interventions experimented were the following: 11 studies tested some form of massage, [83][84][85][86][87][88][89][90][91][92][93] five studies tested the efficacy of birth balls, 85,94-97 eight studies tested distraction or mind-body interventions, 52,53,[98][99][100][101][102][103] 12 studies tested the efficacy of heat application, 85,93,[104][105][106][107][108][109][110][111][112][113] nine studies tested the efficacy of music therapy, 84,88,[114][115][116][117][118][119][120] two studies tested the efficacy of dance therapy, 116,121 16 studies tested the efficacy of acupressure, 89,110,[122][123][124][125][126][127][128][129][130][131][132][133][134][135] and eight studies applied TENS during labor. 132,[136][137][138][139][140][141][142] An interesting focus of our study was also represented by the extensive heterogeneity in terms of intervention protocols within the bounds of the application of the same therapy, especially regarding massage, acupressure, heath therapy and dance therapy. ...
... In our analysis, four studies involved the use of distraction through virtual reality, 52,53,102,103 one through distraction facilities such as puzzles and movies, 101 through Islamic praying, 100 one through the combination of skin caressing and breathing techniques, 98 and one through the combination of skin caressing, rocking, and hypnotic communication exerted by the researcher. 99 Regarding TENS, five studies applied electricity at acupoints 132,139-142 and four applied it at the lower back area, [136][137][138]141 with Báez-Suárez also comparing the application of constant high frequencies versus the use of fluctuating frequencies. 137 Regarding the timing of the pain scores measurement, the trials included showed a vast heterogeneity: 70.31% of the studies (n = 45) set the timing of the measurement in relation to the timing of the intervention (e.g., immediately after intervention, 20 minutes after intervention), 17.46% (n = 11) in relation to the cervical dilatation progression, 7.93% (n = 5) decided to set a fixated measurement frequency (e.g., every hour) and 3.17% of the trials (n = 2) recorded the mean pain intensity based on the postnatal recollection of the patient. ...
the aim of the study was to conduct a meta-analysis to evaluate the efficacy of non-invasive and non-pharmacological techniques on labor first-stage pain intensity. Literature databases were searched from inception to May 2021, and research was expanded through the screening of previous systematic reviews. Inclusion criteria were: (1) population: women in first stage of labor; (2) intervention: non-pharmacological, non-invasive, or minimally invasive intrapartum analgesic techniques alternative and/or complementary to pharmacological analgesia; (3) comparison: routine intrapartum care or placebos; (4) outcomes: subjective pain intensity; and (5) study design: randomized controlled trial. Risk of bias of included studies was investigated, data analysis was performed using R version 3.5.1. Effect size was calculated as difference between the control and experimental groups at posttreatment in terms of mean pain score. A total of 63 studies were included, for a total of 6146 patients (3468 in the experimental groups and 2678 in the control groups). Techniques included were massage (n = 11), birth balls (n = 5) mind-body interventions (n = 8), heat application (n = 12), music therapy (n = 9), dance therapy (n = 2), acupressure (n = 16), and transcutaneous electrical nerve stimulation (TENS) (n = 8). The present review found significant evidence in support of the use of complementary and alternative medicine for labor analgesia, and different methods showed different impact. However, more high-quality trials are needed.
... Few studies focused on specific outcome variables like "mental health of pregnant women -anxiety" (Noorbala et al., 2019), "perinatal mood and anxiety disorders" (Waters et al., 2020), "anxiety of pregnant women undergoing interventional prenatal diagnosis" (Kang, 2020), "labor fear" (Uludağ & Mete, 2020), "fear of women undergoing labor" (Waisblat et al., 2017), "pain catastrophizing" (Duncan et al., 2017), "pregnancy worries and stress" (Seyed Kaboli et al., 2017), "fear of delivery" (İsbir & Serçekuş, 2015) and "perceived stress during pregnancy" (Beattie et al., 2017). ...
... Legrand et al. (2017) also found a positive effect on decreasing state anxiety and also showed a re-increase in the return-to-baseline phase, but this study has to be interpreted carefully, as only one person was examined and the rating of the study was weak. Waisblat et al. (2017) examined the effect of hypnotic communication on fear of women undergoing labor and found that hypnotic communication (communication that focusses on the awareness of the patient towards sensations and images that support relaxation and comfort) was more effective than standard communication. In addition fear of labor was significantly lower in a "philosophy of hypnobirthing" group compared to the control group (received routine care) (Uludağ & Mete, 2020). ...
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Background: Fears and anxieties during pregnancy and childbirth are a frequent phenomenon and can have negative consequences on wellbeing, psychological health and birth outcomes. Therefore, it is important to focus on the interventions to reduce those fears and anxieties during pregnancy and childbirth. A systematic review was conducted to examine the current literature on psychological interventions to reduce anxieties and fears during pregnancy and childbirth. Scopus and PubMed were searched from 2015 up until December 2020 for relevant studies. Included were pregnant women, with no restriction on age ranges or parity. Entered in the review were quantitative studies, including randomized controlled trials (RCTs), non-randomized controlled trials as well as treatment evaluations. After reviewing titles, abstracts and studies, 72 studies were included in this review as they met the inclusion criteria. Standard methodological procedures for systematic reviews were used. The quality assessment of included articles was done by using the Quality Assessment Tool for Quantitative Studies (EPHPP). Results: The main results of this review concern the fear and anxiety reducing effects of psychoeducation, relaxation techniques, guided imagery, supportive care through a midwife, group discussion, “lifestyle based education”, writing therapy, cognitive behavioral therapy groups and stress intervention, individual structured psychotherapy, communication skills training, counseling approaches (except distraction techniques), a motivational interviewing psychotherapy, emotional freedom techniques, breathing awareness and different hypnotherapeutic techniques on different fears and anxieties during pregnancy and childbirth. For mindfulness-based interventions mixed results are found. The effect of an acceptance and commitment therapy, biofeedback interventions, a mind body intervention, mental health training courses, the group intervention Nyytti® as well as cognitive analytic therapy is unclear, due to weak ratings. Antenatal class attendance reduced delivery fear significantly only in first time mothers. An internet-based problem-solving treatment did not reduce anxiety during pregnancy. Conclusion: A broad range of interventions show positive effects on fear of childbirth and fear and anxiety in pregnancy. Further research should address other acknowledged psychotherapeutic practices, like psycho-dynamic as well as systemic interventions, as they are underrepresented within this review. Furthermore , there is a need for manualized therapeutic interventions, with regards to a combination of effective intervention components.
... [37] Controlling FOC has several goals, including assisting the mother in embracing the unknowns associated with childbirth, managing the pregnancy, reducing pregnancyrelated anxiety, and increasing the proportion of vaginal births (VB). [38] A few newer methods for lowering FOC include childbirth education, [39] breathing exercises, [40] hydrotherapy, [41] hypnosis, [42] continuity of midwifery care, [43] midwife counselling, [44] haptotherapy, [45] doula support, [46] and cognitive and behavioural therapies. [47] Birth pain has been the focus of study and treatments for FOC. ...
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Tokophobia, also known as maieusiophobia or parturiphobia, is a condition that affects 5-15 percent of pregnant women. Given the unpleasant and unpredictable sensation, it can be viewed in part as a typical human occurrence, but extreme cases that interfere with the woman's ability to go about her everyday business are classified as pathological kinds of Tokophobia. It is a terrible illness that is quite distinct. Due to a lack of appropriate psychological assessments, it has been challenging to research the prevalence and effects of tokophobia. Due to its complexity and ramifications for obstetrics, anesthesiology, psychology, and psychiatry, it is urgent and desirable to establish a multidisciplinary approach to treating dread of childbirth. It is essential to comprehend the genesis and development of the condition in order to better comprehend the aetiology and developmental stages of tokophobia and to promote suitable, effective, and evidence-based therapies. More research is necessary because there hasn't been much done in these fields. Focusing on the evaluation of the care pathways and applicable treatments can help with this.
... (14)(15)(16) Doğum korkusu yönetiminde amaç, kadının doğumu ile ilişkili belirsizlikleri kabul etmesine, doğum eylemine yönelik olumlu duygulara sahip olmasına, gebelikteki kontrolüne ve doğumla ilişkili anksiyetesine yardım etmektir. (17) Doğum korkusunu azaltmaya yönelik doğuma hazırlık sınıfı, (18) nefes teknikleri, hidroterapi, hipnoz, (19) doula desteği, bilişsel ve davranışsal terapiler (20) gibi birçok yaklaşım kullanılmaktadır. Bu yaklaşımlardan biri de psikoeğitimdir. ...
Kadınları doğum ve anneliğe geçişe hazırlamaya odaklanan bilgilendirici ve psikolojik müdahaleler gibi nonfarmakolojik yaklaşımların doğum korkusunu azaltmada fayda sağladığı belirtilmektedir. Bu çalışmanın amacı, gebelerde doğum korkusuna yönelik müdahalelere ilişkin randomize kontrollü çalışmaların incelenmesidir. Çalışmada, Aralık 2020-Ocak 2021 tarihleri arasında “pregnant women” and “fear of childbirth” and “randomized controlled trial” anahtar kelimeleri kullanılarak, Google Scholar, PubMed, Scopus, Web of Science ve “Cochrane” veri tabanları tarandı ve ulaşılan makaleler değerlendirildi. Sistematik derlemeye, yayın dili Türkçe veya İngilizce olan, araştırma örneklemleri gebelerden oluşan, tam metnine ulaşılan, Ocak 2015-Aralık 2019 tarihleri arasında yayınlanan randomize kontrollü çalışmalar alındı. Çalışmadan, İngilizce ve Türkçe dışındaki dillerde yazılmış olan, derlemeler, sistematik derlemeler, olgu sunumları, tezler, randomize kontrollü dışındaki çalışmalar, kongre kitabında yayınlanan bildiriler, tam metnine ulaşılamayan makaleler dışlandı. Sırası ile başlık, özet ve tam metine göre yapılan inceleme neticesinde alınma kriterlerine uyan 14 makaleye ulaşıldı. Makalelerin seçiminin aşamaları ve kapsam dahilindeki ve hariç tutulan çalışmaların tüm aşamaları PRISMA akış şemasında belirtildi. Gebelerde psiko-eğitim tekniklerinin, ebe tarafından verilen bireysel danışmanlık programının, nefes alma farkındalığının, intrapartum destekleyici bakımın ve doğuma yönelik eğitim müdahalelerinin doğum korkusunu azaltmada etkili olduğu, 18 saatlik farkındalık temelli anneliğe hazırlık programının, gebe kadınlarda doğum korkusunun yanı sıra öz yeterliliği de iyileştirdiği, haptoterapi müdahalesinin doğum korkusunu azaltabilecek belirli becerilerin geliştirilmesini kolaylaştırdığı, distraksiyon tekniklerinin ardından doğum korkusunun düşük olduğu, ancak farkın anlamlı olmadığı, gebelerin internet tabanlı bilişsel davranış terapi müdahalesine kıyasla yüz yüze danışmanlıktan daha memnun oldukları belirlendi. İncelenen çalışmalardan 12’sinde doğum korkusunun azaldığı belirlendi.
La pratique de l’hypnose transforme une capacité naturelle en un outil thérapeutique qui s’installe de plus en plus durablement dans le domaine du soin. Cet article est une synthèse des applications de l’hypnose et un état des lieux de la recherche récente dans le domaine de la périnatalité. Le champ d’application de l’hypnose est vaste et couvre toute la période périnatale, du parcours préconceptionnel au postpartum. Malgré des résultats parfois équivoques concernant l’apport de l’hypnose pour l’utilisation d’antalgiques ou la douleur rapportée durant l’accouchement, les diverses études font état d’une meilleure expérience subjective de l’accouchement, de la grossesse et de la période périnatale, plus généralement en améliorant le vécu émotionnel et le bien-être de la femme. Dans le domaine des grossesses pathologiques, particulièrement complexe de par son impact somatopsychique, l’apport de l’hypnose reste à être exploré.
Background: Hypnosis has been increasingly used in recent years in healthcare, with several applications during pregnancy, labor and birth. Yet, few studies have assessed the impact of hypnosis on women's childbirth experience. Aim: This systematic review examines the use and effects of hypnosis-based interventions during pregnancy and childbirth on women's childbirth experience. Methods: A literature search was performed on several databases (Science Direct, PsychINFO and PubMed). Published articles reporting on hypnosis-based interventions carried out during pregnancy and/or childbirth that evaluated childbirth experience were included in the review. The articles were assessed with the Mixed Methods Appraisal Tool (MMAT). Key findings: Nine articles met the inclusion criteria. The methodological value of the articles was limited for half of the studies (four studies scored 60% or less on the MMAT). Despite this methodological limitation, the results suggest a positive impact of hypnosis-based interventions on childbirth experience, in alleviating fear and pain and enhancing sense of control during labor. The hypnosis-based interventions improved women's emotional experiences and outlook towards birth, with less anxiety, increased satisfaction, fewer birth interventions, more postnatal well-being and better childbirth experience overall. Implications for practice: The findings of this review suggest that hypnosis-based interventions improve childbirth experience. Further studies should be undertaken in order to better determine and develop hypnosis-based interventions aiming at improving this experience. Such interventions could enhance several aspects of the childbirth experience by taking into account women's partners, medical and surgical history, narratives of childbirth and specific aspects of complicated pregnancies that women can go through.
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Abstract This article describes the history, rationale, and guidelines for developing a new definition of hypnosis by the Society of Psychological Hypnosis, Division 30 of the American Psychological Association. The definition was developed with the aim of being concise, heuristic, and allowing for alternative theories of the mechanisms (to be determined in empirical scientific study). The definition of hypnosis is presented as well as definitions of the following related terms: hypnotic induction, hypnotizability, and hypnotherapy. The implications for advancing research and practice are discussed. The definitions are presented within the article.
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Pain relief by touch has been studied for decades in pain neuroscience. Human perceptual studies revealed analgesic effects of segmental tactile stimulation, as compared to extra-segmental touch. However, the spatial organization of touch-pain interactions within a single human dermatome has not been investigated yet. In two experiments, we tested whether, how, and where within a dermatome touch modulates the perception of laser-evoked pain. We measured pain perception using intensity ratings, qualitative descriptors, and signal detection measures of sensitivity and response bias. Touch concurrent with laser pulses produced a significant analgesia, and reduced the sensitivity in detecting the energy of laser stimulation, implying a functional loss of information within the ascending Aδ pathway. Touch also produced a bias to judge laser stimuli as less painful. This bias decreased linearly when the distance between the laser and tactile stimuli increased. Thus, our study provides evidence for a spatial organization of intra-segmental touch-pain interactions.
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THERE IS AN EVER REOCCURRING QUESTION IN MEDICAL PRACTICE: Does the positive attitude and communication of the medical staff make any difference? Our aim is to present a comprehensive overview of the medically relevant effects of positive suggestions by reviewing the recent literature. We will review the studies measuring the effects of suggestive communication of the past 20 years. In cases of studies presented in more details we quote from the suggestion scripts used in the study, too. Some of the reviewed papers report that positive suggestions lead to decreased pain and use of pain medication and positively affect physiological factors like bowel motility, blood pressure and bleeding during surgery as well. However, the literature also contains studies in which only partial or no positive effects were found. We emphasize further, more detailed investigation of positive suggestion techniques and its integration into the education of medical professionals.
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The paper introduces a series of articles where several detailed clinical examples will be presented on the effectiveness of using suggestive techniques in various fields of interventional medicine. The aim of this series is to raise the attention to the patients heightened openness to suggestions. By recognizing the unavoidable nature of suggestive effects on one hand we can eliminate unfavourable, negative suggestions and on the other hand go on and consciously apply positive, helpful variations. Research materials, reviews and case study will describe the way suggestions can reduce anxiety and stress connected to medical intervention, improve subjective well-being and cooperation, and increase efficiency by reducing treatment costs.
Background: Historically, women have been attended and supported by other women during labour. However, in hospitals worldwide, continuous support during labour has become the exception rather than the routine. Objectives: Primary: to assess the effects of continuous, one-to-one intrapartum support compared with usual care. Secondary: to determine whether the effects of continuous support are influenced by: (1) routine practices and policies; (2) the provider's relationship to the hospital and to the woman; and (3) timing of onset. Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2013). Selection criteria: All published and unpublished randomised controlled trials comparing continuous support during labour with usual care. Data collection and analysis: We used standard methods of The Cochrane Collaboration Pregnancy and Childbirth Group. Two review authors independently evaluated methodological quality and extracted the data. We sought additional information from the trial authors. We used random-effects analyses for comparisons in which high heterogeneity was present, and we reported results using the average risk ratio (RR) for categorical data and mean difference (MD) for continuous data. Main results: Twenty-two trials involving 15,288 women met inclusion criteria and provided usable outcome data. Results are of random-effects analyses, unless otherwise noted. Women allocated to continuous support were more likely to have a spontaneous vaginal birth (RR 1.08, 95% confidence interval (CI) 1.04 to 1.12) and less likely to have intrapartum analgesia (RR 0.90, 95% CI 0.84 to 0.96) or to report dissatisfaction (RR 0.69, 95% CI 0.59 to 0.79). In addition, their labours were shorter (MD -0.58 hours, 95% CI -0.85 to -0.31), they were less likely to have a caesarean (RR 0.78, 95% CI 0.67 to 0.91) or instrumental vaginal birth (fixed-effect, RR 0.90, 95% CI 0.85 to 0.96), regional analgesia (RR 0.93, 95% CI 0.88 to 0.99), or a baby with a low five-minute Apgar score (fixed-effect, RR 0.69, 95% CI 0.50 to 0.95). There was no apparent impact on other intrapartum interventions, maternal or neonatal complications, or breastfeeding. Subgroup analyses suggested that continuous support was most effective when the provider was neither part of the hospital staff nor the woman's social network, and in settings in which epidural analgesia was not routinely available. No conclusions could be drawn about the timing of onset of continuous support. Authors' conclusions: Continuous support during labour has clinically meaningful benefits for women and infants and no known harm. All women should have support throughout labour and birth.
Although the discovery and understanding of the function of the vestibular system date back only to the 19th century, strategies that involve vestibular stimulation were used long before to calm, soothe and even cure people. While such stimulation was classically achieved with various motion devices, like Cox’s chair or Hallaran’s swing, the development of caloric and galvanic vestibular stimulation has opened up new possibilities in the 20th century.With the increasing knowledge and recognition of vestibular contributions to various perceptual, motor, cognitive, and emotional processes, vestibular stimulation has been suggested as a powerful and non-invasive treatment for a range of psychiatric, neurological and neurodevelopmental conditions. Yet, the therapeutic interventions were, and still are, often not hypothesis-driven as broader theories remain scarce and underlying neurophysiological mechanisms are often vague. We aim to critically review the literature on vestibular stimulation as a form of therapy in various selected disorders and present its successes, expectations, and drawbacks from a historical perspective.
Background: Difficulty with the labor epidural technique has been described using a variety of criteria, but remains inadequately defined. We sought to determine the reasons cited for difficulty with the insertion of labor epidural techniques among anesthesiologists, nurses, and patients. We hypothesized that the perception of procedural difficulty would correlate among participants and with the elapsed duration of the insertion attempt. Methods: A total of 140 participant sets (i.e. anesthesiologist, nurse and patient) were asked to complete a questionnaire on procedural difficulty, immediately before (i.e. anticipated) and after (i.e. perceived) a standardized epidural technique. Procedural duration, using specified start and end times, was recorded in seconds by an independent co-investigator. Demographic data for all groups were recorded. Results: Perceived difficulty with the epidural technique was similar among all groups (range 10-14%; P=0.29) and correlated with anticipated difficulty (anesthesiologist P=0.0004; nurse P=0.00001; patients P=0.006) and procedural duration (all groups P <0.001). The most common reasons cited for perceived difficulty were procedural duration (anesthesiologist P=0.58), number of attempts (nurse P=0.02), and pain experienced (patient P=0.035). Conclusions: Difficulty with the epidural technique is associated with anticipated difficulty and procedural duration. The reasons for perceived difficulty differ among anesthesiologists, nurses and obstetric patients, with patients most commonly citing pain experienced.
This was a feasibility pilot study to evaluate the efficacy of the nonpharmacologic pain management technique of gentle human touch (GHT) in reducing pain response to heel stick in premature infants in the neonatal intensive care unit (NICU). Eleven premature infants ranging from 27 to 34 weeks' gestational age, in a level III NICU in a teaching hospital, were recruited and randomized to order of treatment in this repeated-measures crossover-design experiment. Containment with GHT during heel stick was compared with traditional nursery care (side lying and "nested" in an incubator). Heart rate, respiratory rate, oxygen saturation, and cry were measured continuously beginning at baseline and continuing through heel warming, heel stick, and recovery following the heel stick. Infants who did not receive GHT had decreased respiration, increased heart rate, and increased cry time during the heel stick. In contrast, infants who received GHT did not have decreased respirations, elevated heart rates, or increased cry time during the heel stick. No significant differences were noted in oxygen saturation in either group. GHT is a simple nonpharmacologic therapy that can be used by nurses and families to reduce pain of heel stick in premature infants in the NICU.